It was predicted that colorectal cancer care might fare particularly badly, in particular due to suspension of non-emergency diagnostic endoscopy following safety concerns from the British Society of Gastroenterology, discontinuation of the National Bowel Cancer Screening programme, recommendation by the Royal College of Surgeons against laparoscopic procedures, and shortage of ICU capacity to support open bowel resections.
With cessation of both screening and most routine outpatient activity, it was predicted that those colorectal cancer diagnoses would be displaced into the 2WW and emergency pathways.
They demonstrate peak reductions for April for 2WW referrals (63% reduction) and colonoscopies (92% reduction), with restitution to normal rates by October, 2020. The authors calculate there to have been a sustained relative reduction of 22% in the number of colorectal cancer cases referred for treatment across all routes to diagnosis from April to October, 2020. In total, they calculate that, across those 7 months, more than 3500 fewer people than in 2019 were diagnosed and treated for colorectal cancer in England.
Morris and colleagues offer the first clear quantitation of the drop in presentations, diagnosis, and treatment of colorectal cancer cases for England in 2020. An interesting question emerges regarding those apparently missing cancer diagnoses. Have they yet to appear as a downstream bulge of late or emergency presentations? Have some of them already been absorbed unnoticed within the COVID and non-COVID-related excess deaths of 2020? The data presented by Morris and colleagues do not include sex-specific or age-specific rates, which might provide additional insight into the demographic groups to which the missing cases correspond. Furthermore, comprehensive description of routes to diagnosis for this period once available will be informative.
However, although the reduction in activity shown by Morris and colleagues alludes to substantial disruption to colorectal cancer pathways, the actual extent of per-patient delay cannot be deduced. Delays in the 2WW pathway are available from the Cancer Waiting Times datasets, but these metrics fail to reflect delays in patient presentation, delays in primary care referral, or indeed delays in the other three routes to diagnosis. When cancer stage data become available for the 2020 colorectal cancer diagnoses, this will allow evaluation of net overall upwards stage-shifting, from which attributable excess colorectal cancer mortality can be indirectly predicted.
However, only via analysis over the next decade for statistical deviation from expected colorectal cancer death rates can we attempt to quantify directly the excess mortality, as colorectal cancer deaths attributable to COVID-19-related disruption will be intermingled and indistinguishable from the expected colorectal cancer deaths within routinely reported statistics.
However, while the clinical and health-economic cases for ring-fencing have been well-made, can cancer services really be protected in the face of acute pressure on capacity? It is politically challenging to prioritise the excess deaths of tomorrow over the emergencies of today.
The data from Morris and colleagues well validate the long-stated case for dedicated stand-alone facilities of the sort elsewhere in Europe that have allowed continuity with minimal disruption of cancer 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.
I declare no competing interests.
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Published: January 14, 2021
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