Covid-19: Cancer mortality could rise at least 20% because of pandemic, study findsBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1735 (Published 29 April 2020) Cite this as: BMJ 2020;369:m1735
All rapid responses
As we consider the unintended consequences of COVID-19 with the focus moving from the reasons for reduced admissions traditionally related to a myriad of common clinical disorders to those other services such as cancer and diagnostics (endoscopy and colonoscopy, bronchoscopy) and the startling predicted figures quoted in the recent article (1) we also need to consider how this will be delivered in the new era of COVID. On average during a typical clinical session up to 12 scopes can be performed but this drops to 3-4 with the need for PPE and safety. Again surgery in most cases is taking much longer. Hence when the dust settles and the long lists are reviewed for those still alive in need of these interventions, more deaths are likely to occur as the NHS will not be effectively equipped or organised structurally to deal with the volume.
This will also have impacts on clinical training; less procedures; smaller clinics; reduced theatre lists will all reduce the experience of trainees and their ability to sign off competencies to progress in their training. Finally what will become of teaching medical students? It could be a double edged sword and represent and opportunity with more time to teach and train the doctors of the future or they may not be allowed to participate in these important clinical environments due to the need for full PPE. There is much to consider.
Finally if one was to perhaps consider the possible "benefits" as a result of COVID; as the coronavirus pandemic has brought the UK to a grinding halt, there has been a huge drop in emissions from fossil fuel combustion. Normally high-pollution would see increased admissions from chronic lung disease, cardiac arrests, strokes, and asthma-related issues amongst other conditions (2). The lockdown perhaps through improved air quality may have also reduced illness and admissions from reduced traffic on the roads, those from accidents and potential future cancers related to pollution. Cleaner air may have a further silver lining, as it may also benefit those who suffer COVID-19 from reduced cardiac disease from pollution but also reduce further spread as particulate matter has the potential to act as carriers for this virus, leading to rapid spread over larger areas (2). The UK and NHS will be very different places in the future and there will need to be many innovate practices after evaluation to enable it to function to manage "normal business" effectively with COVID and future viruses here to stay.
1. Covid-19: Cancer mortality could rise at least 20% because of pandemic, study finds; BMJ 2020;369:m1735
2. Hansel NN, Mccormack MC, Kim V. The Effects of Air Pollution and Temperature on COPD. COPD. 2016;13(3):372-9. doi:10.3109/15412555.2015.1089846
Competing interests: No competing interests
We read with great interest the pre-print article by Lai et al (1) which estimated that the direct and indirect effects of the COVID-19 emergency could lead to a 20% rise in cancer deaths in the UK and the US. Most people around the world are affected in some way by the COVID-19 pandemic, but the stresses are particularly heightened for people with, or being treated for, cancer. Recent data from the ISARIC project in the UK (2) showed that individuals with any malignancy are at increased risk of death following COVID-19 infection requiring hospital admission. In addition to being directly susceptible to COVID-19, there is growing concern that the lockdown in the UK, aimed at reducing virus transmission and allowing the NHS to cope with the number of patients with severe COVID-19 disease, may be having an unintentional adverse impact on patients with chronic illnesses, including cancer. The impact of reticence to attend primary care with symptoms of cancer, deferred referral from primary care, decreased capacity for optimal investigations to identify new cancers, and deferral of definitive cancer treatment, such as surgery, radiotherapy and chemotherapy, may all adversely impact on mode of presentation and cancer stage in the longer term. In the short term, management of late presentation of cancer with complications (e.g. bowel obstruction) is also associated with a higher morbidity and mortality. For instance, there is an approximately 10-fold greater 90 day-mortality for patients undergoing emergency colorectal cancer resections compared to those undergoing elective surgery (11.5% versus 1.7%) (3). Furthermore, we have previously shown that elderly patients are the most likely to be disadvantaged by any measures constraining early diagnosis (4).
