The COVID-19 pandemic disrupted healthcare systems worldwide, and England’s National Health Service (NHS) was no exception. The unprecedented challenges posed by the virus necessitated measures such as lockdowns to curb its spread, but these actions also had far-reaching consequences for routine medical services. One area of significant concern was cancer care, where delays and cancellations became particularly alarming due to the time-sensitive nature of diagnosis and treatment. A recent study published in Social Science & Medicine (https://www.sciencedirect.com/science/article/pii/S0277953624004428) examines the ripple effects of these disruptions on cancer patients in England, providing a detailed look at how their care was impacted.
As the pandemic intensified in early 2020, the NHS was forced to reprioritise its resources to manage the influx of COVID-19 patients. This shift led to the postponement of elective surgeries and non-urgent medical appointments, both to free up hospital capacity and to protect patients and staff from potential exposure to the virus. Cancer care, despite being a critical service, was not immune to these disruptions. Although the NHS made concerted efforts to shield oncology services from the worst impacts, the scale of the crisis meant that delays and cancellations were inevitable for many patients.
For cancer patients, these interruptions were particularly distressing. Timely diagnosis and treatment are crucial in oncology, as even short delays can lead to disease progression and reduced chances of successful outcomes. Beyond the physical implications, the psychological toll was immense. The uncertainty surrounding rescheduled appointments and postponed treatments exacerbated feelings of anxiety and helplessness among patients and their families. The study’s findings shed light on how these challenges played out in real terms, revealing both the resilience and the vulnerabilities of the healthcare system during this unprecedented period.
The study focuses on two cohorts of cancer patients:
Pre-COVID cohort: Patients diagnosed with cancer between mid-2017 and early 2018 who had appointments cancelled during the same period in 2018.
COVID cohort: Patients diagnosed between mid-2019 and early 2020 who faced cancellations during the early months of the pandemic (March-May 2020).
Using detailed patient data from an electronic medical records database, the researchers compared outcomes between these two groups to evaluate the pandemic’s impact on healthcare utilisation and short-term survival. Cancelled appointments caused notable delays in care for the COVID cohort compared to the pre-COVID cohort. On average, patients in the COVID cohort waited an additional 19 days for their next appointment, representing a 55% increase over the pre-pandemic baseline. Figure 1 below highlights this gap. Kaplan-Meier survival curves tracking the time to the next appointment reveal that pre-COVID patients returned to care much faster than their counterparts impacted by the pandemic.
During the seven months following a cancelled appointment, patients in the COVID cohort used significantly fewer healthcare services compared to the pre-COVID cohort, reflecting a substantial disruption in care. Outpatient visits, for instance, dropped notably, with COVID cohort patients attending one fewer visit on average—a 14% reduction. This decline in outpatient engagement suggests that many patients faced challenges in accessing regular follow-up care, which is often critical for monitoring cancer progression and managing symptoms.
Inpatient admissions also showed a stark contrast. Patients in the COVID cohort experienced nearly two fewer hospital stays during this period, amounting to a 32% reduction. This trend could indicate both reduced availability of hospital resources during the pandemic and a hesitancy among patients to seek in-hospital care due to fears of contracting COVID-19.
The duration of hospital stays further underscores the disparity. When COVID cohort patients were admitted, their first inpatient stay was almost a full day shorter than that of the pre-COVID cohort, representing a 50% reduction. This abbreviated hospital time might reflect expedited discharges to minimise exposure risks or constraints on hospital capacity.
Notably, these reductions were observed across both general healthcare services and cancer-specific care, highlighting the pandemic’s widespread impact on the healthcare system. The diminished utilisation of services raises concerns about the long-term consequences for patient health, particularly for individuals requiring intensive monitoring and treatment for conditions like cancer. Figure 2 below illustrates these trends, showcasing the significant drop in healthcare engagement among the COVID cohort compared to their pre-COVID counterparts.
