Every year in the UK 11,500 women die from breast cancer. The incidence of the disease is 129 per 100,000 population with 55,000 new diagnoses annually.
Of the 55,000 new cases, the vast majority are picked up on routine mammography, to which 2.5 million women over the age of 50 are invited every year.
The UK is already well behind other wealthy European nations in our cancer survival rates. At 8th from bottom of the EU27 for all cancers (excluding melanoma) and bottom of the pile for breast cancer survival we had a problem before 2020 brought its own challenges. Many commentators have suggested that the factors contributing to poor outcomes are late presentation of symptomatic disease and decreasing take-up and compliance with the screening programmes. Delay in treating cancer is what causes worse outcomes.
Covid-19 has decimated the mammography screening programme for breast cancer with a current backlog of 1 million unscreened women. It is therefore not unreasonable to conclude that there will be a significant reduction in the 5-year survival rates owing to missed diagnosis and early interventions which should have been picked up in 2020.He must have tried it a hundred times, shut his eyes so that he wouldn't have to look at the floundering legs, and only stopped when he began to feel a mild, dull pain there that he had never felt before. "Oh, God", he thought, "what a strenuous career it is that I've chosen! Travelling day in and day out.
In addition to the new diagnoses being missed, there is the combined tragedy of delayed follow-up appointments for anomalous mammograms and delays in starting treatments for confirmed cases owing to the effective shutdown of the NHS this year. The mental health toll on the sufferers and those around them cannot be dismissed as insignificant in addition to the morbidity associated with further delayed diagnosis.
Breast is not the only cancer for us to worry about. Bowel, lung and prostate tumours can also be included in this debate. I choose breast for illustrative purposes only. The point is, excess undiagnosed cancer cases is clearly a sequelae to either the pandemic itself or the response to the pandemic. Where cancer is concerned, people will die before their time and it IS attributable to Covid-19. Its a death from Covid.
Commentary has aligned itself along two opposing trenches. Both the pro and anti-lockdown narratives recognise that all cause mortality will rise, each blaming the other side for the causes. Pro-lockdowners say that unless and until Covid is brought to heel cancer services cannot resume because of the pressure on NHS services caused by Covid; anti-lockdowners say that it is because of flawed data justifying lockdowns that cancer patients will suffer.
If you are a cancer patient and die early, neither argument will give succour to your pain and grieving. You are leaving your loved ones behind well before your time, regardless of who wins the argument.
If instead, the arguments focus on how screening programmes can recover to pre-Covid levels in addition to assimilating the burden of the missed screening appointments, it may prove a route to reconciling the arguments waging between the pros and the antis. I say that what lies in the no-man’s land between their trenches is herd immunity turbo-charged by rapid vaccination.
While social distancing and excessive cross contamination prevention persists, mammography cannot resume normal service. These factors build in delays and reduce scanning capacity down to 30-50%. In order to deal with a backlog, they will need to achieve greater than 100% capacity for the short term and only then can they revert to normal capacity.
The weakness of the anti lockdown argument is that the virus does exist. It can cause severe short and long term problems across all demographics of sufferers and is devastating care homes and the elderly. Long term cocooning and social distancing still have negative health, social and economic problems. Waiting for naturally acquired herd immunity is uncertain, geographically patchy, and could be both too long in arriving and in the process cause too many covid-related complications, hospitalisations and premature death.
The weakness of the pro-lockdown argument is that the data lag and policy-making are at times incoherent. There has also been a reluctance by the government to canvass a full spectrum of expert opinion and embrace sceptical rationale. The combinations of these and many other factors has resulted in a significant loss of trust in government. Poor compliance of the public with the policies lies at the door of poor communications. By comparison, Emmanuel Macron is benefitting from increased popularity and approval ratings from a naturally sceptical French public. This, in spite of the fact that French Confinement is harsher, longer and frighteningly authoritarian. He speaks not of R values needing to be less than 1.0 but rather daily case numbers to fall below 5000. With exactly the same PCR testing regime in place and broadly equivalent population numbers and demographics, that goal seems wholly unrealistic for France. But they love him for it. He speaks coherently and apologetically as he condemns hospitality to ruin. With no sign of a scientist within the Élysee Palace, there is currently no plan to open up. Somehow this messaging works while the UK’s marginally more libertarian approach is failing to reach the nation’s collective heart.
Across all western nations, and none more so than the UK, one of the single biggest causes of new infections is nosocomial. Hospital acquired Covid happens in 30% of all daily infections. Hospitals and health care settings have become dangerous places to be if you are otherwise healthy. Except of course, people without Covid, being admitted for other causes are not otherwise healthy. Whatever their chances of death from underlying disease or injury, Covid will double it. Health care workers though, are fit and healthy and they too run the risk of contracting the disease. In fact, health and social care workers are seen as vectors for the disease and until repeated rapid swabbing is available, the risk that they pose to patients will continue.
In a screening setting such as mammography, distancing and contamination control methods will not be sufficient to get the numbers required through the doors. Staff could infect the client, the machinery could infect the client, the aerosols from the previous patient could infect the client. None of these factors are insignificant on their own and combined they present a perfect storm for the potential infection of otherwise healthy candidates. The demographic for this type of screening is the 50+ and therefore an already at-risk category. It simply can’t be the case that attending preventative screening is the cause of succumbing to a serious disease. At current screening rates, there will be increased mortality from cancers. At increased screening rates without wide scale immunity, there will be increased mortality from Covid.
So regrettably, vaccination is the only means by which the logjam is to be broken. Each side of the debate has to concede the weakness of its arguments whether for or against lockdown and accept that urgency is key to alleviating all cause mortality and the perpetual existential drama of imminent lockdowns. Time really is of the essence in achieving herd immunity if we stand any chance of mitigating the universally accepted fact that Covid has both direct and indirect effects on society as a whole, to our liberties and critically to our physical and mental health. I can see no other way.