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Delays in Cancer Patient Referrals and Diagnostic Testing Will Impact Cancer Survival Says Study

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Delays to cancer referral through reduced use of the urgent GP referral pathway during the coronavirus pandemic could result in more than a thousand additional deaths in England, a new study reports.

New modelling suggests that delays in patients presenting and being referred with suspected cancer by their GP, and resulting bottlenecks in diagnostic services, are likely to have had a significant adverse effect on cancer survival.

During lockdown, urgent so-called two-week wait GP referrals in England for suspected cancer have dropped by up to 84% – raising fears that undiagnosed cancers could be progressing from early-stage tumours to advanced, incurable disease.

The researchers suggest the NHS would need to ramp up diagnostic capacity rapidly to avoid further unnecessary deaths – and might prioritise certain tumour types in which avoidance of delay is particularly impactful, such as bladder, kidney and lung cancer.

The impact of reduced urgent referrals

Scientists at The Institute of Cancer Research, London, used 10-year cancer survival estimates for England for 20 common tumour types to create models estimating the impact of reduced patient referrals through urgent GP pathways linked to the COVID-19 pandemic.

The researchers modelled the impact of three different scenarios of lockdown-accumulated backlog – reflecting a 25, 50 or 75 per cent reduction in people across England coming forward with symptoms and receiving urgent GP referrals over the three-month lockdown period.

Their modelling indicated if all these patients presented and were referred for diagnostic investigation promptly post end of lockdown in mid June, the presentational delay would result in an estimated 181, 361 or 542 excess deaths respectively.

Since extra diagnostic services like scans and biopsies are unlikely to be immediately available to address fully the backlog, the researchers also estimated the additional lives that might be lost due to consequent diagnostic delays.

Consequent diagnostic delays

The researchers estimated that in a good-case scenario, which assumes all patients present in the month post lockdown and the necessary additional diagnostic capacity is made fully available spread across the three months post lockdown, delays in diagnosis would result in up to another 276 additional deaths. If the additional capacity were delayed and only provided spread across months three to eight post lockdown, there could be up to 1,231 additional deaths, their modelling suggested.

The study was published in The Lancet Oncology and was largely funded by the ICR itself, with support from Breast Cancer Now and Cancer Research UK.

The research team found that the impact of a delayed referral and diagnosis depended on factors such as cancer type and stage, aggressiveness of the disease and patient age.

Prioritising referral of particular groups

The number of cases that progress from urgent GP referral to diagnosis of an aggressive but treatable cancer varies widely by tumour type. Reflecting this, their modelling suggests that avoiding delays for suspected bladder, kidney and lung cancers, especially in younger patients for whom there is less risk from hospital-acquired COVID-19 infection, would have most impact on lives and life-years lost.

These findings suggest that strategies that prioritise referral of particular groups of patients would achieve the best outcomes and limit the number of additional deaths from cancer linked to the pandemic. However, the estimates are based on limited evidence and results need to be interpreted with caution when considering strategies for specific groups.

Researchers estimated that across all 20 cancer types, a uniform per-patient delay of one month in diagnosis just via the urgent referral pathway would result in 1,412 lives lost and 25,812 life-years lost if these disruptions lasted a full year – while a six-month delay would result in 9,280 lives and 173,540 life-years lost.

In addition to delays in diagnosing and treating cancer, crucial cancer research aiming to find new treatments for patients has also been disrupted. The ICR, a charity and research institute, has launched a major fundraising appeal to kick-start its research and make up for the time lost to the coronavirus crisis.

Ensuring cancer patients are not left behind

Study leader Professor Clare Turnbull, Professor of Cancer Genomics at the ICR, said:

“We have shown that delays in presenting to GPs with symptoms and subsequently to accessing diagnostic tests could cause more than a thousand additional deaths if sufficient extra capacity isn’t provided promptly to deal with the backlog.

“It’s vital that we do everything we can to ensure cancer patients are not left further behind by the disruptions to care caused by the COVID-19 pandemic. That means ramping up capacity as quickly as possible to allow cancer diagnostic services to clear the backlog. Our data indicate prioritisation of particular patient groups may be effective in mitigating the extent of excess deaths and lost life years.”

'A heavy toll on people with cancer'

Professor Paul Workman, Chief Executive of the ICR, said:

“It has become clear that the COVID-19 pandemic is taking a heavy toll on people with cancer – by delaying their diagnosis, disrupting access to surgery and other aspects of care, and pausing vital research into new treatments.

“We know that cases of cancer have remained hidden during the pandemic, because patients have missed out on GP referral and access to diagnostics, and this study reveals the likely impact on survival rates.

“It adds to evidence of the vital need to get cancer diagnostic and treatment services fully back up and running, and research programmes moving forward once again, to minimise the impact on patients today and in the future.”

Reference: Sud, et al. (2020). Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study. The Lancet Oncology. DOI: https://doi.org/10.1016/S1470-2045(20)30392-2

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