Surprisingly, the study found no statistically significant differences in short-term survival (up to 19.5 months) between the two cohorts. While Kaplan-Meier survival curves suggested slightly better survival rates for the COVID cohort, this advantage disappeared after adjusting for demographic and clinical factors. The absence of significant differences in mortality may reflect the prioritisation of patients with advanced or aggressive cancers during the pandemic. However, the study’s authors caution against complacency, noting that long-term impacts remain unknown.
The findings challenge the assumption that all delays in cancer care necessarily lead to poorer outcomes. Despite the disruptions observed, short-term survival rates among the COVID cohort remained comparable to those of the pre-COVID cohort. Several factors may explain this unexpected result. Firstly, oncologists may have prioritised the treatment of critical cases during the pandemic. Patients with advanced-stage cancers or those at higher risk of adverse outcomes might have received timely interventions despite the broader disruptions. This focused allocation of resources could have helped mitigate the potential negative effects of delayed appointments for the most vulnerable patients. Secondly, the study’s follow-up period was relatively short, spanning only up to 19.5 months after diagnosis. Cancer’s long-term prognosis often depends on extended monitoring and treatment, meaning the current findings may not fully capture the delayed impacts on survival. It is possible that any adverse effects of treatment postponements or reduced healthcare utilisation could manifest beyond this timeframe. Another plausible explanation is the substitution of care. Some patients may have accessed alternative forms of treatment outside of traditional hospital settings. For instance, primary care physicians might have taken on a greater role in managing cancer-related issues during the pandemic, or telemedicine consultations could have partially compensated for the reduction in in-person visits. Such adaptations may have helped offset some of the potential harm caused by delayed or cancelled appointments.
These insights underscore the complexity of healthcare delivery during a crisis. While the stability in short-term survival rates offers reassurance, it also highlights the importance of understanding the nuanced factors that influence patient outcomes during systemic disruptions. Further research is needed to explore the long-term implications and to evaluate how the healthcare system can better adapt to future challenges.
This study highlights the resilience of the NHS during a time of unprecedented strain but also draws attention to the vulnerabilities within the system. The ongoing challenges faced by the NHS, including workforce shortages and backlogs, make the lessons from the pandemic particularly urgent. Ensuring the protection of critical treatments such as cancer care should be a priority during any future crises. Safeguarding these essential services requires robust contingency planning and resource allocation to minimise disruptions and uphold patient outcomes. Expanding healthcare infrastructure is another crucial step. By increasing capacity, the NHS can better absorb surges in demand, reducing the need for service cancellations and delays during emergencies. Investments in infrastructure must be complemented by strategies to address workforce issues, ensuring that there are enough skilled professionals to meet patient needs even in challenging circumstances. Finally, there is a pressing need to monitor the long-term effects of the pandemic on cancer patients. While the study found no immediate decline in survival rates, the potential for delayed impacts remains a concern. Long-term research is essential to understand how disruptions in care during the pandemic might influence outcomes over time and to identify strategies for mitigating any adverse effects. These insights will not only strengthen the NHS’s ability to respond to future crises but also enhance its day-to-day operations in the years ahead.
The COVID-19 pandemic presented unprecedented challenges to cancer care in England. While the short-term survival rates of affected patients remained stable, the reduced healthcare utilisation raises concerns about potential long-term impacts. This study serves as both a reassurance and a warning—showing the NHS’s ability to adapt under pressure but also highlighting the need for systemic resilience in the face of future crises. The findings offer some comfort to patients and their families but also remind them to advocate for timely and uninterrupted care. This study, provides vital insights into the ripple effects of the pandemic on one of the NHS’s most vulnerable populations. Its lessons will resonate far beyond the pandemic, shaping the future of healthcare delivery in England and beyond.
Dr Catia Nicodemo
Dr Catia Nicodemo is a health economist and Associate Professor at the University of Oxford's Nuffield Department of Primary Care Health Sciences, Medical Division, and Professor at the University of Brunel London, Business Economics. Dr Nicodemo's research focuses on health policy, healthcare management, labour economics, and applied econometrics. She has published extensively on topics including immigration and healthcare, mental health, hospital admissions, and health inequalities.