we are only beginning to understand the impact of the pandemic on patients with cancer, from diagnosis to treatments and end-of-life care.
kelly walker, an elementary school teacher in toronto, had a stem cell transplant in february 2020 as part of her cancer treatments. she was released from hospital weeks later to isolate at home and was soon joined by nearly everyone else in the city as covid-19 restrictions took hold. since then, kelly’s experience of cancer care has been deeply impacted by the pandemic, influenced by waves of community transmission, stresses on our health system and the public health decisions of our governments.
kelly, who has myelodysplastic syndrome, a form of blood cancer, told me she felt “very fortunate to be supported,” throughout her on-going chemotherapy. “not every cancer patient has that and those are the people i worry about,” she said.
the words fortunate and lucky often come up as kelly and i discuss our cancer treatments. although we were both able to receive our diagnoses and care on time, we live with the grim knowledge that canada’s over-burdened health system has not been able to meet the needs of all cancer patients.
in fact, our country may be on the brink of a second epidemic – a cascade of cancers that went undetected for the past two years as patients were unable to seek the primary care they would normally receive.
it was early in the course of the pandemic that projections began emerging around the concept of “deaths secondary to covid,” a term to describe people who died from cancer or other diseases that could have been cured if the pandemic had not stressed health systems. risk factors for secondary loss include delayed cancer detection; delays in surgery or other treatments; and poor management of treatment side effects.
focusing on early diagnosis of breast, colorectal, esophageal and lung cancers, a group of u.k. researchers estimated that diagnostic delays would lead to nearly 4,000 deaths within five years there. in a 2020 research review in the bmj, the researchers estimated, conservatively, that a surgical delay of 12 weeks for all patients with breast cancer for one year would lead to 1,400 excess deaths in the u.k. and 700 in canada.
alex broom and colleagues warned in a november 2020 editorial in clinical cancer research that “little emphasis has been placed on the … consequences of covid-19 for how cancer care (itself) is delivered.”
information is now coming in about secondary deaths and pandemic-related stage migration, where an undetected cancer becomes more severe due to lack of diagnosis or care. in may, ontario’s science advisory table reported a more than 12 per cent increase in deaths in canada, a number exceeding the number of deaths directly related to covid: “the subsequent increase in mortality due to non-covid-19 causes could reflect the impact of delays in care for conditions other than covid-19, including cancer.” in spain, a retrospective study of lung cancer diagnosis found 38 per cent fewer lung cancer cases were diagnosed during the pandemic, with patients seeking initial care with more advanced stages of cancer. a study of 799,496 patients in the u.s. found a 29.8 per cent decline of new diagnoses for eight types of cancer in the first wave, with a 19.1 per cent decrease in diagnoses in the third wave.
as data has trickled in, so have anecdotal accounts – and they are alarming. sheila singh, a pediatric neurosurgeon at mcmaster children’s hospital in hamilton recently spoke to the cbc about an uptick of advanced cancers in children at her hospital due to delays in diagnosis. “i feel like i’ve been practicing in a third world country,” she said. “i have seen disease that has spread so far that it’s almost like cases i’ve read about in rural india. it’s been quite difficult and alarming.”
singh’s experience reflects that of several toronto-based er doctors.
“anecdotally, it seems as though we are seeing more cancers being diagnosed in the emergency department,” keerat grewal, an emergency physician at sinai health and research fellow at the schwartz/reisman emergency medicine institute, told me. “not only do we think we may see this with cancer, but other conditions such as heart disease and stroke.”
she noted a report in the canadian medical association journal showing that the cancer screening backlog continued to increase even up until december 2020.
“we know that delays often result in worse outcomes for patients,” grewal said. “we need to ensure that the backlog of screening and delays are addressed and that we plan appropriately for future cancer care.”
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