Millions of screenings and treatments have been missed resulting in a rise in metastatic cancers.

Cancer survivorship has made great strides, with death rates declining 31% since 1991 and oncology clinical trials dominating therapeutic focus. But cancer patients require uninterrupted care, and the full impact on survivorship of disruptions in care caused by the pandemic may not be fully known for years. Millions of screenings, appointments and treatments were delayed, and already higher cases of stage migration on first diagnosis are being reported. Cancer centers were also forced to lower infusion thresholds and delay urgent surgeries due to critical blood shortages worldwide.

Alarming statistics surrounding the pandemic’s effect include:

• Oncologists in the US, EU, UK and Japan reported a 25-51% drop in caseloads in early 2021.^[1]
• In Europe, up to 1/2 of all cancer patients experienced treatment delays, and 100 million screening tests were not performed, leaving as many as a million undiagnosed cancers.^[2]
• More than 75% of all US cancer patients delayed some aspect of their care with estimates that, in the next decade, more than 10,000 additional cancer deaths will occur due to drops in breast and colorectal screenings.^[3]
• People whose treatment for cancer is delayed by even one month have, in many cases, a 6%–13% higher risk of dying – a risk that keeps rising the longer their treatment does not begin.^[4]
• A Canadian study estimated that during the first half year of the pandemic in Ontario alone, as many as 843 years of lives of cancer patients could have been lost due to only surgery delays.^[5]

(For interactive and updating data on Covid-19’s impact on cancer across 17 European countries visit the European Cancer Organization’s Time To Act Data Navigator  ) 

“Every month delayed in cancer treatment can raise the risk of death by around 10%.”

British Medical Journal

Most currently available data comes from large urban centers in developed countries with good, established healthcare systems. These critical statistics, once documented, will certainly show higher rates in more rural areas and in low-to-middle income countries (LMICs) where healthcare systems are often fragile, and economic insecurity and poverty make cancer care a challenge even in the best of times. While in more developed areas, patient care may have transitioned in part to digital and telemedicine, many in less developed areas have no Internet access or lack the education necessary to utilize digital pathways. We will not know the true setbacks on cancer survivorship caused by the pandemic for years to come, but now policymakers must address the problem before the next crisis arises.

Many oncology clinical trials affected but recovery has been quick

Oncology clinical trials also suffered setbacks, and since these are often the last hope of treatment for many cancer patients, the impact of delays, stoppages and “failure to launch” is significant. Oncology trials are highly complex, and the often very sick patients are at risk for severe consequences when trials are interrupted. An article in Nature Reviews^[6] reported that:

• Patient enrollment was only 20% of the usual rate in the US and Europe at pandemic peak.
• Nearly 60% of investigators of ongoing trials reported either moderate or high impact on delayed or cancelled patient visits. This, in turn, jeopardized not only the patients’ survival but also trial outcomes with incomplete patient visit data.
• New trials for cancer drugs and therapies saw a 60% decrease.
• Over 200 interventional oncology studies were suspended in March and April of 2020. (Data from ClinicalTrials.gov )

Even with these statistics, cancer trials were less severely affected than in other therapeutic areas and also recovered more rapidly. IQVIA’s “R&D Trends 2020” reported an historically high start in new trials — 60% higher than in 2015 — with a strong focus on rare indications. National Cancer Institute-supported clinical trial enrollment has rebounded from a 40% drop early in the pandemic to 80% of pre-pandemic levels. The industry should be commended for creative ways of providing as much continuity of care for cancer patients as was possible with telemedicine and other digital innovations.

Oncology trials moving forward — new approaches promising more targeted treatments

2022 is already seeing a surge in oncology trials with precision medicine such as molecular targets and the identification of more predictive biomarkers at the forefront. The cancer drug pipeline is filled with more than 3,500 potential cancer treatments (as of 2020 and up 75% since 2015) and includes many new innovative therapeutics based on scientific breakthroughs, especially for rare cancers. And the American Association for Cancer Research (AACR), reported that in 2021 there were a high number of submitted clinical trial abstracts displaying a wide breadth of concepts, including important studies in early to late drug development, new molecular entities targeting known alterations, and optimizing noninvasive treatments.

As research focuses on unmet patient needs and gains ground in understanding the underlying biology of cancer, the next generation of oncology therapeutics will enable more targeted and individualized treatments. Products under development such as cancer-killing viruses, antibody therapies and immune cell therapies can activate the immune system to fight cancer, often without harming healthy cells, resulting in less side effects than radiation or chemotherapy.

Immunotherapies (IO) use the patient’s own immune system to attack cancer cells or provide the biological tools the immune system needs to fight the cancer. Some of these are in a class of “checkpoint inhibitors” — drugs that target and block certain proteins produced by immune system cells giving the body a way to more effectively target and kill cancer cells. Checkpoint inhibitors are already in broad use to treat people with cancers including melanoma, lung, kidney, bladder and lymphoma.

Another type of IO is cell therapy, such as CAR-T cell therapy, where a patient’s own immune system cells are taken, altered genetically, lab-grown in large numbers and given back to the patient by infusion. Currently this is used to treat certain blood cancers and is being studied for other cancer types. Two recent large clinical trials showed this therapy to be even more effective than standard treatment for patients with non-Hodgkin lymphoma whose cancer returned after their first-line chemotherapy.^[7] And researchers continue to try to find ways to use CAR-T cells to treat solid tumors.

Combination approaches such as combining an antibody targeting agent with a potent chemotherapy agent into an antibody-drug conjugate (ADC) are in focus with several recently launched, especially in breast cancer. This also includes the area of bispecific antibodies that bind to two targets to connect the cancer cell with immune system cells to target and destroy the cancer such as the recently approved Rybrevant for non-small cell lung cancer.

For solid tumors, biomarkers (mutations associated with solid tumors) continue to be a focus with 81 pipeline drugs targeting solid tumors and 58 pipeline drugs targeting both solid and hematological malignancies.^[8]

 Cancer research still has many challenges

All cancer patients in all locations should have access to clinical trials. Decentralized trials and advancing technology are helping to reach patients who are at a distance from research centers. Still, even in the US, only about 8% of cancer patients participate in trials. When you factor in minority and underserved communities globally, not nearly enough cancer patients are participating in these life-saving trials.

Predictions suggest that by 2040, 75% of the world’s projected 21 million new cancer cases and 13 million annual cancer deaths will occur in LMICs.^[9] As different populations react differently to treatments, it is clear that cancer research should be designed to address the cultural differences and local healthcare systems and clinical practices of all demographics.

It is vital to build capacity for global cancer research by educating and training robust interdisciplinary research workforces, more effectively translating research evidence into routine clinical practice and building technology infrastructures in underserved communities so all may take advantage of remote treatments and decentralized trials. Increased global collaborations will also help to leverage scientific opportunities in a more democratic and inclusive way.

George Clinical has contributed to the advancement of this concept with the participation in clinical trials of our globally respected Scientific Leadership team who are also clinicians. They understand specific populations, local standards of care, disparities and differences in cancer treatments, local regulatory and policy issues, and have established relationships with local oncologists and research sites. Their participation in trials has led to positive outcomes and better treatment options for more types of people in more locations. And because of their influence on the oncology community, they are able to disseminate lessons learned from trials more quickly into clinical practice.