Breast, bowel, lung and prostate cancer are the most common causes of cancer death in the UK. Screening programmes are effective in reducing death from cancer. However, due to the COVID-19 pandemic, many health systems postponed cancer screening and diagnostic tests, resulting in delays in diagnosis and treatment. Likewise, management of diagnosed cancer patients might have worsened. Delays in the diagnosis and continued assessment of cancer will undoubtedly impact the survival and quality of life of the population, as well as increase long-term health costs. Detection of the most affected populations may lead to improvements or developments of new health polices to diminish the impact of COVID-19 in outcomes related to cancer. The broad aim of this study is to examine the rates of cancer diagnosis, appointments, procedures, and death, following the COVID-19 pandemic compared to a time period before the pandemic, and to estimate the number of cancer diagnoses that were missed due to the reduction in screening programmes and tests carried out during the pandemic. We also aim to understand how lockdown impacted the incidence of specific treatments for breast and prostate cancer, and on the diagnosis of side effects of these treatments. For instance, some hormone therapies used in the treatment of breast and prostate cancer can lead to bone loss. We aim to investigate the rate of diagnosis of secondary diseases such as osteoporosis before and after lockdown, and the possibility that such diagnoses may have been missed due to poorer treatment evaluation during the pandemic.
The overall aim is to understand whether healthcare utilisation, cancer-related screening programmes and diagnostic tests, prevalence and incidence of four cancers, endocrine treatments, treatment-related diagnoses, and cancer-related mortality were affected by COVID-19 lockdown; and whether rates have normalised to pre-pandemic levels.
Study Design: Cohort Study
Population: All patients registered in CPRD GOLD between 01.01.2017 to the latest date of data capture with >=1-year prior history will be eligible. Data will be mapped to the Observational Medical Outcomes Partnership Common Data Model.
Variables: Cancer diagnoses (breast, colorectal, lung and prostate), endocrine treatments, and treatment-related diagnoses (osteopenia, osteoporosis, bone fracture). Endocrine therapies for breast/prostate cancer and anti-osteoporotic treatments (bisphosphonates, Denosumab). Death using mortality data from ONS, region and socio-economic status from the Practice/Patient Level Index of Multiple Deprivation.
Analyses: Objective 1: characterisations of healthcare utilisation; Objectives 2 & 5: prevalence/ incidence of cancer, and treatment-related diagnoses; incidence of screening/diagnostic tests; Objective 3: Time-series analyses; Objective 4: characterisations of diagnosed patients; Objective 6: survival analysis, Cox proportional hazards models with propensity-score matching. All study outcomes will be evaluated before/after COVID-19 lockdown/extended periods.
This project will enable us to determine whether screening programmes and diagnostic tests, critical in the diagnosis of the four most common cancers in the UK, have returned to pre-pandemic levels, and whether some procedures/tests have been more affected by the lockdown period for some cancers than others. This may highlight the need to expedite provision of screening and diagnostic procedures for those most affected. Furthermore, this project will allow us to determine whether patients received more endocrine treatments (as bridging therapy), and whether they have fared worse in terms of the management of treatment-related side effects, allowing us to determine whether there is a need to better allocate resources to patients at higher risk for complications.
Primary Outcomes: Diagnosis of primary malignant breast cancer; colorectal cancer; lung cancer; prostate cancer.
Secondary Outcomes: Prescriptions of aromatase inhibitors, aromatase inhibitors with GnRH agonists or antagonists, Tamoxifen, and Tamoxifen with GnRH agonists or antagonists in breast cancer patients; and first-generation androgen deprivation therapies, GnRH agonists, GnRH agonists with first generation androgen deprivation therapy, GnRH antagonists, and second-generation androgen deprivation therapies in prostate cancer patients. Diagnosis of osteopenia, osteoporosis or bone fracture; prescriptions of anti-osteoporotic treatments (bisphosphonates or denosumab); healthcare utilisation (screening appointments, diagnostic tests, GP consultations including both face to face and remote [phone/online]), procedures and measurements; death.
Marta Pineda Moncusi - Chief Investigator - University of Oxford
Nicola Barclay - Corresponding Applicant - University of Oxford
Annika Jodicke - Collaborator - University of Oxford
Antonella Delmestri - Collaborator - University of Oxford
Daniel Prieto-Alhambra - Collaborator - University of Oxford
Danielle Newby - Collaborator - University of Oxford
Martí Català Sabaté - Collaborator - University of Oxford
Wai Yi Man - Collaborator - University of Oxford
Xihang Chen - Collaborator - University of Oxford
Wai Yi Man - Collaborator - University of Oxford
HES Admitted Patient Care;HES Outpatient;ONS Death Registration Data;Patient Level Index of Multiple Deprivation