COVID-19 has had an enormous impact on everyone’s daily lives in Scotland. Thousands of people have lost their lives or become seriously ill. It’s still not known how many people are suffering from ‘long COVID’, and how long their symptoms will last. But aside from these direct consequences, COVID-19 has had a serious impact on the ability of the NHS to deliver services. Many routine appointments and screening tests have been cancelled, and accident and emergency departments saw a big reduction in patients. This blog looks at how COVID-19 and resulting demands on the NHS have impacted on the other Big C, cancer.
The recently published SPICe policy briefing, Health Inequality and COVID-19 in Scotland, looks at how and why COVID-19 has had an uneven impact on many different groups of people across Scotland.
Cancer and inequality
Cancer does not affect all parts of the population equally. Some people are more likely to be diagnosed with, and die from, cancer than others. The reasons behind this are complex.
According to figures from Public Health Scotland, in the most deprived areas of Scotland, cancer incidence is 32% higher than in the least deprived areas. Cancer mortality in these areas is 74% higher than in the least deprived areas.
These stark differences between the most and least well-off areas mean that any negative effects on cancer care and treatment from the pandemic might affect the most deprived areas more, exacerbating existing inequalities.
Most routine cancer screening programmes and appointments were paused in March 2020. This was to reduce the risk of people contracting COVID-19 and to allow staff and resources to be redeployed to other COVID-19 related work in the NHS. Alongside this a growing number of people were choosing not to attend screening appointments, possibly because they were heeding government advice to stay at home, or because they were worried about catching the virus from visiting a hospital.
Cancer is also often detected through admissions to accident and emergency, often after emergency referral by a GP. For example, around a third of cancers in young people were detected after visiting A&E in 2015. A&E visits dropped dramatically during the first lockdown in Spring 2020. This was due to several factors. Reduced mobility resulting in fewer road accidents and fewer weekend admissions because pubs and clubs were closed are just two possible reasons for the fall in attendance. But it is also thought that some people were reluctant to attend their GP or hospital for fear of catching the virus, or thought that health services were closed. This could mean people who should have sought medical help for possible cancer were either not seeking it at all, or were seeking it later.
The charity Cancer Support Scotland has seen more people seeking help with later stage cancer than before the pandemic.
Full figures on cancer in Scotland during the pandemic won’t be available until 2022, but preliminary figures show that COVID-19 disruption has had a big impact on cancer detection. In 2019, around 40,000 new cancer patients were confirmed by pathological testing. In 2020, the equivalent number was around 33,000 new cancer diagnoses. The number of diagnoses doesn’t normally change this much year to year, so this means that in 2020 there may have been around 7000 missed cancer diagnoses. Surviving cancer is more likely the earlier it is detected and treated.
What about people who had already been diagnosed with cancer and were awaiting treatment or surgery? Disruption from COVID-19 has not just affected screening and testing. Many non-urgent treatments were cancelled or delayed in March 2020, and this included some cancer treatments.
Macmillan Cancer Support found that between April and June 2020, around 58% fewer patients commenced treatment following diagnosis by screening programmes, when compared to the average for the previous year.
Aside from later treatment resulting in lower survival rates, these delays could have negative mental health impacts on patients and their families by causing stress in what is already a very worrying time.
Another impact of COVID-19 on cancer care has been a change in the settings of cancer deaths. Since March 2020, more people have been dying from cancer at home instead of in hospital. National Records of Scotland figures show that by December 2020, around 1,200 fewer people than average had died in hospital from cancer, but 1,700 more than average had died from cancer at home. Being able to die at home is of course desirable for some people, but for others, hospital is a better option.
Getting back on track
So how are the Scottish Government and the NHS dealing with the backlog of screening and treatment?
The NHS began to restart paused cancer screening and treatment during the summer of 2020. The Remobilisation Plan set out what would restart and when, but with such a large backlog simply restarting services was not enough to make up for lost time. By the end of 2020, with 7,000 missed cancer patients, clearly more needed to be done. In December 2020, the Scottish Government published its Cancer Recovery Plan. This set out how cancer screening, treatment and care should be carried out from now until 2023. On 11 March 2021 when asked how the Government was dealing with the backlog, First Minister Nicola Sturgeon said:
…Under the cancer recovery plan, two new early cancer diagnostic centres are being established within existing NHS infrastructure by the spring of this year. A programme of prehabilitation is in place, which helps patients prepare for their treatment, and there is a new single point of contact for cancer patients to support them through the treatment journey.
It remains to be seen how the Cancer Recovery Plan will fare with the NHS remaining under pressure from COVID-19, and waiting lists for treatment higher now than before the pandemic. With cancer disproportionately affecting the most deprived people in Scotland, policy makers will need to consider how best to target support to reach those who need it most.
Researcher, Health and Social Care