In an editorial based on their review, Carl Heneghan (Professor of Evidence-Based Medicine at Oxford) and Tom Jefferson (an epidemiologist and expert on respiratory diseases) present the findings from various studies on changes to cancer services due to government-imposed restrictions.
From mid-March until the end of April 2020, a cervical cancer screening unit in Cameroon saw screening numbers drop by nearly 80%. This is troubling because late-stage presentations are linked to decreased cervical cancer survival. The five-year survival rate for U.S. women diagnosed with advanced cervical cancer is 15% compared with 93% for those presenting much earlier with localised disease. A similar outcome is seen in low-income countries. In India, for example, the five-year survival is 9% for advanced disease compared with 78% when the cancer is diagnosed at stage one when it is localised to the cervix.
Several studies in our review reported that when routine services resumed after restrictions were lifted, there was still a shift to later-stage disease presentations, even in countries that were relatively unaffected by the pandemic.
In a Japanese regional treatment centre, no significant changes were seen in the number of patients undergoing surgery. However, the number of patients undergoing surgery with advanced disease increased compared with before the emergency. In three university-affiliated hospitals in Korea, the number of cancers diagnosed remained the same; however, the proportion of patients with stage three-four non-small-cell lung cancer (NSCLC) increased to 75% compared to an average of 63% in the three previous years.
Not all cancers have the same prognosis but presenting late with lung cancer is bad news. In those with early disease, more than 55 out of 100 people will survive for five years or more after diagnosis. But in later stage four disease – which has spread beyond the lungs – only five out of 100 survive for five years or more.
In low resource settings, delays had lethal effects. Among Indian patients presenting to a tertiary care hospital with oral cancers, 39% were deemed inoperable in the early three months of the Covid pandemic – double the number compared with the pre-Covid era.
These delays in care were not restricted to adults as children were affected in a variety of countries. In Turkey, a major Paediatric Oncology Department reported reductions in children undergoing chemotherapy, radiotherapy, surgery, and imaging studies during the Covid period. In Italy, presentations to the National Pediatric Oncology Unit in Milan during the lockdown phase were half of what would normally be expected. And in a U.S. tertiary referral centre, 75% of new leukaemia/lymphoma diagnoses required intensive care in April 2020 compared with a monthly average of 12% in 2018–2019.
Patients with cancer often delay seeking medical advice. The early phase of the COVID-19 pandemic substantially exacerbated these delays. The true extent of the impact of these delays may never be known. However, a substantial body of evidence reports that delays lead to later-stage cancer, which translates into more severe disease and subsequently reduces life expectancy. Low and middle-income countries are disproportionately affected by cancer, where more than two-thirds of all global deaths occur.
Worth reading in full.
The full review can be found here.
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