The authors of the new JAMA Network Open paper say their findings show how vital early detection of cancer can be, while also highlighting the importance of considering unintended side effects in any future pandemic planning.

Co-lead author Dr Kaustubh Adhikari (UCL Genetics, Evolution & Environment and The Open University) said: “When lockdowns were introduced as a much-needed measure to stop the spread of Covid-19, there were extensive unintended consequences. Many screenings were cancelled and medical treatments were delayed.

“As many people missed appointments to detect or treat skin cancer, their cancer progressed to a later stage, which resulted in more expensive care and a greater risk that the treatment would not be successful.

“It’s alarming that for just one disease, there were many years of life lost, a lower quality of life for many thousands of people, and billions of pounds of economic impact – this may be just the tip of the iceberg of the consequences of delayed diagnosis and treatment due to lockdowns. While the lockdowns did save many lives by mitigating the toll of Covid-19 itself, it is important that we learn from the experience to ensure that if another pandemic arises, we can effectively balance different healthcare priorities.”

The team of researchers, from the UK, Switzerland, Germany, US, Italy, Australia and Hungary, were investigating the health economic consequences of delays in diagnosing melanoma, a common type of skin cancer and one of the 10 most common cancers in Europe. The analysis was based on information from 50,072 patients of two cancer treatment centres in Switzerland and Italy, supported by further data from the UK and Belgium.

The researchers estimated how many people’s cancer would have progressed from one stage to the next due to delays in beginning or continuing treatment, as both screening services and treatments were disrupted in 2020 and 2021 due to lockdown restrictions, staff shortages, and fear of infection. They estimated that for roughly 17% of people with melanoma, their cancer would have progressed to a higher stage in 2020-2021, due to delays in diagnosis or treatment of two to three months or longer.

The research team then estimated the additional medical costs, as treating later-stage cancer is more expensive and comes with a lower chance of success. These cost estimates included both the direct costs to healthcare providers (such as the NHS), as well as the broader impacts such as the loss of productivity (indirect costs) due to disability and years of life lost.

The researchers estimated that delays to melanoma diagnoses contributed to 111,464 years of life lost across 31 countries in Europe, with a total economic cost of £6.1bn (€7.1bn or $7.7bn USD). Most of the costs (94.5%) were indirect costs such as loss of productivity.

Co-lead author Dr Elisabeth Roider (University Hospital of Basel) said: “Our findings show that preventative healthcare always needs to be a top priority, both in normal times and in times of crisis; any plans for potential future pandemics need to consider unintended side effects on a wide range of health conditions and plan holistically.

“Delays to diagnosis and treatment can be devastating to people affected by cancer, so getting prompt evaluation and treatment is vital for people concerned about their health, while screening programmes need to be treated as a priority by healthcare system leaders.”

The research was supported by the Research Foundation of the University of Basel, the ProPatient Foundation, University Basel, the Goldschmidt Jacobson Foundation, and the Swiss National Science Foundation.

The UK Government has today (March 1^st) published its response to the consultation on whether or not covid-19 vaccination should continue to be a condition of deployment in health and social care.

The consultation was conduct via an online survey hosted on gov.uk from 9 to 16 February 2022, and over 90,000 responses were submitted. Of these 90% supported revoking the requirement and only 9% opposed this proposal. Amongst the general public some 96% supported the revocation. In addition, the majority of respondents (70%) thought there were no other steps that the Government and health and social care sectors could take to increase vaccine uptake.

The Government acknowledged that the pandemic landscape has changed noting that, “The latest scientific evidence shows that the Omicron variant, relative to Delta, is intrinsically less severe and that a full primary course of an approved vaccine does not provide the intended longer-term public health protection against the spread of covid-19.”

In light of this evidence and the responses received as part of the consultation the Government plans to bring forward to March 15^th regulations to revoke vaccination as a condition of deployment. This is intended to provide a measure of continuity for employers and staff, ahead of the April 1st deadline when unvaccinated staff might otherwise have been facing termination of employment.

In official terms – the regulations will revoke the requirements that CQC registered persons only permit those who are vaccinated against COVID-19, unless otherwise exempt, to be deployed for the provision of a CQC-regulated activity in health and/or social care, and to enter CQC registered care home premises.

It is often the case that the people at the coal face can see clearly what is going on and are best placed to advise on what to do.

About 10 days ago a group of 66 expert medical generalists wrote an open letter to Secretary of State for Health, Matt Hancock. In the letter they argue that whilst a lockdown was justified in the early stages of the pandemic when little was known about the virus, the position is different now and a further lockdown now risks harms to long-term health and well-being that outweigh the benefits.

They say, “We are concerned due to mounting data and real-world experience, that the one-track response threatens more lives and livelihoods than Covid-lives saved.”

