Karol Sikora interview: the NHS cancer timebomb

As Britain entered crisis-mode, NHS hospitals cleared out wards and cancelled elective surgeries so the swell of coronavirus-infected patients could be prioritised. This worked as an emergency strategy to deal with the epidemic and to ensure NHS wards were not overwhelmed, but as we look beyond the immediate crisis, it is increasingly clear that a heavy price is being paid by those who urgently required testing and treatments for other serious illnesses.  

Sufferers of heart attack and stroke have not been presenting themselves for treatment, with excess deaths increasing as a result. But the most acute problem is with cancer care.

I spoke to Professor Sikora, who formerly directed the Ludwig Institute for Cancer Research and the World Health Organisation’s cancer programme. Sikora has made a name for himself as the “positive professor”, having tweeted optimistically about winning the battle against coronavirus even as it reached the height of its severity. When it comes to crises’ longer-term impact on cancer treatment, however, he is much less positive.

Urgent cancer referrals fell by 60% at the peak of the crisis. How worried should we be, and is there a cancer time bomb waiting for us?

Yes. I think there is. The NHS is wonderful, it’s like a battleship, and it switched course to deal with Covid, and basically, it just forgot about the cancer and cardiac patients. What has happened is exactly what one could predict, that the number of cancer patients presenting for treatment right across the UK has really plummeted. This isn’t because cancer has gone away – far from it, it’s at the same rate of around 30,000 a month.

First, fear from patients to come forward. Second, there is a breakdown of primary care services and not seeing patients in general practice. Third, all the tests to diagnose cancer – CT scans, MRI scans, endoscopy – have been cancelled. Now they are very slowly reactivating. Far slower than in mainland Europe, where everything is more or less back to normal. I was actually in Brussels yesterday, at a cancer centre, and it’s back to normal. All the tests are being done in the normal way.

That’s not the case in the NHS. It’s a typical battleship mentality, you turn the ship and then it’s difficult to get it back on course. Everyone’s trying to get something done. There’s a lot of talk in the NHS, a lot of working groups, a lot of Zoom conferences. Not only do you have Zoom conferences, you have pre-zoom conferences. A conference about a conference that’s coming. It drives you potty, I can tell you.

But the problem is you don’t know you’ve got cancer until it’s diagnosed, so that’s the time bomb.

You mentioned endoscopies as one of the diagnostic pathways. They were classed as non-essential elective surgeries at the start of the crisis. Do you think that was a mistake?

I think so. The fundamental issue is that the majority of people that you may think have cancer haven’t actually got cancer. The only way you find out is to screen the lot, so you have to give priority to the lot. If you’ve got 100 people booked for a scan, there’s no way of sorting out which have got cancer or not. You have to do all 100 to find out.

We’ve tried to fast-track people that are likely to have cancer, with the “two-week wait” which was created 20 years ago. But that system broke down during the Covid crisis.

Epidemiologists are worried about a second wave of Covid-19 in the autumn. If that second wave does come, is there a chance this cancer crisis will continue until next year?

Absolutely. And that means a lot of people will die from cancer, probably more than have died from Covid.

You can never be totally sure, but my view is that there isn’t going to be a second wave. It’s a figment of the epidemiologists’ imagination. They’re basing it on the influenza pandemic of 1918. It wasn’t coronavirus, it was a totally different illness. It wasn’t in 2020 either, where we have sophisticated diagnostics. I’ve seen the predictions – the NHS is welded to these. They’ve got a secret plan and an open plan. I asked for the scientific basis of the secret plan and they said “Well, we can’t give it you. It’s advice from the epidemiologists.”

My belief is that the virus is petering out. Ironically, with the virus petering out, the epidemiologists peter out because their advice is no longer needed, so they’ve got a professional vested interest in this thing having a second wave. That’s the problem. 

Now, if there was a second wave it would come in September/October according to the predictions I’ve seen. Then we get the traditional winter pressures, which is an NHS euphemism for not having enough capacity for old people in the winter. Then you grind to a halt. 

Even if there isn’t a second wave, those winter pressures are going to have a severe impact. We’re looking at a multi-year problem with cancer backlogs, aren’t we?

We are. And the other thing is not just the backlog, but when it does come through, it will come through as a burst. You will have a lot of people requiring immediate treatment. The danger with all this is you get up-stage migration. When you delay, patients go to the next stage, and the prognosis is always poorer and the treatment becomes more complex. When you have a lot of high-stage cancer patients coming at once, you overload the whole treatment system.

A lot of people were impressed by the speed with which the NHS shifted its resources at the start of the crisis. Are there operational lessons to learn from that to deal with this particular problem?

The NHS worked perfectly through coronavirus. No doubt. Ok, there was a little fuss about PPE and so on. I think a lot of it was in people’s heads rather than the reality. It was just bad organisation and that got resolved. The difficulty now is it’s really struggling to get back to a semblance of normal. The figure I saw circulating last week was that we’re still working at about 40 percent of total function in the NHS despite being well out of the pandemic.

Critical care units are empty, everything is empty, theatres are not functional. People are standing around twiddling thumbs, and the private sector has gone back to work. You just wonder why it’s been so slow.

Could private hospitals step in this winter and take on a larger proportion of cancer patients?

They are vital for dealing with the surge of cancer patients to come. There are three private cancer networks, 26 private radio therapy centres scattered around the UK, and something like 65 private chemotherapy facilities. They all have more capacity than they need. We are trying to coordinate an effort with NHS England. They are looking at how to do this, exactly along those lines.

The real trouble is we don’t have a timetable for it. With Covid you knew roughly within a week of when the peak was coming. With cancer you can’t do that, you can’t predict. I think it’s going to be later than people think.

I think it will be September when we get the peak of cancer, just because everything has ground to a halt and it’s very slow.

Professor, you’ve always been very optimistic, but now… 

Ha. Well, I think we can sort this out. It’s not beyond the wit of man. If we just get the hospitals working we should be able to mitigate the impact.