INCREASE CANCER DEATHS DUE TO PANDEMIC

The majority of patients who have cancer or are suspected of having cancer are not accessing healthcare services in the United Kingdom or the United States because of the COVID-19 pandemic, the first report of its kind estimates. As a result, there will be an excess of deaths among patients who have cancer and multiple comorbidities in both countries during the current coronavirus emergency, the report warns. The authors calculate that there will be 6270 excess deaths among cancer patients 1 year from now in England and 33,890 excess deaths among cancer patients in the United States. (In the United States, the estimated excess number of deaths applies only to patients older than 40 years, they note.) "The recorded underlying cause of these excess deaths may be cancer, COVID-19 or comorbidity (such as myocardial infarction)," Alvina Lai, PhD, University College London, United Kingdom, and colleagues observe. "Our data have highlighted how cancer patients with multimorbidity are a particularly at-risk group during the current pandemic," they emphasize. The study was published on ResearchGate as a preprint and has not undergone peer review. Commenting on the study on the UK Science Media Center, several experts emphasized the lack of peer review, noting that interpretation of these data needs to be further refined on the basis of that input. One expert suggested that there are "substantial uncertainties that this paper does not adequately communicate." But others argued that this topic was important enough to warrant early release of the data. Chris Bunce, PhD, University of Birmingham, United Kingdom, said this study represents "a highly valuable contribution." "It is universally accepted that early diagnosis and treatment and adherence to treatment regimens saves lives," he pointed out. "Therefore, these COVID-19-related impacts will cost lives," Bunce said. "And if this information is to influence cancer care and guide policy during the COVID-19 crisis, then it is important that the findings are disseminated and discussed immediately, warranting their release ahead of peer view," he added. In a Medscape UK commentary, oncologist Karol Sikora, MD, PhD, argues that "restarting cancer services can't come soon enough." "Resonably Argued Numerical Estimate" "It's well known that there have been considerable changes in the provision of health care for many conditions, including cancers, as a result of all the measures to deal with the COVID-19 crisis," said Kevin McConway, PhD, professor emeritus of applied statistics, the Open University, Milton Keynes, United Kingdom.

Σελίδα 2 από 2 "It seems inevitable that there will be increased deaths in cancer patients if they are infected with the virus or because of changes in the health services available to them, and quite possibly also from socio-economic effects of the responses to the crisis," he continued. "This study is the first that I have seen that produces a reasonably-argued numerical estimate of the number of excess deaths of people with cancer arising from these factors in the UK and the USA," he added. Declines in Urgent Referrals and Chemo Attendance For the study, the team used DATA-CAN, the UK National Health Data Research Hub for Cancer, to assess weekly returns for urgent cancer referrals for early diagnosis and also chemotherapy attendances for hospitals in Leeds, London, and Northern Ireland going back to 2018. The data revealed that there have been major declines in chemotherapy attendances. There has been on average a 60% decrease from prepandemic levels in eight hospitals in the three regions that were assessed. Urgent cancer referrals have dropped by an average of 76% compared to prepandemic levels in the three regions. On the conservative assumption that the COVID-19 pandemic will only affect patients with newly diagnosed cancer (incident cases), the researchers estimate that the proportion of the population affected by the emergency (PAE) is 40% and that the relative impact of the emergency (RIE) is 1.5. PAE is a summary measure of exposure to the adverse health consequences of the emergency; RIE is a summary measure of the combined impact on mortality of infection, health service change, physical distancing, and economic downturn, the authors explain. Comorbidities Common "Comorbidities were common in people with cancer," the study authors note. For example, more than one quarter of the study population had at least one comorbidity; more than 14% had two. For incident cancers, the number of excess deaths steadily increased in conjunction with an increase in the number of comorbidities, such that more than 80% of deaths occurred in patients with one or more comorbidities. "When considering both prevalent and incident cancers together with a COVID-19 PAE of 40%, we estimated 17,991 excess deaths at a RIE of 1.5; 78.1% of these deaths occur in patients with ≥1 comorbidities," the authors report. "The excess risk of death in people living with cancer during the COVID-19 emergency may be due not only to COVID-19 infection, but also to the unintended health consequences of changes in health service provision, the physical or psychological effects of social distancing, and economic upheaval," they state. "This is the first study demonstrating profound recent changes in cancer care delivery in multiple centers," the authors observe. Lai has disclosed no relevant financial relationships. Several coauthors have various relationships with industry, as listed in their article. The commentators have disclosed no relevant financial relationships. The study is available for download from the ResearchGate website. Follow Medscape Oncology on Twitter for more cancer news: @MedscapeOnc.

