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COVID-19’s Collateral Damage: Reduced Colorectal Cancer Care

The COVID-19 pandemic adversely impacted the detection and management of colorectal cancer (CRC) across England, according to a population-based study.

The number of people being referred to hospitals with suspected lower gastrointestinal cancer, and the number subsequently diagnosed, fell sharply during the first lockdown in March and a deficit persisted until September, which translated to >3,500 fewer people than expected starting treatment in the period April to October 2020, based on levels for the same period in 2019, reported Eva J.A. Morris, PhD, of the Big Data Institute at the University of Oxford, and colleagues.

“As delays in diagnosis allow tumours to continue to grow and advance, this bottleneck in the diagnostic pathway is likely to have a profoundly detrimental impact on colorectal cancer outcomes in England,” they wrote in Lancet Gastroenterology & Hepatology.

The study examined data from four population-based datasets for all CRC-related referrals, colonoscopies, surgical procedures, and rectal radiotherapy courses from Jan. 1, 2019 to Oct. 31, 2020. Differences in patterns of care were comparatively investigated for 2019 and 2020, and percentage reductions in monthly numbers and proportions were calculated.

Morris’ group reported that April 2020 saw a 63% (95% CI 53-71) reduction from 36,274 to 13,440 in the monthly number of 2-week referrals for suspected cancer versus the month average in April 2019. Also, there was a 92% (95% CI 89-95) reduction in the number of colonoscopies, from 46,441 to 3,484, although the numbers recovered by October.

Overall, there was a 22% (95% CI 8-34) relative reduction in the number of cases referred for treatment, from a monthly average of 2,781 in 2019 to 2,158 in April 2020. By October, the monthly rate had returned to 2019 levels but did not exceed it.

And there was also a 31% (95% CI 19-42) relative reduction in the numbers receiving surgery in April 2020, as well as a lower proportion of laparoscopic, and a greater proportion of stoma-forming procedures, relative to the monthly average in 2019. By October, laparoscopic surgery and stoma rates were similar to 2019 levels.

For rectal cancer, there was a 44% (95% CI 17-76) relative increase in the use of neoadjuvant radiotherapy in April 2020, relative to 2019’s monthly average owing to greater use of short-course regimens, according to the authors. Although June saw a drop in short-course regimens, rates remained above 2019 levels until October.

By October, achievement of care pathway targets had returned to 2019 levels, but with smaller patient volumes and modifications to usual practice, they noted.

With a second surge in COVID-19 cases hitting the U.K. and new lockdowns imposed, the authors called for measures to overcome barriers to diagnosis and protect the quality of service delivery.

“As pressure grows in the NHS [National Health Service] due to the second wave of COVID-19, urgent action is needed to address the growing burden of undetected and untreated colorectal cancer in England,” they wrote.

In the U.S., an August 2020 study showed a 46.4% decline in weekly new diagnoses across six cancers, including CRC, during the pandemic. Norman E. Sharpless, MD, of the National Cancer Institute attributed the decline to disruptions in screening and assessment of patients, according to the ASCO Post.

David Liska, MD, MA, of the Cleveland Clinic in Ohio, said delay or omission of CRC screening owing to COVID-19 is worrisome for cancer care in this country.

“Anecdotally, I’ve seen several patients recently diagnosed with CRC who had delayed their colonoscopy due to COVID-19-related concerns,” Liska, who was not involved in the U.K. research, told MedPage Today.

While this country lacks Britain’s centralized healthcare system, pooled U.S. data from the Epic Health Research Network including 306 hospitals, 28 states, and 9.8 million patients have shown that during the first several months of 2020, an estimated 95,000 cancer screenings were missed, he said. “These numbers then improved over the following months, but we likely won’t know the far-reaching effects of these missed screening examinations on cancer care and outcomes for several more years.”

In an accompanying commentary, Clare Turnbull, PhD, of the Institute of Cancer Research in London, attributed a dramatic disturbance in cancer care pathway to the “unprecedented pressure on the hospital beds and [ICUs],” as well as “redeployment of staff, fear of nosocomial transmission, reduced primary care access, and population lockdown.”

Although urgent diagnostic colonoscopy has been restored in Britain and primary care is better prepared, Turnbull asked whether cancer care can withstand continuing pressure with the second wave in full swing. She said the current study validates the case for establishing dedicated stand-alone facilities of the type in some continental European countries. These have allowed cancer care continuity with minimal disruption of diagnosis and treatment.

“We can only hope that the pandemic will prompt reconfiguration of cancer services to better protect future delivery in the face of the next extrinsic crisis,” she wrote.

In a September 2020 study, Turnbull and colleagues suggested that one remedial measure would be to prioritize symptomatic patients with suspected CRC using fecal immunochemical testing, which could reduce diagnostic and therapeutic delays during the coronavirus pandemic and potentially prevent CRC deaths.

Last Updated January 19, 2021

Disclosures

The study was funded by Cancer Research UK, the Medical Research Council, Public Health England, Health Data Research UK, NHS Digital, and the National Institute for Health Research Oxford Biomedical Research Centre.

Morris disclosed no relevant relationships with industry. One co-author disclosed support from Merck, Pfizer, and Medco/Novartis, as well as holding a patent for a statin drug. Co-authors disclosed multiple relevant relationships with industry.

Turnbull disclosed no relevant relationships with industry.

Source: MedicalNewsToday.com