Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 3  |  Page : 70-73

Comparison of cancer waiting time targets in urology, pre-COVID era, and during the COVID era – A single-center experience


1 Department of Urology, North Devon District Hospital, Manchester, UK
2 Department of Paediatric Urology, Royal Manchester Children Hospital, Manchester, UK
3 Department of Urology, Stoke Mandeville Hospital NHS Trust, Buckinghamshire, UK

Date of Submission24-Oct-2021
Date of Acceptance07-Nov-2021
Date of Web Publication12-Jan-2023

Correspondence Address:
Muhammad Faisal Khan
North Devon District Hospital NHS Trust, Raleigh Park, Barnstaple, EX31 4JB
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_44_21

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  Abstract 


Objectives: The objective of this study is to measure the impact of COVID-19 pandemic on treatment targets for urgent urology cases in our hospital and compare it with previous research publications. Materials and Methods: We retrospectively collected and analyzed data over 10 months for 2 consecutive years. The data were analyzed from April to October in 2019 and 2020. This includes all suspected cancer. We collected a total number of referrals, time to the first consultation, and time of first definitive treatment. Results: The total number of patients referred in 2019 pre-COVID was 478 as compared to 278 in the subsequent year at the time of the first wave of COVID-19 pandemic. A total number of 118 cancers were detected in 2019 which makes up 24.6% of the total patients referred. Forty-one patients received treatment >62 days. This is 41 (34.7%) of the cancers or 8.5% of the referrals. Similarly, 60 patients were detected with cancer in 2020 making up 22.2% of the total referrals. Nineteen patients received treatment >62 days. This equates to 31.6% of the cancers or 7% of the total referrals. Conclusion: During the COVID-19 pandemic peak, though we did see a slight improvement in the total number of patients breached for their targeted dates of cancer treatment, this is largely due to the significant reduction of around 44% in the total number of referrals. This data also strengthens other large studies for other cancers which show a significantly lower number of patients being referred for cancer diagnosis.

Keywords: COVID-19, delayed treatment, urology cancers


How to cite this article:
Khan MF, Silva LK, Tsampoukas G, Iyer S, Spellar K. Comparison of cancer waiting time targets in urology, pre-COVID era, and during the COVID era – A single-center experience. Hellenic Urology 2021;33:70-3

How to cite this URL:
Khan MF, Silva LK, Tsampoukas G, Iyer S, Spellar K. Comparison of cancer waiting time targets in urology, pre-COVID era, and during the COVID era – A single-center experience. Hellenic Urology [serial online] 2021 [cited 2023 Jan 27];33:70-3. Available from: http://www.hellenicurologyjournal.com/text.asp?2021/33/3/70/367694




  Introduction Top


The year 2020 unified and divided the world with a single stroke, COVID-19 pandemic.

The whole world remained focused on COVID-19 pandemic and other issues were pushed deep down in the priority list. This raised concerns, especially in the medical world about the catastrophe that will unfold once the storm will settle. One paper raised concerns about the possibility of significant increase in the number of avoidable cancer deaths in England as a result of diagnostic delays due to the COVID-19 pandemic.[1]

We decided to look at the cancer management pre-COVID and during the first wave of COVID-19 pandemic in the department of urology within our trust. The idea is that it will not only give us a true picture of our services, but it will also help us design strategies for future, we also want to contribute to the world as more data means a better understanding for the future.


  Materials and Methods Top


We collected referral data from the cancer pathway coordinators for a period between April–October in 2019 and the equivalent period in 2020 to get a direct comparison. The data for all the suspected cancer patients are stored within the TRUST website including patient's demographics, date of referral, date of patients are offered appointments, dates of consultations, and dates and types of investigations and treatments. This data from electronic health records were obtained for each patient to obtain the treatment start dates and calculate the time to treatment. The department deals with adults (16+ years old), and hence no pediatric urology evaluation is made. The data analysis was completed through an Excel sheet. We determined the total number of suspected cancer referrals, simply named under term 2 week wait urological referrals in April–October 2019 and compared it to April–October 2020 in our hospital. We also determine the time between referral to first seen for each patient in each year. The detailed evaluation also included the time between referral to first treatment for each patient. The investigation and treatment pathways were also looked at to cut down the delays.


  Results Top


In 2019 preceding COVID-19 pandemic, our hospital received a total of 478 referrals on a suspected cancer pathway for urology. This number was for April–October. All these patients were offered outpatient appointments for the first consultation within 14 days. Thirty-six patients (7.5%) had their first outpatient clinic after 14 days from referral. This was due to the patient being unable to attend in the initially given time slot. In the subsequent year during the first wave of COVID-19 pandemic, we did see a sharp decline in the number of patients referred for suspected urology cancer. This number for 2020 for the same amount of time fell to 270 patients. This showed a 44% decrease in the total number of referrals. Twenty-five patients (9.2%) had their first outpatient clinic after 14 days from referral. This was again due to patient choice. In 2019, of the 478 referrals, 118 patients (25%) were found to have cancer. The main bulk of the cancers were related to the prostate followed by the bladder. The exact number and percentage of these are as follows:

  • 74 Prostate (62%)
  • 29 Bladder (24.5%)
  • 8 Kidney (6.7%)
  • 5 Testicle (4.23%)
  • 2 Penile (1.6%) [Graph 1].



