Research evidence is showing that the Covid-19 pandemic has worsened outcomes for cancer patients. The impact of the pandemic has been enormous and has touched on every part of normal life. It might, indeed, be expected that Covid-19, directly and indirectly, would have a negative impact on outcomes for other illnesses. However, some research has shown that UK cancer patients are significantly more likely to die than similar patients in other countries.
Covid-19 is still a new illness. Although we have learned a lot about the virus and illness, there is still much that we can only learn with time. One such area is the impact Covid-19 has on the progression and treatment of other illnesses.
It is well known that co-morbidities — having two or more conditions at the same time — will often have a negative effect on health outcomes. Exactly why will depend on the conditions in question, but can be because of the effect of one illness on the immune system, side effects of treatment for one condition, or simply the impact of two, concurrent, illnesses. Many cancers are a particular risk, frequently because aggressive treatments reduce the body’s ability to fight other infections.
An early study published in The Lancet found cancer patients in the US and Canada who were diagnosed with Covid-19 suffered a higher 30-day all-cause mortality rate. In other words, they were more likely to die, whether of Covid-19, cancer, or anything else. The research found some risk factors that correlated with a higher mortality rate but found the same overall increased risk in different treatment types and cancers.
Another review of early research highlighted that some factors appear to have a bigger impact on mortality than others. Some cancer types, for example, haematological cancer, or with high levels of malignancy, were particularly at risk. However, the reasons for this are still far from apparent. While immunosuppression from treatment might be a cause, it’s also possible that factors like reduced lung function or complications from either condition could play a role.
Imperial College London conducted a study of nearly 1,500 patients which also found increased risks of mortality but, worryingly, found that UK patients appeared to be at higher risk than patients in other European countries. The results from the study suggest that UK patients were more than 1.5 times more likely to die within 30 days of a Covid-19 diagnosis (40.38% of UK patients, compared to 26.50% of European patients). The gap was only slightly smaller, 1.4 times, over a six-month period (47.64% compared to 33.33%).
Like other studies, the reasons behind this remain unclear. It might reflect several factors, for example, the UK participants tended to be older and were less likely to have received Covid-19 therapies. The UK had a higher death rate from Covid-19 than other European countries, the reasons behind this might have had an impact on cancer patients as well.
Covid-19 has affected outcomes in other ways too. If a patient does not even see their GP, then it is possible that cancer can go undetected. Covid-19 pandemic has changed patient behaviours, making an initial presentation to primary care less likely. While GPs are still seeing patients with significant symptoms, such as rectal bleeding or unexpected lumps, patients are not attending with other symptoms, such as unexpected weight loss or a persistent cough. The suspension of national screening programmes, which accounted for 5% of diagnoses each year, has also had an impact.
The Nuffield Trust, reporting on cancer waiting times, shows a stark drop in performance on diagnosis and initial treatment of cancer during the pandemic. Faster treatment reduces the risk of complications and improves outcomes. Until recently, there was a two-week wait target: a patient referred with suspected cancer by a GP or screening programme should be seen by a specialist within two weeks. This was replaced in 2020 with the 28-day faster diagnosis standard, a patient should have a diagnosis within 28 days of referral, although this is not being performance managed during the pandemic.
What is clear is that delays have got significantly worse during the pandemic. The two-week targets were usually met until 2017/2018. Then, until the pandemic, the performance tended to be just below the target. However, the arrival of Covid-19 has seen performance plummet.
The NHS’s own data show that there has been a significant drop. The operational standard for the two-week wait is that 93% of patients should have their appointment within two weeks. In January 2020, performance was below this target, at 90.1%, a year later, in January 2021 it was 83.4%.
The Nuffield Trust has identified that waiting times have lengthened generally, so even after being seen by a specialist there is a longer wait for treatment. One of the worst performing areas is for cancer surgery, where only 87.5% of patients received treatment within one month against a target of 96%.
This has resulted in longer overall waiting times. The Nuffield Trust reported much worse performance on the two-month wait target, the total time from referral to the start of treatment. Against a goal of 85% only 76.9% of patients were treated in this time during the second quarter of 2020/21. Performance was even worse for patients referred by a screening service. It is expected 90% of patients referred following screening will commence treatment within two months. However, only 64% of patients were treated within that target.
It is clear that Covid-19 has had a significant, and severe, impact on cancer patients, and in the UK possibly for systemic, rather than medical, reasons. Performance for cancer services have been declining for several years, but has become significantly worse during the Covid-19 pandemic. This means that cancers are identified later, and treatment started later, reducing the likelihood of successful outcomes for patients.
Even when patients are receiving treatment, Covid-19 is affecting their outcomes. Again, because the mortality rate in the UK is higher than other nations, it appears that this might be because of systemic, rather than medical reasons. While there are many factors that might contribute and explain this, given the UK’s overall higher Covid-19 death rate it seems likely that the systemic factors will play at least a partial role.
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