Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study

Morris, Eva J A; Goldacre, Raphael; Spata, Enti; Mafham, Marion; Finan, Paul J; Shelton, Jon; Richards, Mike; Spencer, Katie; Emberson, Jonathan; Hollings, Sam; Curnow, Paula; Gair, Dominic; Sebag-Montefiore, David; Cunningham, Chris; Rutter, Matthew D. D.; Nicholson, Brian D; Rashbass, Jem; Landray, Martin J; Collins, Rory; Casadei, Barbara; Baigent, Colin

doi:10.1016/S2468-1253(21)00005-4

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Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study

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Author(s): Eva J A Morris , Prof, PhD ^a ^, ^c ^, ^* , Raphael Goldacre , MSc ^a ^, ^c , Enti Spata , MSc ^a ^, ^b ^, ^c , Marion Mafham , MD ^a ^, ^c , Paul J Finan , Prof, MD ^e ^, ^f , Jon Shelton , BSc ^d , Mike Richards , Prof, MD ^d , Katie Spencer , PhD ^e ^, ^g , Jonathan Emberson , Prof, PhD ^a ^, ^b ^, ^c , Sam Hollings , PhD ^h , Paula Curnow , DPhil ^h , Dominic Gair , BSc ^h , David Sebag-Montefiore , Prof, FRCR ^e ^, ^f , Chris Cunningham , Prof, MD ⁱ , Matthew D Rutter , Prof, MD ^j ^, ^k , Brian D Nicholson , DPhil ^l , Jem Rashbass , PhD ^h , Martin Landray , Prof, PhD ^a ^, ^c , Rory Collins , Prof, FRS ^a ^, ^c , Barbara Casadei , Prof, FMedSci ^m , Colin Baigent , Prof, FMedSci ^a ^, ^b ^, ^c

Publication date (Electronic): 15 January 2021

Journal: The Lancet. Gastroenterology & Hepatology

Publisher: The Author(s). Published by Elsevier Ltd.

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Abstract

Background

There are concerns that the COVID-19 pandemic has had a negative effect on cancer care but there is little direct evidence to quantify any effect. This study aims to investigate the impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England.

Methods

Data were extracted from four population-based datasets spanning NHS England (the National Cancer Cancer Waiting Time Monitoring, Monthly Diagnostic, Secondary Uses Service Admitted Patient Care and the National Radiotherapy datasets) for all referrals, colonoscopies, surgical procedures, and courses of rectal radiotherapy from Jan 1, 2019, to Oct 31, 2020, related to colorectal cancer in England. Differences in patterns of care were investigated between 2019 and 2020. Percentage reductions in monthly numbers and proportions were calculated.

Findings

As compared to the monthly average in 2019, in April, 2020, there was a 63% (95% CI 53–71) reduction (from 36 274 to 13 440) in the monthly number of 2-week referrals for suspected cancer and a 92% (95% CI 89–95) reduction in the number of colonoscopies (from 46 441 to 3484). Numbers had just recovered by October, 2020. This resulted in a 22% (95% CI 8–34) relative reduction in the number of cases referred for treatment (from a monthly average of 2781 in 2019 to 2158 referrals in April, 2020). By October, 2020, the monthly rate had returned to 2019 levels but did not exceed it, suggesting that, from April to October, 2020, over 3500 fewer people had been diagnosed and treated for colorectal cancer in England than would have been expected. There was also a 31% (95% CI 19–42) relative reduction in the numbers receiving surgery in April, 2020, and a lower proportion of laparoscopic and a greater proportion of stoma-forming procedures, relative to the monthly average in 2019. By October, 2020, laparoscopic surgery and stoma rates were similar to 2019 levels. For rectal cancer, there was a 44% (95% CI 17–76) relative increase in the use of neoadjuvant radiotherapy in April, 2020, relative to the monthly average in 2019, due to greater use of short-course regimens. Although in June, 2020, there was a drop in the use of short-course regimens, rates remained above 2019 levels until October, 2020.

Interpretation

The COVID-19 pandemic has led to a sustained reduction in the number of people referred, diagnosed, and treated for colorectal cancer. By October, 2020, achievement of care pathway targets had returned to 2019 levels, albeit with smaller volumes of patients and with modifications to usual practice. As pressure grows in the NHS due to the second wave of COVID-19, urgent action is needed to address the growing burden of undetected and untreated colorectal cancer in England.

Funding

Cancer Research UK, the Medical Research Council, Public Health England, Health Data Research UK, NHS Digital, and the National Institute for Health Research Oxford Biomedical Research Centre.

