Impact of COVID-19 on cancer in Wales

Submission to the Health Committee inquiry on COVID-19 and health and social care

02 June 2020

Introduction

Since the start of the COVID-19 pandemic, cancer services in Wales have been significantly affected. Urgent suspected cancer referrals from primary care are down. Cancer screening has been paused. Cancer treatments have been altered or delayed. All of this will likely have an impact on cancer survival, as well as add a growing backlog to an already stretched health service.

It is now imperative that cancer services are supported to recover from the pandemic. Achieving this will require ‘COVID-protected’ spaces where cancer diagnosis and treatment can operate as safely as possible. These will need an adequate COVID testing strategy of staff and patients to maintain such sites.

This short briefing offers the latest statistics and CRUK analysis, quantifying this effect on cancer in recent months. In some cases, figures are extrapolated from data in England, where Welsh data is not publicly available.

This briefing is intended to complement the Wales Cancer Alliance submission on 1 May 2020 to the Health Committee’s inquiry.

Cancer incidence and mortality

Before the pandemic, a typical month would see approximately 1,600 cases of cancer diagnosed in Wales. As diagnoses have likely dropped due to a reduction in cancer referrals, a substantial backlog of undiagnosed cancers is building. In some cases, these may be picked up at a later stage when the cancer is less treatable.

There would usually be approximately 740 cancer deaths in Wales in a typical month. This means that for the week ending 22^nd May 2020, for every 10 COVID-19 deaths, there were 13 cancer deaths. This is the first week since the end of March that we estimate there have been more cancer deaths than COVID-19 deaths.

Cancer diagnosis

England, Northern Ireland and Scotland have all reported a reduction of 70-75% in urgent suspected cancer referrals during periods of the pandemic. While no comparative figure has been made for Wales, we would expect it to be broadly similar. We estimate that around 14,000 fewer urgent GP referrals in Wales have been made in the last 10 weeks.

Most recent Welsh Government data shows that in March 2020, 7,041 urgent suspected cancer referrals were made by GPs and confirmed urgent by a specialist. While this only captures the start of lockdown, it is 3,157 fewer than in March 2019, when 10,198 urgent referrals were made.[1]

Data for routine GP referrals that lead to a cancer diagnosis or cancers diagnosed via an emergency presentation are not available for Wales. However, using such data from England, we estimate in a typical month, 380 routine GP referrals and 300 emergency presentations would occur in Wales.

The reduction in urgent referrals is extremely concerning. Early diagnosis of cancer is vital to improve survival in Wales. Before the pandemic, around half of patients had their cancer diagnosed at Stage 1 or 2, when treatment is more likely to be successful.[2] The concern is that this may have dropped during the pandemic.

Cancer screening

For each month that cancer screening services in Wales are suspended, CRUK estimates that around 55,600 invitations to take part in the bowel, breast or cervical cancer screening programmes aren’t being sent out. An accumulating 37,700 people per month are no longer being screened for bowel, breast and cervical cancer following an invite in Wales. Normally, at least 80 patients go on to have a cancer diagnosed through the screening programmes each month in Wales, so right now there are a significant number of early cancers that are going undetected while these programmes are not running.

There are usually around 23,600 bowel cancer screening invitations sent per month in Wales. Following uptake of the invitation, it’s estimated that around 15,200 FIT completed kits per month are usually sent to the central screening laboratory for testing ^{^[3]}. We estimate around 230 colonoscopies per month are usually required across Wales to follow up a positive (abnormal) FIT result.^{^[4]} An estimated over 20 bowel cancers are usually diagnosed through screening per month in Wales. Many adenomas (polyps) are also detected and removed through the programme, some of which may progress into cancer if not removed.

Usually around 12,100 breast cancer screening invitations are sent out per month to 50-70-year-olds registered as female for a routine screening appointment in Wales. Of those invited, around 8,600 people normally have a screening mammogram per month (or around 9,000 including self/GP-referrals), with around 380 referred onwards for further assessment (or around 430 including self/GP-referrals). This usually results in at least 60 (invasive) breast cancers diagnosed through breast screening per month in Wales.

At least 19,800 invitations for cervical screening are sent out per month to people with a cervix or registered as female of the target screening age of 25-64 in Wales. People outside of this age group may also be assessed by the programme, and some people are screened opportunistically by their GP practice, or after self-referring. Overall, usually around 14,500 people per month attend a cervical screening appointment and have a sample taken. At least 560 people are referred for colposcopy per month^{^[5]}, resulting in around 5 cervical cancers diagnosed through screening per month, and many more diagnoses of potentially pre-cancerous conditions of the cervix which, if left untreated, could develop into invasive disease.

Cancer treatment

Data on cancer treatments is not publicly available in Wales. Using data from England, we would usually expect to see the following number of Welsh patients per month receive each type as their first course of treatment:

· Surgery: 710

· Radiotherapy: 420

· Chemotherapy: 440

A UK-wide survey conducted by the Royal College of Surgeons of Edinburgh shows that a third of cancer surgeons have had to stop cancer surgeries completely and that 87% have had to reduce them.[6] Some patients have seen their treatment plans change in light of the pandemic, for example switching to an oral chemotherapy that can be taken at home, or receiving radiotherapy if surgery has been cancelled.

Whilst decisions about a patient care should be made on the basis of what is best for any given individual, it is clear delaying cancer treatments could have significant implications in the longer term. With delays to their treatment, many patients could face fewer treatment options and lower chances of survival; and for the health service, further delays to treatment will create a growing backlog of demand for an already overstretched health service to address.

Recovery of cancer services – COVID-protected spaces and testing

Our understanding is that there is no single reason for the changes and reduction in cancer diagnosis and treatment during this period. We believe that the following are all contributing to a greater or lesser extent:

· Public concern about COVID-19 meaning that patients are less likely to contact their GP about concerning symptoms or attend planned hospital appointments.

· GP reluctance to refer patients for cancer tests where there is an increased risk of COVID-19 infection or a lack of capacity to safely perform diagnostic tests.

· Clinicians having to balance the benefits of cancer treatment with the risk of COVID-19 infection.

· Lack of NHS capacity and equipment, including recovery beds and ICU beds.

As we continue to move beyond the peak of coronavirus in Wales, it is now imperative that cancer services are restored to full operation to deal with the growing backlog of diagnoses and treatment. This will require the establishment of COVID-protected cancer services, where staff and patients can have confidence that cancer diagnostics and treatment can take place as safely as possible.

To maintain COVID-protected cancer services, there must be an adequate COVID testing strategy where patients are tested prior to a test or treatment. It also requires that staff, including non-medical staff such as porters and cleaners, are tested at least once a week, even if they are asymptomatic. We estimate that this would require an additional 1,000 to 1,900 COVID tests per day in Wales. It is important that Welsh Government and NHS Wales factor this into wider testing strategies.

For more information, please contact Public Affairs Manager for Wales

References