Gabriella had been short of breath when climbing stairs for the past week. And yes, now I mentioned it, she did also get breathless when lying flat; she could only sleep propped up in an armchair. And while she’d had no chest pain as such, she’d had variable tight discomfort around her upper abdomen for some time.
Ever since the first wave of Covid-19 crashed over the UK in late March we’ve been operating a total triage service. Anyone wanting an appointment has to first speak to a doctor on the phone. Simple things can be dealt with there and then, keeping the numbers entering the surgery premises down. And if someone does need to be seen, we can direct them to either a “hot” or a “cold” site, depending on whether they have coronavirus symptoms.
Shortness of breath is a cardinal Covid symptom, but Gaby’s was exertional and positional, and she had no other viral features. And as a smoker in her early sixties, I suspected she would need blood tests and an ECG, procedures that can’t be performed at the “hot hub”. So I made her an appointment with me that morning.
I’d thought I would find a cardiac cause, but examination revealed a large upper abdominal mass. She looked to have cancer. If so, the breathlessness might be due to pulmonary emboli. Active cancer is associated with a tendency to form abnormal clots inside veins, which can break off and fly through the circulation, lodging in the lungs. Depending on their size and number, emboli can cause anything from mild breathlessness to sudden death. “We’ve got to get you up to the hospital,” I told her.
A CT scan ruled out pulmonary emboli, but starkly revealed the problem. A lung tumour with numerous metastases deposited elsewhere in the chest, and also throughout the liver. This was going to be incurable, but depending on the tumour type, various treatment options might buy Gaby time. The respiratory physicians booked an urgent bronchoscopy – passing a fibreoptic camera into the lungs to take a biopsy: a high-risk procedure for Covid-19 transmission. Gaby had to test negative before they could proceed. In the days spent waiting for her Covid result, she became noticeably more drowsy, but she managed the bronchoscopy just fine.
That same week, I was also contacted by Rhodri, a fit and active 68-year-old who hardly ever comes in. He’d been feeling mildly nauseous for a while, with unsettled bowels. He’d lost some weight, and now his urine had gone unusually dark. I brought him in. Another abdominal mass. This one associated with a tinge of jaundice. Another same-day referral. A CT showed a pancreatic tumour invading surrounding structures, far beyond any chance of operability.
On average, I pick up eight new cancer cases each year. Two in as many weeks, while admittedly anecdotal, feels distinctly unusual – especially given how advanced both were. During the height of the Covid -19 first wave in April and May, most “normal” general practice simply disappeared. According to Cancer Research UK (CRUK), urgent referrals for suspected cancer under the “two-week wait” pathway (2WW) more than halved during those two months, which CRUK estimates means 20,000 cases will have gone undiagnosed.
I doubt it will be quite that many. Overall, fewer than 10 per cent of 2WW referrals ultimately prove to have cancer; in many instances, GPs are referring “just in case”. My suspicion is that most of the high-risk referrals will still have been made, but Covid-19 will have inhibited a lot of precautionary activity. All that relies on patients seeing their doctor in the first place, though. There will have been significant numbers of patients like Gaby and Rhodri, who might ordinarily have presented at an earlier stage, but who stayed away – either because of fears of contracting coronavirus, or because they didn’t think their symptoms could be anything too serious and they didn’t want to burden the NHS in those extraordinary times.
Delayed diagnosis is not the only impact Covid-19 has had on cancer care. The risk/benefit equations over whether to perform surgery, or use immunosuppressive treatments like chemotherapy, have been altered by the risks of contracting the virus. Three of my patients have had chemo postponed.
Cancer screening has also been suspended, creating months’ worth of backlog and resulting in what CRUK estimates will have been an additional 3,800 missed cancer diagnoses. The cervical smear programme principally detects pre-cancerous changes, and I don’t anticipate large numbers of cases arising from the delays. Breast and bowel screening on the other hand – the UK’s other two national programmes – are detecting established cancers, ideally at a more treatable stage. There will be some delayed detection, therefore, though these screening programmes also “overdiagnose” tumours that would never have gone on to cause clinical disease. The real impact of the pandemic on screen-detected cancer patients will be more nuanced than it might at first appear.
The day Gaby was due to get her bronchoscopy results, she developed sudden severe worsening of back pain and became sweaty and clammy. I suspect the tumour had eroded a major artery in her chest. I spent a fraught two hours at her house, getting on top of her symptoms and preparing her family for what was happening. At one point, the consultant phoned with news that the biopsy had confirmed that chemotherapy might help. I let him know it was too late. Gaby died early that evening.
Rhodri has had a stent inserted to relieve his jaundice, and one hopes he’ll be fit enough for chemotherapy that might extend his life. Neither he nor Gaby was ever going to survive their tumours. But in Gaby’s case at least, I suspect Covid-19 meant her cancer took her before her time.
This article appears in the 15 Jul 2020 issue of the New Statesman, Race for the vaccine