Lung cancer recovery focus post pandemic: an income-deprived area paradigm

Discussion

The two groups demonstrated comparable demographic characteristics with respect to age, gender and WHO performance status. The lung cancer services experienced a substantial surge in the source of referrals from inpatient healthcare teams, whereas a reduction in the use of the 2WW pathway was observed. These findings might not be surprising given the considerable impact of the COVID-19 pandemic. Although strict measures taken by the UK Government saw positive effects with respect to controlling the dissemination of the COVID-19 infection, they might have had a deleterious impact on the diagnostic pathways of significant medical conditions. Protocols, including postponement and triaging of clinical visits as per their presumed severity, have the propensity to result in missed diagnoses or clinical suspicion. Public fears of COVID-19 transmission further accentuate this, because patients with symptoms might express reluctance to enter healthcare settings. Various studies have published findings indicating a reduction in the incidence of malignancies since the start of the pandemic and subsequent lockdown.^12–16 The reduction in referrals from the primary care setting has led to significant concerns of delayed presentations potentially leading to further advanced disease and negative outcomes. Furthermore, Ellis-Brookes et al described how the late presentation of cancer can lead to a late diagnosis and, thus, lower survival rates in the first year after diagnosis.⁴

Lai et al predicted substantial mortality for patients with malignancy because of the impediments in the cancer pathway.⁹ With respect to the increase in inpatient referrals, the pandemic led to an increase in inpatient admissions owing to considerable respiratory compromise and appreciable virulence of the COVID-19 infection. As a result of the frequent use of cross-sectional imaging, pulmonary malignancies might also be detected. Another consideration is the severity of COVID-19 infections in patients with a concomitant lung cancer, because this cohort is at risk of higher morbidity and mortality and, thus, is more likely to be admitted to hospital. The Thoracic Cancers International COVID-19 Collaboration (TERAVOLT) registry indicated that 76% of patients with lung cancer and a COVID-19 infection required admission to hospital.¹⁷ Furthermore, some patients might have undiagnosed lung cancers that increase their susceptibility and severity of a COVID-19 infection.^18,19

The most frequent setting of initial reviews during the COVID-19 pandemic was on inpatient wards, as expected, in contrast to the outpatient clinic settings observed during the previous year. A systematic review conducted by Riera et al identified factors contributing to delays and disruptions to cancer healthcare during the pandemic. Provider/system-related explanations included COVID-19 risk reduction strategies, personnel shortages and concerns regarding service availability.²⁰ Ranganathan et al published findings from a cohort study further evaluating the disruption to healthcare services and reported a 54% reduction in the number of new patients registered with cancer centres along with a 46% reduction in follow-up visits.²¹ Naidich et al reported a decrease in the volume of outpatient imaging in 2020 (327,738 examinations) compared with 2019 (440,314 examinations).²² Unfortunately, because of inherent limitations of the study acknowledged by the authors, specific details categorised by individual imaging modalities were not ascertained. Despite the aforementioned challenges in outpatient service availability, national healthcare organisations strived to maintain cancer diagnostic services at an optimal level right from the start of the pandemic.

With respect to staging, there were few discrepancies in the WHO and TNM distributions across the three groups. TNM M1 and WHO stage IV were at ∼50% across all groups. This is particularly relevant, because these findings potentially testify to the efficacy of the protocols implemented in cancer services during the pandemic. The prominent concerns during the initial stages of the pandemic were delayed diagnoses and potentially advanced progression at later presentation; however, these findings indicate that primary care and cancer services adapted to the logistical impediments of the pandemic and determined diagnostic strategies to enable them to perform at a similar level to the pre-pandemic period. Another possible explanation could be the previously known numbers of ‘late presenters’ in our area of interest. In the NHS Long Term Plan,²³ late presentation associated with an advanced stage of lung cancer can reach 50% of cases, whereas, in our area, this number was closer to 75%, and has been associated with income deprivation and lack of patient engagement with healthcare services. Unfortunately, these confounders have remained unchanged during the pandemic and it is likely those ‘late presenters’ in our area would not engage early even if there was no pandemic. This highlights two important points. First, looking to identify a potential ‘stage shift’ as a sole indicator to assess the impact of the pandemic in similarly income-deprived areas might be inappropriate, because it does not reflect the entirety of the challenges and access issues that this population faces, even during non-pandemic times, which affects treatment pathways and subsequently outcomes.²⁴ Second, because of the above, it is now evident that a targeted national lung cancer screening programme is a necessity to significantly reduce access inequalities in such areas.

Treatment approaches exhibited similarities across the groups, with a palliative approach being the more prevalent strategy, likely because of a large proportion of the patients presenting with metastatic disease. Chemotherapy and radiotherapy were used less, although a few patients during the COVID-19 pandemic started treatment with chemoradiotherapy. This was initially thought to be because of reduced access to curative surgery; however, in our analysis, there was an increase in surgery during the pandemic. Research has indicated that, with proper precautionary measures, a high volume of surgeries can be safely carried out even in a pandemic.²⁵ However, it important to consider the current burden on intensive care units because highly invasive and complex thoracic surgery might necessitate a period of intensive monitoring during recovery.

Although some of the findings of the study are reassuring, we acknowledge that there are several limitations given its retrospective observational nature and because it was a single-centre analysis. Certain demographic information would have not been initially collated and, thus, unknown confounders will be present. Furthermore, matching between groups was not carried out, although baseline demographics were comparable. Stratification into homogenous subgroups was not conducted because of concerns of reduced power to detect effect change. Performance bias will be inevitably present given the difficulties associated with the pandemic that would have made a standardised exposure/process across the three groups unfeasible. Information bias is also inherent in retrospective studies, although the outcome variables were all collated in the same way. Furthermore, there is limited generalisability of the results, because the data were collated from a single centre. However, other income-deprived areas in England experience the same challenges in lung cancer care and, thus, it would be interesting to know the experiences and outcomes of other centres serving similar populations.

One would argue that, to strengthen our findings further, we must also provide survival data. Given that most of our patients from the group diagnosed during COVID-19 are still receiving treatment, such data are not currently available and will be collected as they become available.

Our study is the first to report real-world data specifically from an income-deprived area in England regarding the true effect of COVID-19 on lung cancer diagnosis, staging and treatment. Although small and retrospective, it provides a strong signal that COVID-19 has negatively affected lung cancer care in this income-deprived area, highlighting the need for not only cancer recovery plans in similar areas, but, more importantly, also a nationwide lung cancer screening programme.