The impact of the COVID-19 pandemic on radiotherapy services in England, UK: a population-based study
Summary
Background
The indirect impact of the COVID-19 pandemic on cancer outcomes is of increasing concern. However, the extent to which key treatment modalities have been affected is unclear. We aimed to assess the impact of the pandemic on radiotherapy activity in England.
Methods
In this population-based study, data relating to all radiotherapy delivered for cancer in the English NHS, between Feb 4, 2019, and June 28, 2020, were extracted from the National Radiotherapy Dataset. Changes in mean weekly radiotherapy courses, attendances (reflecting fractions), and fractionation patterns following the start of the UK lockdown were compared with corresponding months in 2019 overall, for specific diagnoses, and across age groups. The significance of changes in radiotherapy activity during lockdown was examined using interrupted time-series (ITS) analysis.
Findings
In 2020, mean weekly radiotherapy courses fell by 19·9% in April, 6·2% in May, and 11·6% in June compared with corresponding months in 2019. A relatively greater fall was observed for attendances (29·1% in April, 31·4% in May, and 31·5% in June). These changes were significant on ITS analysis (p<0·0001). A greater reduction in treatment courses between 2019 and 2020 was seen for patients aged 70 years or older compared with those aged younger than 70 years (34·4% vs 7·3% in April). By diagnosis, the largest reduction from 2019 to 2020 in treatment courses was for prostate cancer (77·0% in April) and non-melanoma skin cancer (72·4% in April). Conversely, radiotherapy courses in April, 2020, compared with April, 2019, increased by 41·2% in oesophageal cancer, 64·2% in bladder cancer, and 36·3% in rectal cancer. Increased use of ultra-hypofractionated (26 Gy in five fractions) breast radiotherapy as a percentage of all courses (0·2% in April, 2019, to 60·6% in April, 2020; ITS p<0·0001) contributed to the substantial reduction in attendances.
Interpretation
Radiotherapy activity fell significantly, but use of hypofractionated regimens rapidly increased in the English NHS during the first peak of the COVID-19 pandemic. An increase in treatments for some cancers suggests that radiotherapy compensated for reduced surgical activity. These data will assist health-care providers in understanding the indirect consequences of the pandemic and the role of radiotherapy services in minimising these consequences.
Funding
None.
Introduction
Similar steps were taken by health-care providers globally.
In WHO global pulse survey, 90% of countries report disruptions to essential health services since COVID-19 pandemic.
- Borras JM
- Lievens Y
- Dunscombe P
- et al.
At the outset of the pandemic, all three treatment modalities were affected by constraints on COVID-19 testing and staff shortages. Surgical services faced additional pressure as a consequence of the adaptation of theatre space for the care of acutely unwell patients requiring ventilation.
COVID-19 rapid guideline: delivery of radiotherapy.
,
Coronavirus (COVID-19): cancer treatment documents.
Within these site-specific guidelines, suggestions included treatment omission or delay, the use of radiotherapy to replace or to bridge to surgery, and the wider use of short, high daily dose (hypofractionated) radiotherapy.
Coronavirus (COVID-19): cancer treatment documents.
Evidence before this study
The indirect consequences of the COVID-19 pandemic on the care of patients with cancer are of concern. However, the extent to which radiotherapy services were affected is unclear. To identify studies reporting on changes in radiotherapy activity during the COVID-19 pandemic, we searched PubMed for articles published in English between Jan 1 and Oct 1, 2020, using the search terms (“cancer” or “malignancy”) AND (“radiation therapy” OR “radiotherapy”) AND (“COVID-19” OR “coronavirus” OR “SARS-CoV-2”). So far, only analyses of radiotherapy activity across single or small numbers of centres, or larger survey-based studies assessing changes to radiotherapy practice have been undertaken. These studies are at risk of responder bias and are not sufficiently comprehensive to detail changes in radiotherapy activity or prescriptions for individual cancers, or to quantify how these have varied as the pandemic has progressed.
Added value of this study
To our knowledge, this is the first comprehensive, nationwide analysis of radiotherapy activity during the first wave of the COVID-19 pandemic, from national lockdown on March 23 to June 28, 2020. We show an overall decrease in radiotherapy activity in the English National Health Service over this period. This decline is predominantly attributable to a reduction in treatments for prostate and non-melanoma skin cancer—malignancies for which there is evidence for the safety of treatment delay. By contrast, treatments for oesophageal, bladder, and rectal cancers markedly increased. We also demonstrate an increase in the use of hypofractionated regimens. Radiotherapy activity remained suppressed up to June, 2020, which might reflect delays in cancer diagnostic pathways.
Implications of all the available evidence
Although radiotherapy activity decreased during the first wave of the pandemic, our data suggest that the overall impact of this decline is likely to be modest. In addition, radiotherapy appears to have mitigated against some of the indirect harms of the pandemic by maintaining curative treatment options despite the challenges facing surgical services. As COVID-19 cases again rise, these data are crucial for modelling indirect harms of the pandemic and establish a new baseline for radiotherapy treatments from which to plan for the ongoing delivery of care throughout subsequent pandemic waves and into the recovery beyond. They also reinforce the need to address any persisting delays in cancer diagnostic pathways.
