Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands

The dreadful consequences of coronavirus disease 2019 (COVID-19) put an unprecedented pressure on health-care services across the globe.1Rosenbaum L The untold toll - the pandemic's effects on patients without Covid-19.N Engl J Med. 2020; (published online April 17.)DOI:10.1056/NEJMms2009984Crossref Scopus (511) Google Scholar The Netherlands, a country with 17·4 million inhabitants that provides its citizens with universal access to essential health-care services—with the general practitioner as the gatekeeper to secondary care—is no exception in this regard. The first patient with COVID-19 in the Netherlands was confirmed on Feb 27, 2020, in the southern part of the country.2Government of the NetherlandsMan diagnosed with coronavirus (COVID-19) in the Netherlands.https://www.government.nl/latest/news/2020/02/27/man-diagnosed-with-coronavirus-covid-19-in-the-netherlandsDate: Feb 27, 2020Date accessed: April 23, 2020Google Scholar Thereafter, the disease spread rapidly throughout the country. Subsequently, strict social distancing policies were implemented by the Dutch government as of March 15, 2020, to mitigate the spread of COVID-19.3Government of the NetherlandsNew measures to stop spread of coronavirus in the Netherlands.https://www.government.nl/latest/news/2020/03/12/new-measures-to-stop-spread-of-coronavirus-in-the-netherlandsDate: March 12, 2020Date accessed: April 23, 2020Google Scholar, 4Government of the NetherlandsCOVID-19: additional measures in schools, the hospitality sector and sport.https://www.government.nl/latest/news/2020/03/15/additional-measures-in-schools-the-hospitality-sector-and-sportDate: March 15, 2020Date accessed: April 23, 2020Google Scholar The mayhem caused by COVID-19 has brought about substantial changes in cancer diagnosis in the Netherlands. Data from the nationwide Netherlands Cancer Registry in the period between Feb 24, 2020, and April 12, 2020—which are based on initial case ascertainment through pathological cancer notifications from the Nationwide Network of Histopathology and Cytopathology—show that there is a notable decrease in cancer diagnoses when compared with the period before the COVID-19 outbreak. This effect was most pronounced for skin cancers (figure) and observed across all age groups and geographical regions, and almost all cancer sites (appendix). Several arguments might explain this decrease. First, individuals with potential, non-specific symptoms of cancer might have barriers to consulting a general practitioner, including moral concerns about wasting the general practitioner's time for non-COVID-19-related symptoms, assumptions about insufficient capacity for essential non-COVID-19-related health-care services, and anxiety about acquiring COVID-19 in a health-care setting. Second, most of the general practitioner consultations for non-acute issues are transitioned to telehealth. A general practitioner might, therefore, postpone initial investigations for symptoms that do not immediately hint towards a potential cancer diagnosis, resulting in delayed or postponed hospital referrals. Third, hospitals might have postponed diagnostic evaluation or have longer turnaround times for diagnostic evaluation because many hospital-based resources are being allocated to tackle COVID-19. Lastly, national screening programmes for breast, colorectal, and cervical cancer are temporarily halted as of March 16, 2020, to alleviate the demand on the health-care system due to COVID-19. The effect of this pause in cancer diagnosis might be more pronounced after extended periods of follow-up. However, this effect might be less notable for cervical cancer because screening aims to identify precancerous lesions. Collectively, fewer cancer diagnoses in the COVID-19 era will result from patient, doctor, and system factors.5Dobson CM Russell AJ Rubin GP Patient delay in cancer diagnosis: what do we really mean and can we be more specific?.BMC Health Serv Res. 2014; 14: 387Crossref PubMed Scopus (44) Google Scholar The upsetting findings of fewer cancer diagnoses were initially disseminated among the Dutch community on April 2, 2020, and again on April 15, 2020, by the Netherlands Comprehensive Cancer Organisation—which hosts the Netherlands Cancer Registry—to create awareness of this issue. The aims of this dissemination were multifold. First, individuals were encouraged to consult their general practitioner whenever symptoms continued to be troublesome. Second, general practitioners were encouraged to refer patients with suspected cancer to oncology specialists. Third, an appeal was made to restart national cancer screening programmes. Lastly, misconceptions were eliminated about a heightened risk of contracting COVID-19 in a health-care setting because of inadequate policies for infection control at the institutional level and resource constraints in the delivery of essential oncological care. Priorities for cancer care amid the COVID-19 pandemic will be meticulously triaged on the basis of a multitude of factors that are outside the scope of this Comment. General frameworks to inform cancer treatment decisions during the COVID-19 pandemic are discussed elsewhere.6Hanna TP Evans GA Booth CM Cancer, COVID-19 and the precautionary principle: prioritizing treatment during a global pandemic.Nat Rev Clin Oncol. 