Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency

Abstract

Background: Cancer and multiple non-cancer conditions are considered by the Centers for Disease Control and Prevention (CDC) as high risk conditions in the COVID-19 emergency. Professional societies have recommended changes in cancer service provision to minimize COVID-19 risks to cancer patients and health care workers. However, we do not know the extent to which cancer patients, in whom multi-morbidity is common, may be at higher overall risk of mortality as a net result of multiple factors including COVID-19 infection, changes in health services, and socioeconomic factors. Methods: We report multi-center, weekly cancer diagnostic referrals and chemotherapy treatments until April 2020 in England and Northern Ireland. We analyzed population-based health records from 3,862,012 adults in England to estimate 1-year mortality in 24 cancer sites and 15 non-cancer comorbidity clusters (40 conditions) recognized by CDC as high-risk. We estimated overall (direct and indirect) effects of COVID-19 emergency on mortality under different Relative Impact of the Emergency (RIE) and different Proportions of the population Affected by the Emergency (PAE). We applied the same model to the US, using Surveillance, Epidemiology, and End Results (SEER) program data. Results: Weekly data until April 2020 demonstrate significant falls in admissions for chemotherapy (45-66% reduction) and urgent referrals for early cancer diagnosis (70-89% reduction), compared to pre-emergency levels. Under conservative assumptions of the emergency affecting only people with newly diagnosed cancer (incident cases) at COVID-19 PAE of 40%, and an RIE of 1.5, the model estimated 6,270 excess deaths at 1 year in England and 33,890 excess deaths in the US. In England, the proportion of patients with incident cancer with ≥1 comorbidity was 65.2%. The number of comorbidities was strongly associated with cancer mortality risk. Across a range of model assumptions, and across incident and prevalent cancer cases, 78% of excess deaths occur in cancer patients with ≥1 comorbidity. Conclusion: We provide the first estimates of potential excess mortality among people with cancer and multimorbidity due to the COVID-19 emergency and demonstrate dramatic changes in cancer services. To better inform prioritization of cancer care and guide policy change, there is an urgent need for weekly data on cause-specific excess mortality, cancer diagnosis and treatment provision and better intelligence on the use of effective treatments for comorbidities.

County-Level Longitudinal Clustering of COVID-19 Mortality to Incidence Ratio in the United States

“…Historically, it is shown that patients with preexisting heart and lung diseases had a higher mortality rate from SARS 17,[24][25][26][27][28][29] . The same findings have been reported in China 15,16,60 , and United Kingdom 61 . Lippi et al showed that about 20% of hospitalized COVID-19 cases had heart complications as well 16 .…”

Excess mortality: the gold standard in measuring the impact of COVID-19 worldwide?

“…16,17 Urgent referrals for suspected cancer have fallen in the many countries, 18 which may reflect a decrease in patients presenting with 'red flag' symptoms or changes to clinician thresholds for referral due to health system pressures, leading to both short-and long-term impacts on indirect mortality. 19 Overburdening of the health system and changes to clinical pathways as a response to prioritising COVID-19 cases may leave deficiencies in standard care pathways. 19 Globally, the World Health Organization has found that 42% of countries have experienced disruptions to cancer services, 49% for diabetes and 31% for cardiovascular disease services.…”

“…19 Overburdening of the health system and changes to clinical pathways as a response to prioritising COVID-19 cases may leave deficiencies in standard care pathways. 19 Globally, the World Health Organization has found that 42% of countries have experienced disruptions to cancer services, 49% for diabetes and 31% for cardiovascular disease services. 20 Concerns about the efficacy of the pandemic response will arise if deaths from COVID-19 are limited only at the expense of deaths from other causes.…”

Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study

“…Emergency department attendance declined by 25% in the week after lockdown was implemented, 3 and data from the Royal College of General Practitioners surveillance system 4 has shown that weekly reported incidence of asthma, intestinal infectious diseases, upper respiratory tract infections, and acute respiratory tract infections was markedly reduced. Substantial reductions in hospital admissions for suspected heart attacks 5 and strokes, 6 and urgent general practitioner (GP) referrals for cancer 7 , 8 have also been reported.…”