Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study
Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study
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DOI：
10.1016/s1470-2045(20)30392-2
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发表时间：
2020-08-01
期刊：
影响因子：
51.1
通讯作者：
Turnbull, Clare
中科院分区：
文献类型：
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作者：
Sud, Amit;Torr, Bethany;Turnbull, Clare
背景在新冠肺炎封锁期间，据报道，在英国英格兰，通过等待2周的紧急途径转诊疑似癌症的患者减少了高达84%。我们的目的是研究癌症转诊中锁定累积积压的不同情景对癌症生存率的影响，以及由于延迟转诊而对每个转诊患者的生存率的影响与因严重急性呼吸综合征冠状病毒2医院感染而死亡的风险。方法在这项模拟研究中，我们使用了英国公共卫生组织2008-17年间诊断的20种常见肿瘤类型的年龄分层和分期分层的10年癌症生存估计，年龄在30岁及以上。我们还使用了2013-16年通过2周等待转诊路径进行的癌症诊断数据，这些数据来自NHS Digital的癌症等待时间系统。我们应用了从延迟到治疗的观察性研究产生的癌症进展的每天风险比(HRs)。我们使用2周等待年龄和阶段特定细分，量化了通过2周等待路径诊断的I-III期癌症的年度数量。根据这些数字，我们估计了在英国，由于每个患者在表现、诊断或癌症治疗方面延迟1-6个月，或者这些因素的组合，导致的生命和生命年损失的总数。我们评估了三种情况，在3个月的封闭期内，25%、50%和75%的有症状的患者将他们的表现推迟到封闭期之后。使用转诊到诊断的转换率和新冠肺炎的病死率，我们还估计了每个转诊患者的生存增量。2013-16年间，整个英格兰平均有6,281名I-III期癌症患者通过2周等待路径被诊断出来，其中1,691人(27%)将被预测在10年内死于他们的疾病。在三个月的禁闭期内通过两周的等待途径提交报告(每名患者平均报告延迟2个月)将导致额外181个生命和3316个生命年，这是由于25%的积压转介，50%的积压转介导致额外的361个生命和6632个生命年，以及75%的积压的转介导致额外的542个生命和9948个生命年的损失。与在锁定后的第一个月对积压进行的所有诊断相比，由于25%积压的情况下的诊断延迟，跨1-3个月的额外容量将导致额外的90个寿命和1662个寿命年的损失，在50%的积压方案下的183个额外寿命和3362个寿命年的损失，以及在75%的积压方案下的276个额外寿命和5075个寿命年的损失。然而，由于在25%积压的情况下由于诊断延误而导致的额外诊断能力的延迟，在锁定后的3-8个月中，由于诊断延迟，额外的诊断能力将导致401个额外的生命和733个2个寿命年的损失，在50%的积压的情况下，将导致811个额外的生命和14 873个生命年的损失，而在75%的积压的情况下，将导致1231个额外的生命和22 635个生命年的损失。等待两周的调查性转诊延迟两个月，估计损失在0.0至0之间。每个转诊患者7个生命年，取决于年龄和肿瘤类型。口译提示提供额外的能力来处理积压的诊断将最大限度地减少由于诊断延迟而造成的死亡，这可能会增加由于预期的表现延迟而预测的死亡。对延误将导致大多数寿命年损失的患者群体进行优先排序，值得考虑将其作为减轻癌症患者死亡总负担的一种选择。版权所有(C)2020爱思唯尔有限公司。保留所有权利。
Background During the COVID-19 lockdown, referrals via the 2-week-wait urgent pathway for suspected cancer in England, UK, are reported to have decreased by up to 84%. We aimed to examine the impact of different scenarios of lockdown-accumulated backlog in cancer referrals on cancer survival, and the impact on survival per referred patient due to delayed referral versus risk of death from nosocomial infection with severe acute respiratory syndrome coronavirus 2.Methods In this modelling study, we used age-stratified and stage-stratified 10-year cancer survival estimates for patients in England, UK, for 20 common tumour types diagnosed in 2008-17 at age 30 years and older from Public Health England. We also used data for cancer diagnoses made via the 2-week-wait referral pathway in 2013-16 from the Cancer Waiting Times system from NHS Digital. We applied per-day hazard ratios (HRs) for cancer progression that we generated from observational studies of delay to treatment. We quantified the annual numbers of cancers at stage I-III diagnosed via the 2-week-wait pathway using 2-week-wait age-specific and stage-specific breakdowns. From these numbers, we estimated the aggregate number of lives and life-years lost in England for per-patient delays of 1-6 months in presentation, diagnosis, or cancer treatment, or a combination of these. We assessed three scenarios of a 3-month period of lockdown during which 25%, 50%, and 75% of the normal monthly volumes of symptomatic patients delayed their presentation until after lockdown. Using referral-to-diagnosis conversion rates and COVID-19 case-fatality rates, we also estimated the survival increment per patient referred.Findings Across England in 2013-16, an average of 6281 patients with stage I-III cancer were diagnosed via the 2-week-wait pathway per month, of whom 1691 (27%) would be predicted to die within 10 years from their disease. Delays in presentation via the 2-week-wait pathway over a 3-month lockdown period (with an average presentational delay of 2 months per patient) would result in 181 additional lives and 3316 life-years lost as a result of a backlog of referrals of 25%, 361 additional lives and 6632 life-years lost for a 50% backlog of referrals, and 542 additional lives and 9948 life-years lost for a 75% backlog in referrals. Compared with all diagnostics for the backlog being done in month 1 after lockdown, additional capacity across months 1-3 would result in 90 additional lives and 1662 live-years lost due to diagnostic delays for the 25% backlog scenario, 183 additional lives and 3362 life-years lost under the 50% backlog scenario, and 276 additional lives and 5075 life-years lost under the 75% backlog scenario. However, a delay in additional diagnostic capacity with provision spread across months 3-8 after lockdown would result in 401 additional lives and 733 2 life-years lost due to diagnostic delays under the 25% backlog scenario, 811 additional lives and 14 873 life-years lost under the 50% backlog scenario, and 1231 additional lives and 22 635 life-years lost under the 75% backlog scenario. A 2-month delay in 2-week-wait investigatory referrals results in an estimated loss of between 0.0 and 0. 7 life-years per referred patient, depending on age and tumour type.Interpretation Prompt provision of additional capacity to address the backlog of diagnostics will minimise deaths as a result of diagnostic delays that could add to those predicted due to expected presentational delays. Prioritisation of patient groups for whom delay would result in most life-years lost warrants consideration as an option for mitigating the aggregate burden of mortality in patients with cancer. Copyright (C) 2020 Elsevier Ltd. All rights reserved.