Studying the trends in incidence and deaths for different diseases during the current COVID-19 pandemic is important to help policymakers, public health officials, clinicians and the wider public understand the intended and unintended effects of lockdown. Lai et al call for weekly data on cause-specific mortality, which has been noted to have delays in England, Wales and Northern Ireland, where in 2018 a review of cause of death showed increasing trends in the frequency of reporting delays for all causes, including neoplasms, with 23% of deaths due to neoplasms are often delayed beyond the 7-day reporting period (5). A great strength in Scotland and a notable gap in the current report, are high-quality registrations of deaths including cause of death which are reported weekly in Scotland (6). Using the most recent report from National Records Scotland (NRS) on 29 April 2020, we examined the percentage difference in crude numbers of deaths in 2020 compared to the average for 2015-2019 by week of death within calendar year (MEDRXIV/2020/086231, "Trends in excess cancer and cardiovascular deaths in Scotland during the COVID-19 pandemic 30 December 2019 to 20 April 2020"). We also examined the trends in reported cardiovascular disease deaths, another chronic disease for which there is great concern that there may be direct and indirect adverse effects of the COVID-19 emergency on mortality.
During this time, we note a peak in excess deaths at week 14, about four weeks after the first case in Scotland was detected on 1 March 2020. Similar trends for both cancer and cardiovascular disease deaths after the first COVID-19 case was registered in Scotland increased to week 14, and declining thereafter. The observed short-term increase in cancer and cardiovascular deaths might be associated with undetected/unconfirmed deaths related to COVID-19, given the known issues of lack of widespread testing for infection and that both conditions increase susceptibility to the disease. These data are consistent with the increase in risk of death noted in the ISARIC UK report (2), and reaffirm the importance of dynamic tracking of mortality data during the pandemic. The reduction in cardiovascular related deaths earlier in the year prior to week 10, compared with previous years, is likely due to a milder influenza season (7-8). Whether trends in excess deaths stabilize beyond 20 April 2020 remains to be determined as new excesses might occur due to changes in health services and health seeking behaviors.
Understanding the impact of the COVID-19 pandemic, the changes to cancer services and cancer mortality require ongoing monitoring for the foreseeable future as different measures to address the COVID-19 pandemic are implemented. Multidisciplinary, multi-institutional, national and international collaborations for complementary and population specific data are needed to plan, respond and mitigate adverse effects to our populations.
Cancer diagnostic services are frequently over-stretched during normal times and ramping up both diagnostic and treatment services to cope with the backlog and concurrent new cases will require substantial resources. The current COVID-19 constraints on investigations and cancer treatment diagnosis will affect current incident cancers, but it will also affect patients yet to develop cancer, by creating future bottlenecks on stretched and imperfect diagnostic pathways. If the NHS is not adequately resourced, we could see new patients continue to be disadvantaged during the post-COVID catch up and plans to tackle this challenge are desperately needed. Continued monitoring of trends in incidence and mortality are required.
For now, it is important for cancer patients and all the public to know that while COVID-19 is a public health crisis, if they feel unwell or need advice the NHS is still open for normal business.
1. Preprint-Lai A, Pasea L, Banerjee A, et al. Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency. Apr 2020. https://www.researchgate.net/publication/340984562_Estimating_excess_mor....
2. Preprint-Docherty AB , Harrison E, Green CA, et al. Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol’. https://www.medrxiv.org/content/10.1101/2020.04.23.20076042v1
3. National Bowel Cancer Audit v2.0 2019 https://www.nboca.org.uk/content/uploads/2020/01/NBOCA-2019-V2.0.pdf
4. Clark AJ, Stockton D, Elder A, Wilson RG, Dunlop MG. Assessment of outcomes after colorectal cancer resection in the elderly as a rationale for screening and early detection. Br J Surg. 2004 Oct;91(10):1345-51. DOI:10.1002/bjs.4601
5. Impact of registration delays on mortality statistics in England and Wales: 2018. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri...
6. National Records Scotland Weekly deaths statistics https://www.nrscotland.gov.uk/covid19stats
7. UK government Weekly national flu reports: 2019 to 2020 season https://www.gov.uk/government/statistics/weekly-national-flu-reports-201...
8. Stewart, S., Keates, A., Redfern, A. et al. Seasonal variations in cardiovascular disease. Nat Rev Cardiol 14, 654–664 (2017). https://doi.org/10.1038/nrcardio.2017.76
Competing interests: No competing interests