One in two people will develop a form of cancer in their lifetime — it's a frightening statistic and results in approximately 30,000 new diagnoses in the UK every month. But those numbers are changing. New cases are dropping, but for the wrong reasons.
On March 23rd, a country-wide 'lockdown' was initiated by the UK, a move that saw wide-ranging restrictions on freedom of movement, enforced by law, prohibiting non-essential activities in a bid to help curb the already-rapid spread of the novel coronavirus (COVID-19). Gyms, barbers and non-essential shops closed to fight it. Public transport emptied. People followed the #StayHome rules and clapped for the NHS' unwavering resilience every Thursday. At the same time, cancer diagnosis rates plummeted to around a sixth of their previous size.
Daily deaths from coronavirus then began to increase. The NHS, already under immeasurable strain from this evolving respiratory disease and in a constant battle to obtain vital PPE, urged the population to use digital resources and telephone helplines to find help and support from a GP or health professionals. And it worked. Over the course of the next few months, the reproduction number (R) — the rate at which someone can infect other people — began to drop from 1.0 to 0.7. The disease shrank and the remarkable NHS, having solidified its position as an unwavering beacon of hope, was beginning to recover.
The war, however, was far from over. Daily battles against coronavirus continued to be fought in hospitals and care homes, meaning face-to-face medical care to treat other illnesses and ailments was, albeit temporarily, pushed to one side.
To many, it felt that – bar treating coronavirus – the NHS was closed for business. Really, it was anything but. As the statistics showed, thousands of people were refusing to address pre-existing, current or future health concerns through fear of catching coronavirus and, by doing so, were placing themselves at greater risk.
The combination of these two facts led to an alarmingly low rate of cancer diagnoses in the UK. A BBC Spotlight report found that, during April and May 2020, there were 7,500 fewer "red flag" diagnoses and referrals than in 2019, with hospital referrals by GPs falling by 48,278.
"Help Us Help You"
Early diagnosis and stopping the spread, as many people know, plays a significant role in the majority of cancers. In a lot of cases, it's the difference between the cure and palliative care. Did you know that with cancers that affect both sexes, a man has a 67 per cent greater chance of death following diagnosis?
The bottom line is this: with so many people having 'put off' going to see the doctor, a huge backlog has potentially been created. A figure only getting bigger. And with many patients past the early stages of treatment, will the UK be able to cope with a sudden influx of cancer diagnoses?
An Institute of Cancer Research study found that, for every ten COVID-19 patients recovering in hospital and whose lives were saved, four cancer patients could die due to this backlog. According to the study, a three-month delay would lead to almost 5,000 excess deaths and a six-month delay could lead to almost 11,000. We could be driving head-on into a cancer crisis.
The NHS has ensured that vital tests and treatments are going ahead in a 'safe way' for thousands of patients, in an environment that's protected against coronavirus. "The NHS has now set out guidance so that hospitals can further increase the number of cancer tests and treatments they carry out, as well as having the extra capacity to treat future coronavirus patients," said an NHS spokesperson. "So our message to anyone worried about symptoms is, 'Help us help you', and seek help as you always would."
This staggering patient backlog is an issue that Professor Karol Sikora, an Oncologist, Dean of Medicine at the University of Buckingham, Chief of the WHO Cancer Program (1997-1999) and Chief Medical Officer at Rutherford Health, is concerned about.
"If the [cancer diagnosis] delay is only a month, then probably it doesn't go very far and the delay is probably insignificant. If you wait three months, there's a good chance the cancer will spread outside of the primary organ and into the lymph nodes, into the bloodstream and maybe even to other organs. And that puts you into a much poorer outlook category. It also means that you need more treatment, not just perhaps surgery to remove the bowel, but also chemotherapy because it's gotten to lymph nodes and you have to make sure we can kill those cells. It may need radiotherapy as well," explains Sikora.
