By Professor Gordon C Wishart, Chief Medical Officer at Check4Cancer, Visiting Professor of Cancer Surgery at Anglia Ruskin School of Medicine
• The NHS and private sector need to work together nationwide, to deliver urgent access to cancer diagnosis and treatment
• Death rates of cancer patients will increase if private hospital resources are not fully utilised during and after the COVID-19 pandemic
• Access to cancer services must be increased during the lockdown period if we are to avoid a rise in cancer deaths in the UK
• ONS data currently shows increases in non COVID-19 related death rates during the week of 3rd April 20201
It is now 29 days since the UK lockdown started, and we now know that it will last at least another 3 weeks. With no clear exit strategy, it is uncertain if the restrictions on social distancing will be extended beyond that time or, be re-introduced intermittently to reduce the spread of the virus. Until we have effective treatments or a vaccine, this decision will be a delicate balance between patient care, both COVID-19 related and unrelated, NHS capacity and the negative impact on the economy.
Following my previous report, published in ecancer on 14th April 20202, that raised concern that the lockdown was contributing to delays in cancer diagnosis and treatment, there have been multiple case studies in the media to support my opinion that the partnership between the NHS and private hospital networks has not protected cancer patients in all parts of the country. Whenever the lockdown is lifted, there is likely to be a significant backlog of patients with suspicious cancer symptoms that require urgent investigation, and patients who require to start or re-start their cancer treatment. So how prepared is the UK to deal with such a backlog of potential and confirmed cancer cases?
Lack of cancer resources
A report in April 2019 by Cancer Research UK3 suggests that the UK is not well prepared at all to deal with such a crisis. The UK already has worse survival rates than many Western countries including Canada, Australia, Norway & Denmark, attributed by CRUK to the stage of cancer at diagnosis and access to optimal treatment. At the time of the report, it was acknowledged that there was already a shortage of cancer treatment specialists, with 243 additional oncologists and 1560 therapeutic oncologists promised by Health Education England by 2021. This lack of human and cancer treatment resources has been evident for some time with increasing failure to deliver cancer waiting time targets for diagnosis and treatment. It therefore seems unlikely that the NHS is in a strong position to cope with increasing demand for cancer services at the end of the lockdown period, which is why access must be increased during the lockdown period if we are to avoid a rise in cancer deaths in the UK.
Suspension of cancer screening
The 2019 CRUK report also highlighted the falling acceptance of invitations to NHS cancer screening programmes for bowel, breast & cervical cancer throughout the UK. In recent weeks, Scotland, Wales & Northern Ireland have all temporarily suspended their cancer screening programmes, and England may well follow suit. Reinstatement of cancer screening, and the subsequent investigation of those with abnormal test results, will only put further pressure on cancer services at the end of the lockdown period. Furthermore, if cancer screening is suspended for a considerable time, then the reduction in screen-detected cancers will contribute to worse overall survival for breast, bowel & cervical cancer.
Variable implementation of public-private partnership
The partnership between the NHS and private hospital groups led to an expectation that there would be segregation of patients with coronavirus from all other patients who required diagnosis or treatment of time-critical conditions such as cancer. While there is evidence of that partnership working well in certain parts of the country, with cancer hubs now being established in “COVID-light” NHS & private hospitals for cancer treatment in London and Manchester, and urgent breast cancer cases are being treated in private hospitals in Scotland, we need to accelerate similar pathways in the rest of the UK to ensure rapid access to cancer treatment.
My own feedback from the networks of consultants that work with Check4Cancer is that there are still private hospitals with empty operating theatres and consulting rooms, with no activity in their radiology departments. One private hospital designated as a cancer treatment centre, has only had one patient transferred from the NHS. It would therefore appear that while NHS England strongly supports the public-private partnership, local Trusts have been slow to implement this strategy throughout the UK.
A spokesman for NHS England said: “Private hospital beds were first and foremost intended to provide reserve ‘buffer’ capacity for coronavirus patients should it have been needed, so it is a mark of success that that has largely not been the case. Now as the overall number of coronavirus inpatients stabilises and hopefully begins to fall, it will over the coming weeks and months be possible to begin to release anaesthetists and other key staff from looking after coronavirus patients so that more routine operations can resume in both NHS and private hospitals.” Unfortunately, my opinion is that waiting for months to release spare capacity in the private sector will only contribute to delays in cancer treatment and unnecessary cancer deaths.
Reduction in cancer survival
Before the coronavirus pandemic, the poor survival rates for common cancers in the UK was attributed to delays in diagnosis and lack of access to optimal cancer treatment, especially in the elderly. All of these contributing factors are being made worse by the COVID-19 crisis pandemic and the enforced policy of social distancing and are, therefore, likely to result in lower survival for patients being diagnosed with cancer during and soon after the easing of restrictions. Professor Richard Sullivan, Director of the Institute of Cancer Policy at Kings College London recently advised that the number of deaths due to the disruption of cancer services is likely to outweigh the number of deaths from the coronavirus itself over the next five years.
We have to act now to find ways to use the resources currently lying fallow in private hospitals to diagnose patients with suspicious cancer symptoms and treat all urgent cancer cases. If we fail, then the NHS will not be able to cope with the overwhelming demand after the lockdown and many patients will die during the next 5 years as a result of a delay in diagnosis or suboptimal cancer treatment. This is starkly illustrated by the figures for additional non COVID-19 related deaths reported during the week of 3rd April this year. Although some of these may be undiagnosed COVID-19 deaths, many will likely be due to other causes. These higher numbers will undoubtedly persist over many weeks or months unless the government acts swiftly to coordinate immediate access to hospital facilities for cancer patient pathways in the coming days.
2. Cancer Treatment delays could increase death rates due to impact of COVID-19 pandemic on UK hospital capacity, ecancer, 14th April 2020 https://ecancer.org/en/news/17643-cancer-treatment-delays-could-increase-death-rates-due-to-impact-of-covid-19-pandemic-on-uk-hospital-capacity
3. Cancer Research UK Report April 2019 https://www.cancerresearchuk.org/sites/default/files/state_of_the_nation_april_2019.pdf