Cancer treatment delays during the pandemic

The Staff at National Health Service in UK are doing an admirable job during the pandemic. In the particular, the frontline staff (“patient-facing”) are showing great courage in face of great difficulties and are primarily driven by altruism.

But the pressures of pandemic means many routine scans and hospital clinic appointments have been cancelled particularly during the first wave. There is a great worry about delayed diagnosis of cancer and delayed treatment of cancer.

A paper in BMJ reports that cancer patients survival can be significantly compromised.

But, as with everything else in life, things are not always what they look like at first impression. Even things that are logical and common sense at first glance do not turn out to be simple and clear.

Firstly, delays and cancellations of scans paradoxically could have psychologically benefited some cancer patients . This might seem counterintuitive or even an outrageous statement.

But there are some cancers which are being over diagnosed. A Cancer diagnosis does not always mean a death sentence. Some cancers do not cause problems for a long time or never in the life time of a person. These cancers do not need to be diagnosed promptly. Not being diagnosed with these cancers prevents the psychological burden of a cancer diagnosis. This “over diagnosis” would be expectedly less during pandemic.

Secondly, treatment delays could be caused by a cancer that is advanced and the need for time consuming additional investigations and procedures. Sometimes delays are caused by patients needing to see many medical specialists for the treatment. So it’s the aggressive cancer and the complex patient care that would cause the delay and is responsible for poor outcome rather than the delay by itself.

Read the BMJ article and make your views known.

Mortality due to cancer treatment delay: systematic review and meta-analysis
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4087 (Published 04 November 2020)
Cite this as: BMJ 2020;371:m4087

Overdiagnosis in Cancer
H. Gilbert Welch, William C. Black
JNCI: Journal of the National Cancer Institute, Volume 102, Issue 9, 5 May 2010, Pages 605–613, https://doi.org/10.1093/jnci/djq099

Disparities in head and neck cancer: assessing delay in treatment initiation
Urjeet A Patel et al. Laryngoscope. 2012 Aug.

Khorana AA, Tullio K, Elson P, Pennell NA, Grobmyer SR, Kalady MF, et al. (2019) . Time to initial cancer treatment in the United States and association with survival over time: An observational study. PLoS ONE 14(4): e0215108. doi:10.1371/journal.pone.0215108

Does intensive follow benefit Bowel cancer patients?

Photo by rawpixel.com on Pexels.com

The old adage “prevention is better than cure” is mostly true with regards to cancer if you can do it.

If you can’t prevent it , at least catch it early, has been the prime motive behind screening tests for breast, cervical, bowel, lung and prostate cancers. (“early is better”). Cancers that are detected at an early stage can offer a better chance of curative treatment.

So one might logically expect that intensive monitoring and early diagnosis of a cancer relapse or a secondary cancer after initial treatment can be immensely helpful.

But the evidence for intensive hospital follow-up visits and investigations is weak for most cancers except for some cancers such as Testicular Cancers which are highly curable.

Intensive monitoring after bowel cancer treatment can detect treatable cancers. To confirm the benefit of early detection of relapse by intensive monitoring , a trial was conducted comparing intensive follow up versus routine follow up ( in France and Belgium).

Data presented at ESMO ( European Society of Medical Oncology) shows that the intensive follow with scans can detect cancer recurrences which can be treated by further surgery. But unfortunately the intensive follow up did NOT lead to longer life expectancy.

The results might be counterintuitive but after an average follow up more than six years, this trial demonstrates that intensive follow is NOT always best. Scans might be done for psychological reassurance but they could end up causing significant anxiety.

When there are resource constraints (e.g low economic countries) , one has to be careful about frequents routine scans for those without symptoms.

During COVID-19, even in rich countries such as UK where there might be huge waiting lists, one has to consider prioritising scans for those who need most.

References

1. ESMO Daily reporter: INTENSIVE FOLLOW-UP INCREASES FREQUENCY OF CURATIVE INTENT SECONDARY SURGERY IN COLORECTAL CANCER.

2. DRE is useless for follow up of prostate cancer patients. https://www.bmj.com/rapid-response/2011/11/03/dre-useless-follow-prostate-cancer-patients

3. Cancer patients follow up and a new role for GPs. https://www.bmj.com/rapid-response/2011/11/03/cancer-patients-follow-and-new-role-gps

Disclaimer: Please note- This blog is NOT medical advice. This blog is purely for information only and do check the the sources where cited. Please consult your own doctor to discuss concerns and options relevant to you.

The views expressed in this blog represent the author’s views held at the time of drafting the blog and is likely to change overtime, particularly when new evidence comes to light. The blog is not necessarily endorsed by any organisation the author is associated with and views are not substitute for professional advice.

Cancer and COVID-19

Cancer patients, as expected, did badly during the 1st wave of the COVID-19 pandemic

Data presented at ESMO ( European Society of Medical Oncology) shows that Cancers had – higher rates of Hospitalisation, higher risk of Complications and increased risk of Death.

Elderly cancer patients on the whole did very badly but surprisingly cancer patients under age of 50 did far worse than their peers without cancer.

Disclaimer: Please note- This blog is NOT medical advice. This blog is purely for information only and do check the the sources where cited. Please consult your own doctor to discuss concerns and options relevant to you.

The views expressed in this blog represent the author’s views held at the time of drafting the blog and is likely to change overtime, particularly when new evidence comes to light. The blog is not necessarily endorsed by any organisation the author is associated with and views are not substitute for professional advice.

Are Routine blood tests essential during follow up of low grade Lymphoma?

Bloods tests have the potential to pick up various abnormalities including cancer related abnormalities during follow up of cancers.

But , many patients would be surprised to know that there is ongoing debate about usefulness of routine blood tests atleast in some cancers !

In a recent study, Australian investigators assessed the role of routine blood tests during monitoring of patients with low grade lymphoma.

They found that routine blood tests rarely found or detected disease progression in patients who did not have any symptoms.

References

Routine Blood Tests in Asymptomatic Patients With Indolent Lymphoma Have Limited Ability to Detect Clinically Significant Disease Progression. DOI: 10.1200/JOP.19.00771 JCO Oncology Practice – published online before print June 25, 2020. PMID: 32584701

Effectiveness of Routine Blood Testing in Detection of Disease During Active Surveillance for Indolent Non-Hodgkin Lymphoma. By Matthew Stenger. Posted: 7/16/2020 1:40:00 PM . Last Updated: 7/29/2020 1:59:00 PM

Utility of Routine Surveillance Laboratory Testing in Detecting Relapse in Patients With Classic Hodgkin Lymphoma in First Remission: Results From a Large Single-Institution Study. DOI: 10.1200/JOP.19.00733 JCO Oncology Practice – published online before print May 5, 2020. PMID: 32369413

Disclaimer: Please note- This blog is NOT medical advice. This blog is purely for information only and do check the the sources where cited. Please consult your own doctor to discuss concerns and options relevant to you.

The views expressed in this blog represent the author’s views held at the time of publication and is likely to change overtime, particularly when new evidence comes to light. The blog is not necessarily endorsed by any organisation the author is associated with and views are not substitute for professional advice.