When we compared it to 270 referrals in 2020, results were not too different albeit less numerically. A total of 60 cancers were detected making it a total of 22.2%. Again, prostate cancer was the leading diagnosis with exact numbers and percentages as follows:

  • 35 Prostate (58.3%)
  • 23 Bladder (38.3%)
  • 1 Upper tract transitional cell carcinoma (TCC) (1.66%)
  • 1 Kidney (1.66%) [Graph 2].



The next important parameter we compared was the time from referral to first treatment. In 2019, 41 (34.7%) patients received treatment >62 days. All the other patients diagnosed with cancer had their treatment started within 62 days. The reasons of delay in the treatment are discussed later and a lot of improvement has been achieved since this study. The breakdown is as follows:

  • Prostate = 31-Hormone therapy-4, Robotic-assisted radical prostatectomy (RALP)-12, Radiotherapy-10, Watchful waiting 5
  • Bladder = 5– Transurethral resection of bladder tumor (TURBT) 5. All high-grade tumors but superficial require resection at 4-6 weeks, and hence unavoidable breach
  • Penile = 2-Partial penectomy 1, Glansectemy 1
  • Testicle = 1-Right orchidectemy. Awaited chemotherapy postsurgery [Graph 3].
  • Kidney = 2 Laparoscopic nephrectomy 2.



In 2020, there were 19 (31.6%) patients who received treatment >62 days.

  • Prostate = 14 Hormones and radiotherapy 9, RALP 4, and HIFU Trial 1
  • Bladder = 3, TURBT 3
  • Kidney = 1, Radical nephrectomy 1
  • Upper tract TCC: 1 nephroureterectomy 1 [Graph 3].


We saw a sharp drop in the number of referrals to the urology department in the first wave of COVID-19 pandemic. There were 44% fewer referrals in 2020 than in 2019. This could be due to several factors but most importantly a fear of a visit to health-care service was the main palpable factor. When the performance is translated into timely management of cancers, we have seen an improvement in the percentage of patients receiving their treatment within target dates during the COVID-19 pandemic era. This is also demonstrated in [Table 1]. [Table 1] shows head-to-head comparison of the 2 years and shows 3% less breaches in 2020. However, during COVID-19 pandemic, the urology department has to cope with a significantly low volume of patients (the routine or nonurgent cases which have not been discussed here were virtually nonexistent taking off further workload). It will be important to note that during COVID-19 pandemic, there was all sort of strains on health services including depleted staff (either off or relocated), less in patients beds available for most of the wards converted to COVID wards. Furthermore, for extra protective measures and social distancing with extra cleaning and hygiene, a lot of time and space was not available for direct patient care. This means that we had much less capacity to deal with patients. We can safely conclude that improvement in relative numbers for targeted treatment was solely due to a decrease in demand for services for cancer investigations and treatment. This argument is further strengthened from the figures below:
Table 1: Direct comparison of referrals and treatment targets in 2019 and 2020

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  • For prostate cancer in 2019 - out of 13 patients referred for RALP, 12 breached the treatment date
  • For prostate cancer in 2020 - out of five patients referred for RALP, four breached the treatment date
  • The average time for treatment in patients who breached the 62 days target both pre and during COVID time was the same. It was around 3 months with a maximum time of up to 7 months. The maximum delays were again noted for RALP patients.


This simply shows that there was no improvement in specific treatment target time for robotic-assisted laparoscopic prostatectomy or average target time for breach patients.


  Discussion Top


The timeline of COVID-19 pandemic in the United Kingdom (UK) is as follows:

  • The emergency of SARS-CoV-2– the first cases of unexplained pneumonia were noted in the city of Wuhan, China[2]
  • The causative virus was rapidly isolated from patients and sequences with the results from China being shared and published in January 2020[2]
  • Index case entered the UK on 23/01/20 from Hubei province in China[3]
  • First death in the UK March 05[4]
  • First lockdown March 23[5]
  • First vaccine– December 8, 2020[6]


In the UK, the national health system follows very specific time guidelines for the management of cancer-related issues. These cancer waiting time standards are as follows:

National Cancer Waiting Times Monitoring Dataset Guidance– Version 11.0 September 2020.[7]

  • Maximum 14 days from receipt of urgent referral for suspected cancer to first outpatient attendance
  • Maximum 28 days from receipt of urgent referral for suspected cancer to the date the patient is informed of a diagnosis or ruled out of cancer
  • Maximum 31 days until a decision to treat with first definitive treatment
  • Maximum 62 days from urgent referral for suspected cancer to first treatment.