- Martinez D
- Sarria GJ
- Wakefield D
- et al.
,
COVID-19’s impact on radiation oncology. Initial results of a nationwide physician survey, 5/20/20.
,
- Slotman BJ
- Lievens Y
- Poortmans P
- et al.
These studies are at risk of responder bias, have limited information about individual cancers and regimen use, and are not able to quantify longitudinal changes during the pandemic. In the absence of this information, the indirect harms of the pandemic cannot be accurately modelled. Such data are also required by service providers, commissioners, and clinicians to mitigate against these indirect consequences. Mitigation measures include identifying cohorts of patients for whom treatment has been modified and who as a consequence might require tailored clinical follow-up, and establishing a new baseline for radiotherapy treatment patterns from which planning for future waves and for the longer-term recovery of cancer services can be developed.
National Radiotherapy Dataset (RTDS).
This dataset contains information on more than 135 000 courses of radiotherapy delivered across the English NHS each year. In this study, we used the RTDS to explore changes in radiotherapy activity during the first peak in COVID-19 cases.
Results
Table 1Mean weekly courses and attendances in the months before and after the start of the first UK lockdown on March 23, 2020
Observed weekly mean, weekly mean adjusted for missing data with SD, and percentage change compared with corresponding month of 2019.
Figure 1Courses (A) and attendances (B) of radiotherapy delivered within the English NHS over the year preceding and period following the first UK lockdown for the COVID-19 pandemic
The dashed line indicates the beginning of the lockdown on March 23, 2020. ITS=interrupted time series. NHS=National Health Service.
Table 2Mean weekly number of radical episodes and attendances by month by diagnosis
Observed weekly mean, weekly mean adjusted for missing data with SD, and percentage change compared with the corresponding month in 2019 based on adjusted data are presented. Where diagnoses including small numbers of courses are considered, the adjustment for missing data must be interpreted with caution.
Figure 2Bubble plot showing the change in fractionation patterns over time for courses delivered with curative intent for a range of diagnoses
Diagnoses are presented in descending order of total number of courses. The size of the bubble reflects the number of treatments delivered using the specified fractionation category.
Figure 2Bubble plot showing the change in fractionation patterns over time for courses delivered with curative intent for a range of diagnoses
Diagnoses are presented in descending order of total number of courses. The size of the bubble reflects the number of treatments delivered using the specified fractionation category.
Figure 3Change in fractionation patterns delivered for breast cancer across the English NHS before and after the first UK lockdown
Model predictions (lines) of the use of differing regimens for the adjuvant treatment of breast cancer with observed weekly courses (dots). The dashed line indicates the beginning of the lockdown on March 23, 2020. ITS=interrupted time series. NHS=National Health Service.
The proportion of palliative treatment courses delivered using a single fraction rose from a weekly mean of 223 (39·3%) of 568 (SD 37) in April, 2019, to 233 (50%) of 463 (62) in April, 2020, with a corresponding fall in treatments delivered using more than five fractions over the same period (125 [22·0%] of 568 [37] to 74 [16·0%] of 463 [62]).
Discussion
We have shown that the number of patients receiving radiotherapy in the English NHS fell significantly during the first wave of the COVID-19 pandemic. When compared with a year previously, a 20% reduction in radiotherapy courses was seen in April, 2020, immediately after the beginning of the UK national lockdown. Recovery was not complete by June, 2020 (12% reduction), despite the easing of lockdown and decrease in number of NHS inpatients with COVID-19. We project that compared with the same period a year previously (March 23 to June 28, 2019), 3263 fewer treatment courses were delivered with 119 050 fewer treatment attendances across the English NHS. The disproportionately greater fall in treatment attendances largely reflects a rapid increase in the use of ultra- hypofractionated treatment regimens across several tumour sites.
COVID-19’s impact on radiation oncology. Initial results of a nationwide physician survey, 5/20/20.
,
- Slotman BJ
- Lievens Y
- Poortmans P
- et al.
An approximate 25% reduction in patient volume was, for example, reported for centres in Europe, including the UK, with patient volume in the USA predicted to be a third lower. By contrast, at 8%, the reported median reduction in patient volume in Latin America is far more modest than observed in the UK.
- Martinez D
- Sarria GJ
- Wakefield D
- et al.
COVID-19 rapid guideline: delivery of radiotherapy.
,
Coronavirus (COVID-19): cancer treatment documents.
A key concern at the time related to the potential for hospitals to act as a reservoir for SARS-CoV-2,
- Yu J
- Ouyang W
- Chua MLK
- Xie C
and for a potentially heightened risk from COVID-19 for patients with cancer, particularly in those aged 70 years or older.
- Williamson EJ
- Walker AJ
- Bhaskaran K
- et al.