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The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study

Camille Maringe, James Spicer, Melanie Morris … (2020)

Summary Background Since a national lockdown was introduced across the UK in March, 2020, in response to the COVID-19 pandemic, cancer screening has been suspended, routine diagnostic work deferred, and only urgent symptomatic cases prioritised for diagnostic intervention. In this study, we estimated the impact of delays in diagnosis on cancer survival outcomes in four major tumour types. Methods In this national population-based modelling study, we used linked English National Health Service (NHS) cancer registration and hospital administrative datasets for patients aged 15–84 years, diagnosed with breast, colorectal, and oesophageal cancer between Jan 1, 2010, and Dec 31, 2010, with follow-up data until Dec 31, 2014, and diagnosed with lung cancer between Jan 1, 2012, and Dec 31, 2012, with follow-up data until Dec 31, 2015. We use a routes-to-diagnosis framework to estimate the impact of diagnostic delays over a 12-month period from the commencement of physical distancing measures, on March 16, 2020, up to 1, 3, and 5 years after diagnosis. To model the subsequent impact of diagnostic delays on survival, we reallocated patients who were on screening and routine referral pathways to urgent and emergency pathways that are associated with more advanced stage of disease at diagnosis. We considered three reallocation scenarios representing the best to worst case scenarios and reflect actual changes in the diagnostic pathway being seen in the NHS, as of March 16, 2020, and estimated the impact on net survival at 1, 3, and 5 years after diagnosis to calculate the additional deaths that can be attributed to cancer, and the total years of life lost (YLLs) compared with pre-pandemic data. Findings We collected data for 32 583 patients with breast cancer, 24 975 with colorectal cancer, 6744 with oesophageal cancer, and 29 305 with lung cancer. Across the three different scenarios, compared with pre-pandemic figures, we estimate a 7·9–9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis, corresponding to between 281 (95% CI 266–295) and 344 (329–358) additional deaths. For colorectal cancer, we estimate 1445 (1392–1591) to 1563 (1534–1592) additional deaths, a 15·3–16·6% increase; for lung cancer, 1235 (1220–1254) to 1372 (1343–1401) additional deaths, a 4·8–5·3% increase; and for oesophageal cancer, 330 (324–335) to 342 (336–348) additional deaths, 5·8–6·0% increase up to 5 years after diagnosis. For these four tumour types, these data correspond with 3291–3621 additional deaths across the scenarios within 5 years. The total additional YLLs across these cancers is estimated to be 59 204–63 229 years. Interpretation Substantial increases in the number of avoidable cancer deaths in England are to be expected as a result of diagnostic delays due to the COVID-19 pandemic in the UK. Urgent policy interventions are necessary, particularly the need to manage the backlog within routine diagnostic services to mitigate the expected impact of the COVID-19 pandemic on patients with cancer. Funding UK Research and Innovation Economic and Social Research Council.

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Mortality due to cancer treatment delay: systematic review and meta-analysis

Timothy Hanna, Will King, Stephane Thibodeau … (2020)

Abstract Objective To quantify the association of cancer treatment delay and mortality for each four week increase in delay to inform cancer treatment pathways. Design Systematic review and meta-analysis. Data sources Published studies in Medline from 1 January 2000 to 10 April 2020. Eligibility criteria for selecting studies Curative, neoadjuvant, and adjuvant indications for surgery, systemic treatment, or radiotherapy for cancers of the bladder, breast, colon, rectum, lung, cervix, and head and neck were included. The main outcome measure was the hazard ratio for overall survival for each four week delay for each indication. Delay was measured from diagnosis to first treatment, or from the completion of one treatment to the start of the next. The primary analysis only included high validity studies controlling for major prognostic factors. Hazard ratios were assumed to be log linear in relation to overall survival and were converted to an effect for each four week delay. Pooled effects were estimated using DerSimonian and Laird random effect models. Results The review included 34 studies for 17 indications (n=1 272 681 patients). No high validity data were found for five of the radiotherapy indications or for cervical cancer surgery. The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications. Surgery findings were consistent, with a mortality risk for each four week delay of 1.06-1.08 (eg, colectomy 1.06, 95% confidence interval 1.01 to 1.12; breast surgery 1.08, 1.03 to 1.13). Estimates for systemic treatment varied (hazard ratio range 1.01-1.28). Radiotherapy estimates were for radical radiotherapy for head and neck cancer (hazard ratio 1.09, 95% confidence interval 1.05 to 1.14), adjuvant radiotherapy after breast conserving surgery (0.98, 0.88 to 1.09), and cervix cancer adjuvant radiotherapy (1.23, 1.00 to 1.50). A sensitivity analysis of studies that had been excluded because of lack of information on comorbidities or functional status did not change the findings. Conclusions Cancer treatment delay is a problem in health systems worldwide. The impact of delay on mortality can now be quantified for prioritisation and modelling. Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers. Policies focused on minimising system level delays to cancer treatment initiation could improve population level survival outcomes.