Routine cancer care, from screening and diagnostic tests in suspected cases to treatment of known cases with surgery and chemotherapy, has been substantially disrupted as a result of the COVID-19 pandemic, warns an expert from a leading UK charity, Cancer Research UK (CRUK). Sara Hiom, CRUK's director of cancer intelligence, early diagnosis, and clinical engagement, says this is taking its toll on patients and healthcare workers alike. She suspects that there are thousands of cancer cases going undiagnosed or untreated because of a lack of healthcare staff, fears over infection risk, and patients with signs and symptoms not coming forward. Writing in a blog post published by CRUK on April 21, Hiom says this is causing "huge anxiety" to patients and having a psychological impact on physicians unable to "offer the comfort and reassurance they'd like." The issue has been building since the COVID-19 pandemic hit the UK. Earlier this month, consultant oncologist Karol Sikora, MD, PhD, warned that patients in certain areas of the country were not receiving chemotherapy and operations were being put on hold. Sikora, who is chief medical officer at Rutherford Health, which runs several oncology centers, told The Guardiannewspaper on April 4 that treatment had become "inconsistent," with some hospitals having put "blanket bans on cancer treatment." "Not everyone needs to rush ahead with cancer treatment, but others need to continue despite this to get the best long-term cure," he said. Disruptions at All Points on Cancer Pathway In her post, Hiom details how the COVID-19 pandemic has affected many aspects of cancer care in the UK right along the care pathway. Alongside screening services being officially "paused" in Scotland, Wales, and Northern Ireland, she says they are "effectively paused" in England because invitations to screen are not being sent out. This means that around 200,000 people are no longer being screened for colorectal, breast, and cervical cancer across the UK every week. She warns that as a consequence "there will be a significant number of early cancers left undetected before these programs can be reintroduced," particularly in the early stages "when treatment is more effective." The issue of cancer screening being halted was recently discussed on Medscape by Yale pathologist Benjamin Mazer, MD. He argues that the pandemic offers "a natural experiment like no other" and wonders if the break in screening will result in more advanced cancer being diagnosed, and whether that will affect outcomes. In her blog, Hiom also reports that patients are not presenting with signs and symptoms indicative of cancer. The drop in numbers of people visiting their physician with symptoms affects "the whole diagnostic pathway." Urgent referrals for cancer have dropped by around 75% in England since the pandemic started.

