Thousands of patients may have undiagnosed and untreated bowel cancer due to COVID-19 disruption

A new study led by the University of Oxford has found that since the first coronavirus lockdown the number of people diagnosed with bowel cancer in England has fallen sharply, with a deficit persisting up to October 2020.

Between April and October 2020, over 3,500 fewer patients than expected were diagnosed with bowel cancer in England. Since bowel cancer is more likely to be curable if it is detected at an early stage, these results suggest that many patients, whose diagnosis has yet to be made, may die unnecessarily. The results are published today in The Lancet Gastroenterology & Hepatology.

The research was carried out by a team of clinicians and academic researchers from across the UK, including from the University of Leeds and the University of Newcastle. They assessed the patterns of referral for bowel cancer investigation, diagnosis and treatment within the English NHS from 1 January 2019 to 31 October 2020.

The results showed that, compared with an average month in 2019, during April 2020 at the peak of the first wave of coronavirus:

• the monthly number of referrals by GPs to hospital clinics for investigation of possible bowel cancer reduced by 63% (from 36,274 to 13,440);
• the number of colonoscopies performed fell by 92% (from 46,441 to 3,484); and
• the monthly number of people with confirmed bowel cancer referred for treatment fell by 22% (from 2,781 to 2,158), and the number of operations performed fell by 31% from (2,003 to 1,378).

This is the first study to assess the impact of the COVID-19 pandemic on the diagnosis and management of bowel cancer across England.

‘These results reflect serious disruption in the normal identification and treatment of patients with bowel cancer,’ said lead author of the study Professor Eva Morris from the Nuffield Department of Population Health, University of Oxford. ‘Early diagnosis is key to obtaining the best survival for bowel cancer so these delays in diagnosis are likely to have severe consequences on survival rates from the disease.’ Over 90% of patients diagnosed with bowel cancer at Stage I of the disease survive for at least five years, compared with only 10% of patients diagnosed at Stage IV.

Keith Dawber is someone who has been directly affected. He experienced a change in his bowel habit in March 2020 but his GP surgery was closed and he had to wait until June to speak to his doctor over the telephone. He said, ‘My symptoms started at a really bad time as I couldn’t speak to my GP straightaway and as the months went by, I was seeing more blood in my stool. In June I was able to speak to my doctor who referred me for further testing and, in August 2020, I was diagnosed with stage 3 bowel cancer. I had surgery followed by chemotherapy, which I finished on Christmas Eve. I’m now waiting for a scan to see if I need further treatment.’

Professor Sir Mike Richards, a trustee of Cancer Research UK, said, ‘Far fewer patients with symptoms suggestive of bowel cancer were referred to hospital during the first wave of the pandemic. This may have been linked to fear about catching the virus and to the government’s call to ’stay at home’ and ‘protect the NHS’. Diagnoses and treatments were therefore delayed, with a likely adverse impact on cancer survival.’

The study also shows that the first lockdown had a short-term impact on the numbers of people being treated. Reassuringly, the NHS managed to rapidly adapt services to deliver care safely. Unfortunately, however, treatment rates had only just returned to normal by October and, with the pressure the NHS is currently under as a result of the second surge of COVID-19 cases, it seems likely that diagnostic and treatment rates may have fallen again. The researchers are continuing to monitor these figures to inform decisions about treatment and help ensure that the issue of undetected and untreated bowel cancer in England is addressed.

Brian Nicholson, a GP involved in the study, said, ‘This study shows that during the pandemic the NHS has changed pathways to create capacity to ensure they can still treat patients with bowel cancer rapidly. Hospital services and GPs have taken care to develop safer ways of working to reduce the risk of infection. If people have symptoms like altered bowel habit or blood in their poo that may suggest bowel cancer, they must talk to their GPs as soon as possible as early diagnosis saves lives. We need to get this message out there.’

Chris Cunningham, a colorectal surgeon, said, ‘Although in the first wave of the pandemic rates of surgery fell this study shows we rapidly adapted services, in line with guidance, to restore care. Unfortunately, this new surge in COVID-19 cases is now hitting surgical capacity again and so we need urgent action to balance resources between treating COVID-19 and cancer to ensure the number of avoidable deaths is kept at a minimum.’

David Sebag-Montefiore, Professor of Clinical Oncology at the University of Leeds and Leeds Teaching Hospitals NHS Trust, and Director of the Leeds Cancer Research UK Radiotherapy Research Centre of Excellence said, ‘Radiotherapy treatment has continued during COVID-19 for cancer patients, and has adapted to minimise the risk of coronavirus transmission. For instance, during the first wave of COVID-19 there was a fourfold increase in the use of a shorter, higher dose one-week course of radiotherapy for bowel cancer patients, instead of a five-week course of radiotherapy and chemotherapy. The use of a shorter course of radiotherapy ensured patients received effective treatment that minimised the risk of COVID-19 infection, an approach recommended by international COVID-19 radiotherapy guidelines.’

Genevieve Edwards, Chief Executive at Bowel Cancer UK, said, ‘This research shows the clear impact of the pandemic on bowel cancer patients, and ultimately, their long-term chances of survival. It also highlights the unintended consequences of the ‘stay at home’ message and the impact of the temporary disruption to bowel cancer screening and diagnostic services. Sadly, for many, that will have meant a later diagnosis and poorer outcomes as a result. NHS staff have worked incredibly hard to keep vital cancer services going, and the NHS continues to be open for anyone worried about symptoms. But it needs additional resources to withstand the pressures caused by the new variant coronavirus sweeping the country, or cancer services – and the patients that rely on them – will suffer in the months ahead.’