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"The NHS is sort of working at about 40 percent of capacity. It will get better provided COVID[-19] keeps away, which we hope it will. But we'll have two problems. The first problem is dealing with the diagnostic backlog. In other words, many hospitals that have three thousand people waiting for an MR scan and maybe two thousand people waiting for a CT scan. There's a limit to how many can go through the system."
"The second problem is that when the cancers do get diagnosed, everybody's going to come together probably around July. We're going to have three months of cancer patients wanting treatment there and then."
Coronavirus transmission risks should not make anyone wary of visiting a doctor. It's important to remember that if any of this sounds familiar or if you're experiencing any of the below symptoms or warning signs, contact your local GP immediately — here's how to find your closest practice — for a further referral.
- Unexplained weight loss
- Unusual swellings or lumps anywhere on the body
- Changes in the size, shape or colour of a mole
- Ulcers or sores that won’t heal
- Blood in urine or faeces
- Changes in bowel habits that last longer than six weeks
- Problems passing urine
- A cough or hoarse voice persisting for longer than three weeks
- Difficulties swallowing
- Heavy night sweats
- Read more here
Worryingly, cases like these are already emerging. Earlier this month, The Guardian published an interview with 27-year-old Sherwin Hall, who had a tumour measuring 14cm in his pelvis and 30 small tumours in his lungs. Sherwin, a delivery driver, believes his illnesses developed in the time that he wasn't available to get a cancer scan, with doctors finding the cancer already particularly aggressive and fast-growing within Hall's body.
“I’m fighting for my life because I didn’t have a scan. I should have had the scan months earlier, but didn’t because normal NHS care was suspended because of the coronavirus," Sherwin Hall told The Guardian."
Hall was previously diagnosed with prostatitis — an inflamed prostate gland — in March, but remained unsure about his diagnosis. As his pain began to become excruciating, he even considered taking his own life. “I did my own research and knew it was something else. I kept begging them in April and May to give me an MRI scan but I didn’t have one until last week," he said. "Both my GP and my consultant told me that I couldn’t get one because scanning services were slowed down because of the coronavirus."
“Looking at cancer specifically, the situation is very serious. Thousands of cancer patients have not received the care they need. We are receiving enquiries from people with cancer throughout the country, who fear their condition is getting worse as they wait for tests and medical treatment. This is extremely distressing both for them and their loved ones," explains Mary Smith, specialist medical negligence lawyer and patient safety expert at Novum Law.
"[Sherwin Hall] is just one example of the suffering diagnosis and treatment delays have caused... sadly, Sherwin is now fighting for his life after his cancer was not picked up sooner. We owe it to people like Sherwin, to do our utmost to raise awareness of the risks that delays to diagnostics and treatment can have on patients’ lives."
Having since started chemotherapy for his cancer, Hall's case is unfortunately not an anomaly. More cases are emerging by the day and, as Professor Sikora believes, it's only going to get worse. "It depends, critically, how long this inertia in diagnosis goes on for. It could go up significantly. If diagnostic services shut down as they did in April and things didn't get started again until October, there would be a lot of deaths from undiagnosed cancer coming on. The deaths wouldn't occur immediately, it's not like COVID-19. It would take several years, maybe, until you noticed that there was a change in our cancer treatment, because of the late-stage presentation of the disease."
A study published in the journal Lancet also explored how cancer patients were more likely to die after contracting the novel coronavirus, with 13 per cent of cancer patients in the US more likely to pass away from the respiratory disease. Similarly, researchers in England found that, of 800 patients with various types of cancer and COVID-19, there was an even higher death rate of 28 per cent, with the risk rising substantially in older patients and/or those with pre-existing health conditions, such as high blood pressure. If a 'second wave' was to hit the UK, patients with early or mid-stage cancer or a late diagnosis would, theoretically, be at a substantially greater risk of death from contracting COVID-19.
