Healthcare in England was affected by the COVID-19 pandemic across the pancreatic cancer pathway: A cohort study using OpenSAFELY-TPP
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Curated by eLife
eLife assessment
This study provides useful information on the impact of the pandemic on the quantity of healthcare delivered to patients with pancreatic cancer in England. The authors showed that there was no difference in the number of diagnoses of pancreatic cancer during the pandemic compared to the preceding 5-year period, but a reduction in surgical resections by nearly 25%. They reported no difference in deaths between the two periods. They show no differences in rates of diagnosis, but the clinical relevance is incomplete as they have not compared survival from cancer between those time periods.
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Abstract
Healthcare across all sectors, in the UK and globally, was negatively affected by the COVID-19 pandemic. We analysed healthcare services delivered to people with pancreatic cancer from January 2015 to March 2023 to investigate the effect of the COVID-19 pandemic.
Methods:
With the approval of NHS England, and drawing from a nationally representative OpenSAFELY-TPP dataset of 24 million patients (over 40% of the English population), we undertook a cohort study of people diagnosed with pancreatic cancer. We queried electronic healthcare records for information on the provision of healthcare services across the pancreatic cancer pathway. To estimate the effect of the COVID-19 pandemic, we predicted the rates of healthcare services if the pandemic had not happened. We used generalised linear models and the pre-pandemic data from January 2015 to February 2020 to predict rates in March 2020 to March 2023. The 95% confidence intervals of the predicted values were used to estimate the significance of the difference between the predicted and observed rates.
Results:
The rate of pancreatic cancer and diabetes diagnoses in the cohort was not affected by the pandemic. There were 26,840 people diagnosed with pancreatic cancer from January 2015 to March 2023. The mean age at diagnosis was 72 (±11 SD), 48% of people were female, 95% were of White ethnicity, and 40% were diagnosed with diabetes. We found a reduction in surgical resections by 25–28% during the pandemic. In addition, 20%, 10%, and 4% fewer people received body mass index, glycated haemoglobin, and liver function tests, respectively, before they were diagnosed with pancreatic cancer. There was no impact of the pandemic on the number of people making contact with primary care, but the number of contacts increased on average by 1–2 per person amongst those who made contact. Reporting of jaundice decreased by 28%, but recovered within 12 months into the pandemic. Emergency department visits, hospital admissions, and deaths were not affected.
Conclusions:
The pandemic affected healthcare in England across the pancreatic cancer pathway. Positive lessons could be learnt from the services that were resilient and those that recovered quickly. The reductions in healthcare experienced by people with cancer have the potential to lead to worse outcomes. Current efforts should focus on addressing the unmet needs of people with cancer.
Funding:
This work was jointly funded by the Wellcome Trust (222097/Z/20/Z); MRC (MR/V015757/1, MC_PC-20059, MR/W016729/1); NIHR (NIHR135559, COV-LT2-0073), and Health Data Research UK (HDRUK2021.000, 2021.0157). This work was funded by Medical Research Council (MRC) grant reference MR/W021390/1 as part of the postdoctoral fellowship awarded to AL and undertaken at the Bennett Institute, University of Oxford. The views expressed are those of the authors and not necessarily those of the NIHR, NHS England, UK Health Security Agency (UKHSA), or the Department of Health and Social Care. Funders had no role in the study design, collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
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Author Response
Review #1 Public Review:
This is an interesting study which attempts to assess the effect of the pandemic on diagnoses of pancreatic cancer. The authors have used a large national database to evaluate this, however, it should be noted that this database only captures 40% of the population in England. The authors have looked at specific parameters including Body Mass Index (BMI) as well as markers of diabetes and liver function. Only BMI had a difference in the frequency of measurements during the pandemic, presumably due to reduced face-to-face visits to allow weight and height to be captured.
Interestingly the authors noticed a reduction in surgery for pancreatic cancer by 25%, yet reported that there were no differences in the frequency of death within 6 months following the diagnosis of pancreatic cancer. The …
Author Response
Review #1 Public Review:
This is an interesting study which attempts to assess the effect of the pandemic on diagnoses of pancreatic cancer. The authors have used a large national database to evaluate this, however, it should be noted that this database only captures 40% of the population in England. The authors have looked at specific parameters including Body Mass Index (BMI) as well as markers of diabetes and liver function. Only BMI had a difference in the frequency of measurements during the pandemic, presumably due to reduced face-to-face visits to allow weight and height to be captured.