Reflecting this concern, many guidelines advocated the deferral of treatment if it was safe to do so, or if the potential risks of treatment outweighed the benefits.
- Zaorsky NG
- Yu JB
- McBride SM
- et al.
,
- Pisansky TM
- Hunt D
- Gomella LG
- et al.
The extent to which evidence supports treatment delays in non-melanoma skin cancer is less well defined, although for small basal cell carcinomas delay is unlikely to change the likelihood of cure.
- Kwan W
- Wilson D
- Moravan V
Additionally, a differential effect of age on treatment delivery was seen in breast cancer, potentially reflecting altered clinical decision making based on an assessment of risk and informed by the results of the PRIME-II trial.
- Kunkler IH
- Williams LJ
- Jack WJL
- Cameron DA
- Dixon JM
Similarly, specific concerns for adverse COVID-19 outcomes in patients with lung cancer might have contributed to the reduction in 2 Gy per fraction treatments (often delivered with concurrent chemotherapy) in favour of mild-to-moderate hypofractionation.
- Sud A
- Jones ME
- Broggio J
- et al.
,
- Lai AG
- Pasea L
- Banerjee A
- et al.
However, these studies have not taken into account the use of radiotherapy in place of surgery, as shown here. Equally, although equipoise exists between radiotherapy and surgery for the treatment of bladder cancer and oesophageal squamous cell carcinoma, surgery is superior in oesophageal adenocarcinoma.
- Huddart RA
- Birtle A
- Maynard L
- et al.
,
- Crosby T
- Hurt CN
- Falk S
- et al.
For rectal cancer, radiotherapy offers a mechanism to support delayed surgery with the potential for a substantial minority to avoid resection entirely. One immediate consequence of this shift in treatment patterns should be an urgent review of post-treatment surveillance protocols to ensure that patients who received an alternative treatment approach, and for whom cancer recurs can, where appropriate, be swiftly identified and referred for salvage resection. In the long-term, analysis of the outcomes of patients who have undergone radiotherapy in place of surgery, for reasons unrelated to their individual baseline condition, could provide valuable comparative data in settings in which randomisation between surgery and radiotherapy has historically been challenging.
- Huddart RA
- Birtle A
- Maynard L
- et al.
- Brunt AM
- Haviland JS
- Wheatley DA
- et al.
,
- Coles C
- Aristei C
- Bliss J
- et al.
In this context, the decision in March, 2020, to move away from a per-attendance tariff for national radiotherapy commissioning is likely to have supported providers in rapidly adopting this new evidence base.
In addition, as a UK-wide study, the experience of delivering these quality-assured hypofractionated regimens within a trial setting will likely have aided its rapid implementation.
- Brunt AM
- Haviland JS
- Wheatley DA
- et al.
These changes show that, at least for some indications, the pandemic has beneficially catalysed the adoption of a new evidence base.
- Spencer K
- Parrish R
- Barton R
- Henry A
Government updates.
Consistent with this finding, there was limited change in compliance with the 31-day treatment targets in radiotherapy, which remained above 95% throughout the study period.
Cancer waiting times.
The time between diagnosis and commencing treatment might have limited the effect of the pandemic in May (compared with April and June), as previously diagnosed patients began their treatment. These results reinforce concerns about the effect of the COVID-19 pandemic on cancer diagnostic pathways and, in turn, outcomes.
- Maringe C
- Spicer J
- Morris M
- et al.
,
- Sud A
- Torr B
- Jones ME
- et al.
This will require examination in the future, once complete cancer registration data are available.
- Lewis PJ
- Morris EJA
- Chan CSK
- Darley K
- Sebag-Montefiore D
- Evans M
Radiotherapy activity in the English NHS fell significantly during the first wave of the COVID-19 pandemic. This decrease occurred predominantly in cancers for which treatment can be safely delayed and through the use of hypofractionation. By contrast, increased activity in specific diagnoses suggests that radiotherapy was used to compensate for reduced surgical activity. Overall, the effect on cancer outcomes of changes in radiotherapy activity during the first pandemic peak is likely to be modest, and an increase in radiotherapy use might have helped to mitigate against the loss of surgical capacity. However, the continued suppression in radiotherapy activity up to June, 2020, supports an urgent need to restore diagnostic pathways.
KS led study design, analysed data, developed figures, interpreted data, and developed the initial manuscript draft. CMJ contributed to study design and figure development, interpreted data, and contributed to the writing of the manuscript. RG, CR, MS, and SL contributed to study design; data extraction, verification, and interpretation; and writing of the manuscript. RS contributed to study design and data analysis, interpreted the data, and reviewed the manuscript. LM contributed to the study design, data extraction, and figure development, and reviewed the final manuscript. PL, ME, DS-M, and TR contributed to the interpretation of the results and development of the manuscript. EM contributed to the study design, data analysis and interpretation, and development of the manuscript. All authors had full access to all of the data extracted from PHE, and the corresponding author had final responsibility for the decision to submit for publication.
We declare no competing interests.