>> SARS-CoV-2 not only has infectious consequences for health. A comprehensive literature analysis now addresses effects on malignant diseases1. There were also interviews with 17 decision-makers from the health sector. The work shows that there has been less cancer screening, fewer examinations for suspected cancer and fewer cancer diagnoses during the pandemic. This is due to the behavior of patients themselves, but also to declining capacities or other restrictions caused by Covid-19 (Fig. 1). The situation has now normalized somewhat and more healthcare services are available to patients. Nevertheless, there is an urgent need for action.
Delayed diagnosis:
Data from several EU nations
Background: Clear evidence of the effects of the pandemic on malignant diseases is now accumulating. For example, the World Health Organization (WHO) published results of a survey conducted in 2020. Experts found that cancer treatment was interrupted during the pandemic in more than 40 percent of all countries surveyed2. And analyzes from the Dutch cancer registry show cancer case numbers declining by up to 40 percent at the height of the pandemic3. In Slovenia, three national cancer screening programs have been temporarily suspended. There was also a significant decrease in the number of initial referrals and first outpatient visits to oncologists. The number of services also fell sharply for x-rays, mammograms and ultrasound examinations4.
The Spanish Society of Cardiology warns against fewer doctor-patient contacts and fewer interventional procedures in Covid-19 times5. Similar trends have been recorded by the Spanish Breast Cancer Federation - with fewer diagnoses, fewer consultations and fewer planned surgical procedures6. In France, oncologists tried to care for patients as before despite SARS-CoV-2. Nevertheless, there was an unprecedented decline across the entire service spectrum7. The French cancer society “La Ligue Contre le Cancer” expects an estimated 30,000 undetected cases of cancer as a result of the pandemic8.
Different malignant diseases – different consequences
For several types of cancer, including bowel cancer, oesophageal cancer, lung cancer, liver cancer, bladder cancer, pancreatic cancer, stomach cancer, larynx cancer and oropharyngeal cancer, British oncologists expect that a three-month delay in diagnosis is associated with a 10% lower 10-year survival rate9. Spanish oncologists believe that in some types of cancer such as lung cancer, which generally has one of the worst prognosis, the effect could be as high as 33.
A similar picture emerges in Austria, where the lockdown has led to fewer newly diagnosed gynecological cancers, including breast cancer. This is considered a major problem because many types of cancer are now considered potentially curable if diagnosed early11. Sobering analyzes also come from Italy. Experts expect more breast cancer in advanced stages in the near future - and with more chemotherapy, more radiation and more surgical procedures12.
Skin cancer is another worrisome malignancy in Covid-19
times, data from a Dutch cancer registry shows. Already in the first months of the pandemic there were significant drops in new diagnoses compared to the period before Covid-1913.
Sweden even suspended some health screenings during the height of the pandemic. For example, the number of mammography screenings decreased in 18 of 21 health regions14. And in Stockholm, the number of cancer diagnoses fell by 30 percent in April and May 2020, compared to the same period before the pandemic. Regional media reported another example. Doctors referred 50 percent fewer patients with suspected lung cancer to specialists than in previous years15.
Looking for causes
These trends observed across Europe are due to both problems in health systems and the fear of many laypeople. Interviews show that during periods of high SARS-CoV-2 infection, patients
Activity often avoided contact with doctors' offices or clinics. They were worried about becoming infected through contact with doctors. In Italy, there was even evidence that cancer patients downplayed symptoms to avoid seeing a doctor16. All this happened despite numerous campaigns by medical associations or ministries. Patients in Great Britain, on the other hand, did not make appointments for fear of overloading doctors or clinics.
Health systems in many countries have reduced services for the prevention or diagnosis of malignant diseases for various reasons. An example: The National Screening Service in Ireland stated that measures to protect staff and participants meant that fewer people could be screened during Covid-19 times than before17.
In many European countries, colon cancer and breast cancer prevention appears to be severely affected. Great Britain has therefore tried to make scheduling more flexible. In other words, patients were able to choose suitable appointments themselves. The procedure may disadvantage people who tend not to take the initiative on their own. Before Covid-19, they were allocated appointments.
