On Sunday 29 March, I lost my uncle to coronavirus, a disease that neither I, as a scientist, nor indeed the majority of the world’s population, had even heard of just over four months ago. A couple of days later, my colleague Professor Eduard Vrdoljak, an oncologist from the University of Split, while consoling me on my loss, also shared with me the worrying trend that he had begun to notice in his home country of Croatia, that people were increasingly becoming more concerned about receiving a diagnosis of coronavirus than one of cancer. Since then, I have heard similar anecdotal stories from colleagues in the UK and in other European nations.
As someone who has worked across the cancer spectrum for over 30 years, I am regrettably only too familiar with the adverse impact that cancer can have on the lives of patients, their families and their carers. We are experiencing a challenging new reality, where the COVID-19 pandemic is increasingly compromising our normal way of life and significantly reducing our society’s health and wellbeing. The numbers of deaths attributed to COVID-19 in the UK are extremely concerning, having just passed 35,000 as I write this, but it is worth remembering that over 165,000 people in the UK die from cancer every year.
One aspect of the current emergency that greatly worried both Eduard and I, and my friend and colleague Professor Richard Sullivan from Kings College London, was the realisation that government-backed public health measures to combat the COVID-19 emergency in many parts of Europe and across the US, that incorporate less social exposure combined with more social distancing (commonly known as national lockdowns), could have had unintended but profound effects on cancer services and cancer outcomes globally. We recently emphasised our concerns in an opinion piece published in a major European cancer journal. We highlighted how the understandable focus of a repurposed health service on the COVID-19 pandemic could inadvertently compromise national cancer screening programmes, prompt an increase in late cancer diagnoses, and lead to the cancellation or postponement of cancer treatments. The net result of these unintended effects on cancer services could precipitate significant increases in cancer mortality and cancer-associated adverse health issues, at local, national and global levels.
On 29 April, exactly one month after my uncle passed away, I, alongside colleagues from University College London and DATA-CAN, the UK’s Health Data Research Hub for Cancer, posted a scientific paper online which reports the results of a large research study. In this paper, we present robust evidence which adds credence to the concerns highlighted in our opinion piece. We employed near “real-time” cancer intelligence and data collected by DATA-CAN researchers in Leeds, London and Belfast, from major cancer centres in England and from all five Health and Social Care trusts in Northern Ireland. Our analysis of these data shows unequivocally that both urgent referral rates (our early warning system or “red flag” for catching cancer at its earliest stage) and patient attendances for chemotherapy delivery (an appropriate proxy measure of a cancer service’s activity) have dropped significantly, to an average of 76% and 60% of pre COVID-19 pandemic levels respectively.
Furthermore, in a robust analysis from over 3.8 million health records from patients in England (the largest and most comprehensive study of its kind reported to date), we estimate that the COVID-19 pandemic could result in at least 6,300 excess deaths in the next 12 months in patients living with cancer. This is a conservative estimate and is based only on newly diagnosed cancer cases in England in the current year. If we extrapolated our results to all patients living with a diagnosis of cancer, the number could rise to nearly 18,000 excess deaths, an extremely sobering number.
And it’s not only in data from the UK that we see these dramatic increases in predicted excess deaths from cancer. Performing a similar analysis on publicly available data from the United States, provides us with a conservative estimate of 20,000-30,000 excess deaths in cancer cases diagnosed in the current year, a significant increase on the US’s annual death rate from cancer for those diagnosed in the current year.
What is particularly instructive about our study is that nearly eight out of ten of the excess deaths that we predict will occur in the next 12 months are in patients with cancer who have at least one other additional health condition. These comorbidities, as we term them, include cardiovascular disease, hypertension, obesity and diabetes, common conditions in the population, but many of which we could control using already available medicines or through self-management of our own individual health and wellbeing.
Despite the challenges that we highlight, we must encourage cancer patients, or citizens who are worried that they may have cancer symptoms, to continue to access health services. Critically however, we must ensure that those health services are fully able to support them. Responding to a question that was posed by the media on the basis of our work, Prime Minister Boris Johnson, in his first daily press briefing since returning to good health after his COVID-19 infection and hospitalization, emphasized the importance of delivering cancer services for our citizens. This is really important, and we hope that our work can help inform the second phase of the NHS’s response to COVID-19, particularly by resuming cancer services at pre COVID-19 levels.
While welcoming Prime Minister Johnson’s encouraging words, our results from both UK and US data are concerning. We believe that countries across the world need to rapidly understand how the emergency is adversely affecting cancer outcomes and act accordingly, otherwise we risk adding cancer with associated underlying health conditions to the escalating death toll of the COVID-19 pandemic. We must recognize that people with cancer with comorbidities need to be considered as an extremely vulnerable group of patients and that their care is managed appropriately and in a timely fashion. To facilitate this, the government in the UK should ensure that the health service maximises access to real-time national data on mortality (to allow us to determine which comorbid disease combinations pose the greatest risk) and on health services activity (to monitor how health system change during the emergency is impacting on care delivery and future health outcomes). This cancer intelligence is crucial to how we best serve our cancer patients, both now but even more crucially in the COVID-19 recovery phase. Data can really save lives, but only if we can access it in “real-time” and use it intelligently. I have been privileged to have worked in cancer for the last 30 years, when we have made enormous progress in our fight against this killer disease, particularly here in the UK. It is important that we do not allow that great work to be undone over the next 3-6 months. We must act now, or we risk the unintended consequence of the current COVID-19 pandemic precipitating a future cancer epidemic.
Professor Mark Lawler is Associate Pro-Vice-Chancellor, Professor of Digital Health and Chair in Translational Cancer Genomics at Queen’s University Belfast, He is the scientific lead of DATA-CAN, the UK’s Health Data Research Hub for Cancer