2020; 17: 268-270Crossref PubMed Scopus (304) Google Scholar, 7Schrag D Hershman DL Basch E Oncology practice during the COVID-19 pandemic.JAMA. 2020; (published online April 13.)DOI:10.1001/jama.2020.6236Crossref Scopus (204) Google Scholar, 8Marron JM Joffe S Jagsi R Spence RA Hlubocky FJ Ethics and resource scarcity: ASCO recommendations for the oncology community during the COVID19 pandemic.J Clin Oncol. 2020; (published online April 9.)DOI:10.1200/JCO.20.00960Crossref PubMed Scopus (95) Google Scholar, 9van de Haar J Hoes LR Coles CE et al.Caring for patients with cancer in the COVID-19 era.Nat Med. 2020; (published online April 16.)DOI:10.1038/s41591-020-0874-8Crossref PubMed Scopus (244) Google Scholar It does merit brief acknowledgment that the effect of a reasonable delay in the management of particular low-risk malignancies (eg, many skin cancers) will only marginally affect the quantity and quality of life. Conversely, the treatment for potentially curable cancers with an imminent risk of early death (eg, acute leukaemias) cannot be safely postponed. The data discussed here support the National Oncology Taskforce and the National Coordination Centre for Patient Distribution to safeguard optimal patient access to essential oncological care throughout all hospitals in the Netherlands. The Netherlands Cancer Registry will, in due course, complete the registration of current and new cases via retrospective medical records review. These more detailed data—including various patient (eg, COVID-19 positivity), tumour, and treatment characteristics, and follow-up—will ultimately establish the effect of the COVID-19 outbreak on oncological care in the Netherlands. This information can also guide the public, policymakers, and physicians in the future whenever an outbreak of a similar magnitude occurs. This online publication has been corrected. The corrected version first appeared at thelancet.com/oncology on May 4, 2020 This online publication has been corrected. The corrected version first appeared at thelancet.com/oncology on May 4, 2020 RHAV reports grants from Bristol-Myers Squibb and Roche, outside the submitted work. All other authors declare no competing interests. We thank Maaike van der Aa, Mieke Aarts, Katja Aben, Amanda Bos, Boukje van Dijk, Vincent Ho, and Jan Maarten van der Zwan from the Netherlands Comprehensive Cancer Organisation, Elisabeth de Vries from the University Medical Centre Groningen, Ivo Smeele from the Dutch College of General Practitioners, and the National Institute for Public Health and the Environment – Centre for Population Screening for providing feedback on an earlier draft of this Comment. Download .pdf (.18 MB) Help with pdf files Supplementary appendix Safeguarding cancer care in a post-COVID-19 worldAs the world comes to grips with the coronavirus disease 2019 (COVID-19) pandemic, reports are emerging on how cancer care is being deprioritised, delayed, and discontinued. These decisions made under the duress of the pandemic will have grave consequences for cancer mortality for years to come. Full-Text PDF Impact of the COVID-19 pandemic on the symptomatic diagnosis of cancer: the view from primary careThe entire landscape of cancer management in primary care, from case identification to the management of people living with and beyond cancer, is evolving rapidly in the face of the coronavirus disease 2019 (COVID-19) pandemic.1 In a climate of fear and mandated avoidance of all but essential clinical services, delays in patient, population, and health-care system responses to suspected cancer symptoms seem inevitable. Full-Text PDF Correction to Lancet Oncol 2020; 21:750–51Dinmohamed AG, Visser O, Verhoeven RHA, et al. Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands. Lancet Oncol 2020; 21: 750–51—In this Comment, the estimated data in the figure and appendix for week 15 were amended. Additionally, the first sentence of paragraph 5 has been deleted. These corrections have been made to the online version as of May 4, 2020, and will be made to the printed version. Full-Text PDF