They point out that 30,260 excess deaths have occurred in private homes since March but fewer than 1 in 10 of these was due to covid-19. There has also been an increase in acute cardiovascular deaths, most of which did not relate to covid-19.

In addition, there is a signal that child suicide death rates in the UK increased during lockdown and contributing factors appeared to include restriction to education and other activities, disruption to care and support services, tensions at home and isolation.

Finally, the older, ‘shielded’, people with multiple long-term health conditions – the very group that restrictions were intended to protect – experienced higher levels of depression, anxiety and loneliness compared with those who were not shielding and were more likely to be less physically active than usual.

The authors of the letter make a plea for ongoing restrictions and infection control measures to be balanced against “the myriad harms, both logged and latent”.

They close by saying “Covid deaths alone can no longer be used as the unilateral measure of harm. Public health goes beyond deaths and ICU beds.” Adding, “the wider harm to babies, children, young people and adults of all ages can no longer be ignored”.

Although there is a relentless focus on death rates in the media it is perhaps worth reminding ourselves that the number of deaths registered in the UK in Week 40 was 11,444 of which 343 involved coronavirus. The number of deaths due to all causes was 591 deaths higher than the five-year average.  Future analyses will tell whether this was due to late diagnoses or missed treatments for other treatable conditions.

The Care Quality Commission report, The state of health care and adult social care in England 2019/20, published 15^th October 2020 includes a detailed description of the impact of the pandemic on healthcare including details of reductions in referrals and delays in treatment.

The CQC noted that, “The impact of COVID-19 on the NHS in terms of elective, diagnostic and screening work has been enormous. Some life-changing operations have still not been rescheduled and there are people whose cancer has not been diagnosed or treated. As we enter a second wave, there must be learning to ensure that non-COVID-19 patients are not left behind.”

There are many similarities between the approach described in the Great Barrington Declaration and the ‘middle path’ advocated by the World Health Organisation (WHO). In an interview for Spectator TV Professor David Nabarro, WHO special envoy for covid-19, describes this as, “holding the virus at bay whilst keeping economic and social life going”. Such an approach is potentially achievable but will be challenging, he acknowledges.  In order to be successful it will require a robust scheme for infectious disease control, including testing, contact tracing and isolation. This needs to work in tandem with general measures – physical distancing, face protection, hand hygiene, self-isolation of infected cases and protection of those most at risk, he explains. Local actors need to be involved as much as possible, as local knowledge enables more effective responses to localised spikes of infection.  Thirdly, everyone needs to be “onside” and “all pulling together”.  This involves providing people with accurate information so that they have a good understanding of the issues and the measures that need to be implemented. It is an approach that is working well in East Asia, Germany and parts of Canada, he says.

Lockdowns

“Lockdown should not be used as the primary control measure”, says Professor Nabarro. Lockdown serves only one purpose and that is to stop everything to provide a “breathing space” that should be used for rebalancing or reorganising the overall response or building up track and trace systems, he adds. In addition to the damaging social and economic consequences for local communities, lockdowns have far-reaching effects; reductions in the volumes of trade and tourism can have disastrous effects for some poorer countries. The WHO anticipates a doubling in world poverty and childhood malnutrition by next year as a result of these effects. “Lockdowns have one consequence that you must never, ever belittle – that is, making poor people an awful lot poorer”, he said.  Local, integrated responses would be preferable to lockdowns because they are more likely to bring about effective control and are far less damaging.

In the UK, data from the Office for National Statistics show that lockdowns have been almost completely ineffective at limiting the spread of infection with SARS-Cov-2, indeed case numbers actually rose spectacularly after the introduction of lockdowns.  Leicester was the one notable exception – something that Professor Nabarro attributes to strong local engagement and an integrated approach.

Public Health England’s weekly covid surveillance reports show that by week 39 (week ending 27t h September) restaurants accounted for some four percent of incidents (confirmed outbreaks with two or more cases linked to a particular setting); far greater numbers of outbreaks were associated with care homes, educational settings and workplaces. In spite of this information, hospitality venues are now the targets of stringent lockdown measures.

Further support for the’ middle path’ comes from a recent independent modelling study which shows that a combination of case isolation, household quarantining and social distancing of the over-70s is more effective than general social distancing (for reducing deaths) and that, perhaps counter-intuitively, adding school and university closures to the other measures actually results in a greater number of deaths.¹

The two approaches described, ‘focused protection’ and ‘the middle way’ are broadly similar. They should both reduce harm (from disease) to the vulnerable and reduce economic and social harm to those at little risk from the disease. They go hand-in-hand with clear, honest, accurate public health messaging about levels of risk and the measures required to minimise the risks.

References

1.Rice K, Wynne B, Martin V, Ackland GJ. Effect of school closures on mortality from coronavirus disease 2019: old and new predictions. BMJ 2020;371:m3588