Interestingly the authors noticed a reduction in surgery for pancreatic cancer by 25%, yet reported that there were no differences in the frequency of death within 6 months following the diagnosis of pancreatic cancer. The reduction in surgery is likely related at least in part to the loss of operating lists due to pandemic restrictions, however, this paper is not equipped to address another important possibility behind this, which is that pancreatic cancers were presenting too late for surgical intervention. It is not sufficient to comment that pancreatic cancer treatment was not affected by the pandemic based on the data presented on deaths within 6 months of the diagnosis of pancreatic cancer alone, as the median survival of patients diagnosed with pancreatic cancer within the pandemic has not been captured and compared to that of patients diagnosed in the preceding 5 years.
Therefore while the study can conclude no difference in pancreatic cancer diagnoses before and during the pandemic, more work needs to be done to truly assess if the pandemic had any effect on the outcomes from pancreatic cancer for patients diagnosed within this timeframe.
Thank you for taking time to undertake the review and for all the constructive comments. This study was designed to assess the effect of the pandemic on pancreatic cancer services in England. We focused on the quantity of healthcare.
We acknowledge and understand the comments by the reviewer with regards to the limitations of this study in relation to the effect of the COVID-19 pandemic on diagnosis and survival. We did not assess the effect of the pandemic on the staging information and survival length.
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eLife assessment
This study provides useful information on the impact of the pandemic on the quantity of healthcare delivered to patients with pancreatic cancer in England. The authors showed that there was no difference in the number of diagnoses of pancreatic cancer during the pandemic compared to the preceding 5-year period, but a reduction in surgical resections by nearly 25%. They reported no difference in deaths between the two periods. They show no differences in rates of diagnosis, but the clinical relevance is incomplete as they have not compared survival from cancer between those time periods.
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Review #1 Public Review:
This is an interesting study which attempts to assess the effect of the pandemic on diagnoses of pancreatic cancer. The authors have used a large national database to evaluate this, however, it should be noted that this database only captures 40% of the population in England. The authors have looked at specific parameters including Body Mass Index (BMI) as well as markers of diabetes and liver function. Only BMI had a difference in the frequency of measurements during the pandemic, presumably due to reduced face-to-face visits to allow weight and height to be captured.
Interestingly the authors noticed a reduction in surgery for pancreatic cancer by 25%, yet reported that there were no differences in the frequency of death within 6 months following the diagnosis of pancreatic cancer. The reduction in surgery is …
Review #1 Public Review:
This is an interesting study which attempts to assess the effect of the pandemic on diagnoses of pancreatic cancer. The authors have used a large national database to evaluate this, however, it should be noted that this database only captures 40% of the population in England. The authors have looked at specific parameters including Body Mass Index (BMI) as well as markers of diabetes and liver function. Only BMI had a difference in the frequency of measurements during the pandemic, presumably due to reduced face-to-face visits to allow weight and height to be captured.
Interestingly the authors noticed a reduction in surgery for pancreatic cancer by 25%, yet reported that there were no differences in the frequency of death within 6 months following the diagnosis of pancreatic cancer. The reduction in surgery is likely related at least in part to the loss of operating lists due to pandemic restrictions, however, this paper is not equipped to address another important possibility behind this, which is that pancreatic cancers were presenting too late for surgical intervention. It is not sufficient to comment that pancreatic cancer treatment was not affected by the pandemic based on the data presented on deaths within 6 months of the diagnosis of pancreatic cancer alone, as the median survival of patients diagnosed with pancreatic cancer within the pandemic has not been captured and compared to that of patients diagnosed in the preceding 5 years.
Therefore while the study can conclude no difference in pancreatic cancer diagnoses before and during the pandemic, more work needs to be done to truly assess if the pandemic had any effect on the outcomes from pancreatic cancer for patients diagnosed within this timeframe.
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