Mental Health, Cancer and COVID-19
There is, unfortunately, another worrying trend that can contribute to a sharp spike in cancer death rates — male pride and mental ill health. "There's a huge amount of mental health issues in the population at the best of times and, in lockdown, it amplifies relatively small changes in people's mental status. It makes it seem worse. Especially with depression, despair and loneliness," says Professor Sikora.
"Mental health is pretty fragile, with COVID-19's uncertainty. For people living with uncertainty, because they've got another illness like cancer or heart disease, they're not sure how their treatment's going to go, they get anxious about it." Add to this the intimate procedures of checking for prostate or testicular cancer and it's little surprise so many men dodge a check-up, even without a global pandemic.
It's nothing new, unfortunately — men generally address health issues or growing concerns later than women. Such were the findings from a study by the National Pharmacy Association (NPA), which found that men are considerably less likely to use care services, to consult a pharmacist face-to-face or seek treatment when sick. “For all the conversations around gender that are going on at the moment, we still have that stereotypical sense of the strong, silent leader of the family who represents infallibility,” said Daniel Marks, co-founder of the male cancer initiative Father and Son Day, in a previous interview with Men's Health. “And for him to show any sign of vulnerability or weakness is seen as somehow undermining that image. It is our collective undoing."
Telephone or smartphone consultations, using apps such as Babylon, an AI application that provides accessible healthcare for millions via smartphone, are becoming less preferential, especially where older patients are concerned, because it's unfamiliar.
"General practice is open and 111 is open, but it's not going to be the same. A lot of it will be done and online and on telephone. Older people don't like telephone consultations because they're not familiar with it. For younger people, smartphones are there and you can have video links — GPs are getting better at it now. Not everybody needs examination and they can be sent for the appropriate scan or diagnostic process," explains Professor Sikora. This shift towards rapid-fire digital diagnosis could, in turn, save lives due to time being freed up for more serious cases. "They [GPs] can actually get more done in the morning with 80 per cent of their patients down the [phone] line and only 20 per cent catching up [in person]. Some patients will always have to be up to be examined.
Medical experts are urging the government and healthcare consultants to consider utilising the now-quiet Nightingale hospitals to prepare for an influx of late-stage cancer patients, with the country now already several steps behind other nations such as Germany or France.
"They seem to have more resilience in the system. They seem to have recovered the diagnostic pathways for cancer quickly, even in Wuhan. It's not just carrying on treating it, but carrying on the diagnosis of cancer," Professor Sikora explains. "It's probably a capacity issue. When you look at Europe – France and Germany, for example – and you look at us [UK] with scans, CT and MRI scans, we're way below that number of scans per million people. That's reflected in the fact that they continued to diagnose cancer and began to treat it, even at the peak of the [coronavirus] pandemic. We didn't. We just stopped everything.
Endoscopy, Professor Sikora explains, is perhaps the best example of UK health services under-delivering vital early-stage cancer diagnosis. "The estimate is that the number of endoscopies is running at under 10 per cent of what they should be, so that's a pretty frightening statistic. If it's not a service that's available anymore, then you're not going to get diagnosed."
So, what happens next? As 'lockdown' measures begin to ease in the UK, and a fraction of normal life begins to resume, patient psychology and pre-diagnosis procedure could improve, with both Matt Hancock, Secretary of State for Health and Social Care, and Chris Witty, Chief Medical Advisor for the UK Government, gaining a firmer grasp on what could be another perilous situation to face the country. Similarly, UK PM Boris Johnson has committed that anyone who needs urgent cancer care will receive it — but, if a so-called 'second wave' hits, an impending cancer crisis could soon be a reality.
It is our job then, as friends, fathers, sons, grandsons, partners, brothers, housemates and more to talk and to share. While the NHS begins to recover – fighting an unprecedented battle (and winning) – we can encourage others to visit the doctor, to book a video call with a GP or to share an uncomfortable conversation when the waters become troubled.
This could be a crucial stepping stone into getting an illness diagnosed early on. We all owe it to ourselves and to those we know.
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