By 2028, the NHS aims for 55,000 more people each year to survive cancer for at least five years after diagnosis. Achieving this requires access to timely diagnosis and treatment. However, cancer services were under pressure even before the Covid-19 pandemic, with waiting times for appointments and surgery worsening.
Activity levels were disrupted along the whole pathway
Some patients begin a cancer pathway with a referral for suspected cancer, either from a GP or national screening service, followed by an outpatient appointment with a consultant, and then a diagnosis. Others are diagnosed via an emergency presentation, such as at A&E. Following a diagnosis, the patient starts treatment or enters palliative care.
The cancer types included in breakdowns of the published data vary along the pathway. Where possible, we looked at activity from February 2020 onwards for five cancer types – skin, breast, lower gastrointestinal, urological, and lung – which make up approximately 70% of first consultant appointments for suspected cancer.
The most recent month of data available also varies along the pathway, with data on referrals up to April 2021, outpatient appointments and treatments up to March 2021, and diagnoses and emergency presentations up to December 2020.
GP referrals for suspected cancer decreased sharply during the first wave of the pandemic, following a considerable fall in the number of GP appointments. In April 2020, referrals fell for all five cancers, but recovery has varied. By April 2021, lung referrals were 29% lower than just before the pandemic, while breast referrals were 10% higher.
While approximately two-thirds of cancers are diagnosed following a GP referral, patients may also be referred for suspected cancer via a national screening service, accounting for around 6% of diagnoses.
Breast and bowel screening services were paused locally in England in March 2020, and invitations for cervical screening were suspended in April 2020. The number of patients starting treatment following referral from a screening service fell sharply, but the published data does not tell us how many people had screening appointments cancelled or delayed.
First consultant appointments for suspected cancer fell dramatically in April 2020, but have since increased. The initial decrease was similar for all five cancers, but recovery has varied. First appointments for suspected breast cancer were 38% higher in March 2021 than just before the pandemic, while appointments for suspected lung cancer were 16% lower.
The Rapid Cancer Registration Dataset provides initial estimates of the number of cancers diagnosed in 2020, although figures for recent months may not be complete. Following a sharp fall in diagnoses in April 2020, the number of breast cancers diagnosed had recovered by December 2020. However, urological cancer diagnoses remain 23% lower than in February 2020.
While many cancer diagnoses follow a GP or screening service referral, around 17% follow an emergency presentation such as at A&E. The total number of cancers diagnosed via emergency presentation fell between February and April 2020 from 3,937 to 3,250, alongside the overall decrease in diagnoses, but increased sharply to 4,985 in July 2020. While emergency presentations of cancer had fallen by December 2020, the increase is concerning as it suggests patients were unable to access services until their symptoms had worsened.
To maintain cancer treatment during the pandemic, “Covid-free hubs” were established and treatments were delivered which have less impact on the immune system or require fewer hospital visits. However, the total number of first treatments for cancer fell sharply in April and May 2020, with considerable variation by cancer type.
First treatments for lower gastrointestinal cancer fell by 10% between February and May 2020, while treatments for urological cancer fell by 52%. By March 2021, the number of first treatments for breast, lung, lower gastrointestinal, and skin cancers had recovered to above pre-pandemic levels.
What does this mean for recovery?
New guidance sets out aims to fully restore services, including meeting the increased levels of referrals and treatment required to address the fall in the number of first treatments by March 2022. Activity therefore needs to not just recover to pre-pandemic levels, but exceed it to clear the backlog of patients waiting for diagnosis or treatment. But while overall cancer activity is recovering, considerable variation remains by cancer type.
The fall in referrals is worrying as this suggests there are people with potential cancer symptoms who are not yet known to services. Understanding why referrals remain low for certain cancers could help to address this. For example, concerns were raised about symptoms of lung cancer being mistaken for Covid-19, and a public awareness campaign was launched in February 2021.
Estimates of the potential increase in excess deaths from cancer vary hugely, but mortality alone will not capture the full impact of the pandemic. If diagnosis and treatment are delayed, cancers may progress to a later stage, requiring more invasive treatment for patients and more support from services. It is also important to recognise the severe impact of delays on patient experience and quality of life.
The pandemic has contributed to the roll-out of innovative ways of delivering treatment, but has also put considerable strain on services. With existing workforce and diagnostic equipment shortages, cancer services are likely to feel the effect of the pandemic for years to come.