Σελίδα 2 από 2 Additionally, physicians are reluctant to send their patients to the local hospital in case they contract COVID-19, and many diagnostic tests such as endoscopy, bronchoscopy, guided biopsies, and computed tomography, are not taking place to protect patients and staff. Hiom estimates that, as a result, 2300 cancer cases are going undiagnosed across the UK, a figure that "will be stacking up over time." Cancer Surgery Being Delayed Patients already diagnosed with cancer have been hit hard by the pandemic. Despite national guidelines saying that urgent and essential cancer treatment must continue, those waiting in particular for surgery have had, in some hospitals, their appointments canceled or delayed by 3 months or more. "We've been hearing that patients requiring major surgery aren't able to have it as either there are no recovery beds with ventilation, no [intensive care unit] beds if surgery were to go wrong, or because the surgery is just too risky for patients and staff," Hiom writes. "Unfortunately, these issues are heavily affecting those who might benefit from surgery the most, as many 'curative' operations are complex," she continues. There are also cases of chemotherapy and palliative care being affected by the COVID-19 pandemic, with either fear over the risks of infection or a lack of staff preventing high-priority treatment. Comments on the CRUK post from patients with cancer and relatives show the anxiety that has resulted. Patricia Matthewman said her son was diagnosed with cancer on March 17 and was told he needed chemotherapy "ASAP." However, 2 weeks later he was told his treatment was postponed "until further notice." "How are we supposed to live with this," she writes. "He is 47 years old with a wife and 2 children. I am terrified." Another woman, who has secondary breast cancer, said all her appointments with her oncologists have been canceled and her personal physician called her to make sure she has an advance do not resuscitate order. She writes that she is "literally being left to die." Some oncologists have tried to "mitigate some of this disruption," Hiom writes. For example, some are using hormone therapy or radical radiotherapy instead of surgery for some cancers. How One Oncologist Has Adapted   One oncologist who has adapted his practice in response to the pandemic is Clive Peedell, MD, from the James Cook University Hospital, Middlesbrough, UK, and cofounder of the National Health Action Party. In a series of posts on Twitter, he explains that he has switched to teleconsultations for routine and treatment follow-up, but still has in-clinic visits for most of his new patients and those he is worried about. "To be fair, this could be a good new way to do a lot of my work in future," he says. Clive Peedell@cpeedell  · Apr 22, 2020 Replying to @cpeedell For starters, I’ve been assigned to the #COVID19 wards rota. Somewhat scary for a non-acute physician, but actually a privilege to be able to help the dedicated teams on the frontline. Meanwhile, the cancer service must continue..... Clive Peedell@cpeedell I am now doing mainly teleconsultations for routine follow up and treatment follow ups. Still bringing most new patients, and patients I’m worried about, to my clinics for full assessment. To be fair, this could be a good new way to do a lot of my work in future. 186 1:12 PM - Apr 22, 2020 Twitter Ads info and privacy 33 people are talking about this However, Peedell acknowledged that it has been "a new tough new world for oncologists" in terms of treatment decisions. "We lack the data to accurately guide us and we are taking a pragmatic approach based on national and international expert consensus opinion," he added. Clive Peedell@cpeedell  · Apr 22, 2020 Replying to @cpeedell I am now doing mainly teleconsultations for routine follow up and treatment follow ups. Still bringing most new patients, and patients I’m worried about, to my clinics for full assessment. To be fair, this could be a good new way to do a lot of my work in future. Clive Peedell@cpeedell In terms of treatment decisions, this has been a tough new world for oncologists. We lack the data to accurately guide us and we are taking a pragmatic approach based on national and international expert consensus opinion. Practice has definitely changed and continues to change. 129 1:12 PM - Apr 22, 2020 Twitter Ads info and privacy 26 people are talking about this Peedell notes that he is giving less chemotherapy and has stopped adjuvant chemotherapy for patients with lung cancer after surgery, which will reduce the cure rate "by at least 5% in these patients." On a more positive noted, Peedell adds: "Interestingly, I'm actually giving more lung cancer radiotherapy than ever before, because the surgeons are operating much less due to #COVID19 risks, and we can use stereotactic radiotherapy to treat early stage lung cancer as a very good alternative to surgery." Clive Peedell@cpeedell  · Apr 22, 2020 Replying to @cpeedell We have also deferred all curative prostate radiotherapy. I am less concerned about this because it won’t effect mortality because we can cover the higher risk patients with hormone treatment. However, there’s going to be a huge backlog to address when we lift restrictions Clive Peedell@cpeedell Interestingly, I’m actuality giving more lung cancer radiotherapy than ever before, because the surgeons are operating much less due to #COVID19 risks, and we can use stereotactic radiotherapy to treat early stage lung cancer as a very good alternative to surgery. 139 1:12 PM - Apr 22, 2020 Twitter Ads info and privacy 29 people are talking about this No funding or conflicts of interest declared. Cancer Research UK. How coronavirus is impacting cancer services in the UK. Published online April 21, 2020. Blog