Reduce the backlog:
This is how health systems react
But what happens next? There is now a silver lining on the horizon. Various vaccines have been approved. They work - albeit to different degrees - against the wild type and against newly emerging variants of SARS-CoV-2. As the vaccination campaigns have progressed, the seven-day incidence has decreased significantly in many European countries - and decision-makers are trying to use various strategies to reduce the treatment backlog for patients with malignant diseases (Fig. 2).
Doctors' practices and clinics are once again making more resources available for screenings. Sooner or later there will be a peak in newly diagnosed malignancies. Health systems should prepare for this soon. In the USA, for example, attempts are being made to make limited resources available for endoscopic examinations to patients with particularly high priority18. British health authorities plan to involve regional cancer centers more closely in patient care19. Local oncologists are also working on new protocols to give patients faster access to diagnostics and therapy.
In addition, communication plays an important role, as reported by the Netherlands Comprehensive Cancer Organization as a quality institute for oncological and palliative research and practice. She wants to encourage patients to visit their family doctor even in times of pandemic with offers tailored to the target group. And doctors, for their part, should not hesitate to refer sick people to an oncologist if they suspect it. Great Britain relies on its own campaigns20,
while doctors in Italy received structured information on lay communication. The idea of including community nurses and nurses alongside doctors in primary care comes from Great Britain21.
Other approaches include a more fundamental restructuring of primary care. This could, for example, involve organizations restructuring themselves at a local level - by classifying them for Covid-19 and other indications. In Great Britain there is also a proposal to use devices from secondary care in primary care. This saves time.
Strengths and weaknesses of modern technologies in oncology
Another peculiarity characterized the Covid-19 era. New technologies have gained immense importance since spring 2020. This includes doctor consultations via video or telephone, online tools for booking appointments in practices, but also social media. Such solutions have been around for a long time, but it was only Covid-19 that helped them achieve a breakthrough.
This does not mean that personal consultations are a thing of the past. Hybrid approaches with on-site contacts and digital tools will probably shape our future22. It would also be conceivable for patients to visit doctors in their practice, but if necessary, a family member would be connected digitally. In oncology, video consultations are only suitable for individual questions such as follow-up checks.
There are limits to this optimistic view. Some citizens do not have access to digital systems because they lack internet access, do not use computers or smartphones, or are overwhelmed by online interactions. This affects seniors more often than younger people. And not every doctor is well versed in modern online communication.
Solutions come from several EU countries. In Spain, volunteers help older people use these systems. And Bulgaria has partially offered doctors training in digital interactions.
Covid-19 as an opportunity for
Changes
Innovative technologies can do even more. Initial studies from Great Britain show advantages when prioritizing oncological patients, collecting data for health services research or introducing online appointment booking systems. The future will be shaped by better use of medical records, as is already the case in the Estonian patient portal. During digital screening, algorithms from the field of artificial intelligence recognize patterns in data that provide evidence of malignant diseases.
There are also some advantages in the transfer of knowledge. In the UK, world-class speakers from around the world were invited for Zoom meetings; They would hardly have had time to travel and present new research results on site. Scientific online congresses in all disciplines are also easier to access for participants - with less time expenditure and no travel or accommodation costs.
Knowledge is also an important aspect of lay communication. In recent months, many people have started to take an interest in health topics. This represents an opportunity to raise awareness among the population about routine examinations and check-ups.
Covid-19 has also presented the healthcare sector with a unique opportunity to restructure services, for example by increasing hospital capacity flexibility and becoming more patient-centric. Nobody should rest on their laurels. Doctors and hospitals must remain flexible for future challenges.
EU states in the fight against cancer: Strong alone – stronger together
The pandemic has also shown that diseases know no borders: an important idea not only for SARS-CoV-2. As part of the European Health Union, EU member states undertake to advance the diagnosis, treatment and prevention of chronic diseases such as cancer23. The goal is for medical services to be innovative and available to everyone.
The European plan to combat cancer specifies numerous measures. Health politicians want to ensure that all people at particular risk receive screenings for breast cancer, cervical cancer and colon cancer by 2025. But it is also about advancing research and implementing new technologies more than before. <<
by: Murray Aitken1 and Emma Moore2

1: Executive Director, IQVIA Institute for Human Data Science
2: Head of Market Research & Consultancy, IQVIA
German adaptation: Dr. Gisela Maag,
Press Spokesperson, IQVIA Germany
(Contact: [email protected])

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