The impact of the COVID-19 pandemic on radiotherapy services in England, UK: a population-based study

Abstract

Background: The indirect impact of the COVID-19 pandemic on cancer outcomes is of increasing concern. However, the extent to which key treatment modalities have been affected is unclear. We aimed to assess the impact of the pandemic on radiotherapy activity in England.

Methods: In this population-based study, data relating to all radiotherapy delivered for cancer in the English NHS, between Feb 4, 2019, and June 28, 2020, were extracted from the National Radiotherapy Dataset. Changes in mean weekly radiotherapy courses, attendances (reflecting fractions), and fractionation patterns following the start of the UK lockdown were compared with corresponding months in 2019 overall, for specific diagnoses, and across age groups. The significance of changes in radiotherapy activity during lockdown was examined using interrupted time-series (ITS) analysis.

Findings: In 2020, mean weekly radiotherapy courses fell by 19·9% in April, 6·2% in May, and 11·6% in June compared with corresponding months in 2019. A relatively greater fall was observed for attendances (29·1% in April, 31·4% in May, and 31·5% in June). These changes were significant on ITS analysis (p<0·0001). A greater reduction in treatment courses between 2019 and 2020 was seen for patients aged 70 years or older compared with those aged younger than 70 years (34·4% vs 7·3% in April). By diagnosis, the largest reduction from 2019 to 2020 in treatment courses was for prostate cancer (77·0% in April) and non-melanoma skin cancer (72·4% in April). Conversely, radiotherapy courses in April, 2020, compared with April, 2019, increased by 41·2% in oesophageal cancer, 64·2% in bladder cancer, and 36·3% in rectal cancer. Increased use of ultra-hypofractionated (26 Gy in five fractions) breast radiotherapy as a percentage of all courses (0·2% in April, 2019, to 60·6% in April, 2020; ITS p<0·0001) contributed to the substantial reduction in attendances.

Interpretation: Radiotherapy activity fell significantly, but use of hypofractionated regimens rapidly increased in the English NHS during the first peak of the COVID-19 pandemic. An increase in treatments for some cancers suggests that radiotherapy compensated for reduced surgical activity. These data will assist health-care providers in understanding the indirect consequences of the pandemic and the role of radiotherapy services in minimising these consequences.

Funding: None.

Figure 1

Courses (A) and attendances (B) of radiotherapy delivered within the English NHS over the year preceding and period following the first UK lockdown for the COVID-19 pandemic The dashed line indicates the beginning of the lockdown on March 23, 2020. ITS=interrupted time series. NHS=National Health Service.

Figure 2

Bubble plot showing the change in fractionation patterns over time for courses delivered with curative intent for a range of diagnoses Diagnoses are presented in descending order of total number of courses. The size of the bubble reflects the number of treatments delivered using the specified fractionation category.

Figure 2

Bubble plot showing the change in fractionation patterns over time for courses delivered with curative intent for a range of diagnoses Diagnoses are presented in descending order of total number of courses. The size of the bubble reflects the number of treatments delivered using the specified fractionation category.

Figure 3

Change in fractionation patterns delivered for breast cancer across the English NHS before and after the first UK lockdown Model predictions (lines) of the use of differing regimens for the adjuvant treatment of breast cancer with observed weekly courses (dots). The dashed line indicates the beginning of the lockdown on March 23, 2020. ITS=interrupted time series. NHS=National Health Service.