Whereas "Definitive treatment" is defined as:

  • "A treatment is an intervention intended to manage the patient's disease, condition, or injury and to avoid further intervention. It is a matter of clinical judgment in consultation with the patient"[7]
  • "For cancer waits a first definitive treatment is defined as the start of the treatment aimed at removing or eradicating cancer completely or at reducing tumor bulk."[7]


What cannot be classified as the first treatment for urological cancers

  • Surgical biopsy for diagnostic purposes, including transurethral resection of bladder tumor commonly called TURBT (unless the tumor is effectively removed by the procedure). *New Guidance from July 2020*[7]
  • Palliative care for any patient who is fit for active treatment (unless they decline active treatment options and wish to have only palliative treatment)[7]
  • Furthermore, it is worth noting that active monitoring is not counted as treatment. Time to active monitoring counts as– FDS (Faster Diagnosis Standard). If the final decision is another form of treatment other than active monitoring, the clock does not stop and they should have further treatment within 31 days.[7]


The COVID-19 pandemic stirred fear and panic among the general population and one study showed that almost half of people with potential cancer symptoms did not contact their GP during the first wave of the pandemic. They also found that 31% did not seek help after coughing up blood, 41% did not seek help for an unexplained lump or swelling, and 59% did not seek help after noticing changes to the appearance of a mole.[8] There are quite a few papers published discussing the effects of COVID-19 pandemic on other cancer-related issues such as disease progression,[9] and screening and treatment. A paper mentioned a significant reduction in the number of admissions for urological diseases in China.[10] A systematic review by Riera et al. concluded that the reduction of the COVID-19 burden unintentionally posed a major risk on cancer care worldwide.[11]

There is no doubt COVID-19 pandemic has changed the world in every aspect and health services are no exception. There is an urgent desire to look for other than traditional ways of providing service. Different healthy proposals are suggested.[12] These included measures such as:

  1. Remote consultation services over the phone/video link within our trust
  2. Furthermore, we radicalized the system by incorporating more help from our Allied health professionals including urology specialist nurses. They were more engaged in giving diagnoses to patients and proposing treatment plans after discussion with the respective consultants and in our specialist multidisciplinary team meeting
  3. More and more services were brought back to our local hospital from regional centers such as transperineal prostate biopsies and were done under local anesthesia thus saving a lot of theater time
  4. For low surgical risk patients, more and more preoperative assessment was done over the phone
  5. Cancers were segregated and preference was given to cancer with more potential of harmful effect to patients (such as muscle invasive localized bladder cancers).



  Conclusion Top


We can say that though COVID-19 pandemic has caused a lot of disruption to the medical services, at the same time, it has allowed us to rethink and improve our quality of services.

We recommend that more and more studies related to COVID-19 pandemic should be encouraged. These can include studies about patient's experience, staff experience, and management level experience including financial constraints. The more we know, the better it will be for future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Maringe C, Spicer J, Morris M, Purushotham A, Nolte E, Sullivan R, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: A national, population-based, modelling study. Lancet Oncol 2020;21:1023-34.  Back to cited text no. 1
    
2.
3.
Lillie PJ, Samson A, Li A, Adams K, Capstick R, Barlow GD, et al. Novel coronavirus disease (COVID-19): The first two patients in the UK with person to person transmission. J Infect 2020;80:578-606.  Back to cited text no. 3
    
4.
Mahase E. COVID-19: UK records first death, as world's cases exceed 100000. BMJ 2020;368:m943.  Back to cited text no. 4
    
5.
Available from: https://www.bbc.co.uk/news/uk-56491532. [Last accessed on 2022 Nov 10].  Back to cited text no. 5
    
6.
Available from: https://www.bbc.co.uk/news/uk-55227325. [Last accessed on 2022 Nov 10].  Back to cited text no. 6
    
7.
8.
Quinn-Scoggins HD, Cannings-John R, Moriarty Y, Whitelock V, Whitaker KL, Grozeva D, et al. Cancer symptom experience and help-seeking behaviour during the COVID-19 pandemic in the UK: A cross-sectional population survey. BMJ Open 2021;11:e053095.  Back to cited text no. 8
    
9.
Chen G, Wu Q, Jiang H, Li Z, Hua X, Hu X, et al. Impact of treatment delay due to the pandemic of COVID-19 on the efficacy of immunotherapy in head and neck cancer patients. J Hematol Oncol 2020;13:174.  Back to cited text no. 9
    
10.
Li Z, Jiang Y, Yu Y, Kang Q. Effect of COVID-19 pandemic on diagnosis and treatment delays in urological disease: Single-institution experience. Risk Manag Healthc Policy 2021;14:895-900.  Back to cited text no. 10
    
11.
Riera R, Bagattini ÂM, Pacheco RL, Pachito DV, Roitberg F, Ilbawi A. Delays and disruptions in cancer health care due to COVID-19 pandemic: Systematic review. JCO Glob Oncol 2021;7:311-23.  Back to cited text no. 11
    
12.
Kumar D, Dey T. Treatment delays in oncology patients during COVID-19 pandemic: A perspective. J Glob Health 2020;10:010367.  Back to cited text no. 12
    



 
 
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