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COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England

Marion Mafham, Enti Spata, Raphael Goldacre … (2020)

Summary Background Several countries affected by the COVID-19 pandemic have reported a substantial drop in the number of patients attending the emergency department with acute coronary syndromes and a reduced number of cardiac procedures. We aimed to understand the scale, nature, and duration of changes to admissions for different types of acute coronary syndrome in England and to evaluate whether in-hospital management of patients has been affected as a result of the COVID-19 pandemic. Methods We analysed data on hospital admissions in England for types of acute coronary syndrome from Jan 1, 2019, to May 24, 2020, that were recorded in the Secondary Uses Service Admitted Patient Care database. Admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), myocardial infarction of unknown type, or other acute coronary syndromes (including unstable angina). We identified revascularisation procedures undertaken during these admissions (ie, coronary angiography without percutaneous coronary intervention [PCI], PCI, and coronary artery bypass graft surgery). We calculated the numbers of weekly admissions and procedures undertaken; percentage reductions in weekly admissions and across subgroups were also calculated, with 95% CIs. Findings Hospital admissions for acute coronary syndrome declined from mid-February, 2020, falling from a 2019 baseline rate of 3017 admissions per week to 1813 per week by the end of March, 2020, a reduction of 40% (95% CI 37–43). This decline was partly reversed during April and May, 2020, such that by the last week of May, 2020, there were 2522 admissions, representing a 16% (95% CI 13–20) reduction from baseline. During the period of declining admissions, there were reductions in the numbers of admissions for all types of acute coronary syndrome, including both STEMI and NSTEMI, but relative and absolute reductions were larger for NSTEMI, with 1267 admissions per week in 2019 and 733 per week by the end of March, 2020, a percent reduction of 42% (95% CI 38–46). In parallel, reductions were recorded in the number of PCI procedures for patients with both STEMI (438 PCI procedures per week in 2019 vs 346 by the end of March, 2020; percent reduction 21%, 95% CI 12–29) and NSTEMI (383 PCI procedures per week in 2019 vs 240 by the end of March, 2020; percent reduction 37%, 29–45). The median length of stay among patients with acute coronary syndrome fell from 4 days (IQR 2–9) in 2019 to 3 days (1–5) by the end of March, 2020. Interpretation Compared with the weekly average in 2019, there was a substantial reduction in the weekly numbers of patients with acute coronary syndrome who were admitted to hospital in England by the end of March, 2020, which had been partly reversed by the end of May, 2020. The reduced number of admissions during this period is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease. The full extent of the effect of COVID-19 on the management of patients with acute coronary syndrome will continue to be assessed by updating these analyses. Funding UK Medical Research Council, British Heart Foundation, Public Health England, Health Data Research UK, and the National Institute for Health Research Oxford Biomedical Research Centre.

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Author and article information

Journal

Journal ID (nlm-ta): Lancet Gastroenterol Hepatol

Journal ID (iso-abbrev): Lancet Gastroenterol Hepatol

Title: The Lancet. Gastroenterology & Hepatology

Publisher: The Author(s). Published by Elsevier Ltd.

ISSN (Electronic): 2468-1253

Publication date PMC-release: 15 January 2021

Publication date (Electronic): 15 January 2021

Affiliations

[a ]Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK

[b ]Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK

[c ]Big Data Institute, University of Oxford, Oxford, UK

[d ]Cancer Research UK, London, UK

[e ]Leeds Teaching Hospitals NHS Trust, Leeds, UK

[f ]Leeds Institute for Medical Research at St James's, University of Leeds, Leeds, UK

[g ]Leeds Institute of Health Sciences, University of Leeds, Leeds, UK

[h ]NHS Digital, Leeds, UK

[i ]Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK

[j ]Population Health Sciences Institute, University of Newcastle, Newcastle, UK

[k ]Department of Gastroenterology, North Tees University Hospital NHS Trust, Stockton on Tees, UK

[l ]Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

[m ]Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK

Author notes

[* ]Correspondence to: Prof Eva Morris, Nuffield Department of Population Health, The Big Data Institute, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK

Article

Publisher Item ID: S2468-1253(21)00005-4

DOI: 10.1016/S2468-1253(21)00005-4

PMC ID: 7808901

PubMed ID: 33453763

SO-VID: 47ffd87e-37e3-4a82-8a05-61b530902b90

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Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study

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Novel Coronavirus Disease COVID-19

Most cited references 29

The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study

Mortality due to cancer treatment delay: systematic review and meta-analysis

COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England

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