Cancer still stands as the second leading cause of death (9.6 million deaths every year).1 With 18,433 victims from the coronavirus outbreak,2 Covid-19 infection is likely to increase cancer-related mortality, as case fatality rates are much higher for vulnerable populations, such as elderlies and those with coexisting conditions (cardiovascular disease, diabetes, chronic respiratory diseases, high blood pressure, and cancer).3 As healthcare providers are reorganizing to provide high priority to Covid-19 pandemic, shortages of hospital beds and availability of the healthcare workforces are observed, asking professionals in charge of cancer to postpone diagnosis and treatments.5 However, restricting in-hospital visits is resulting in postponing primary diagnosis and cancer therapies. Normalization of cancer diagnostic and therapy after the Covid-19 outbreak remains unknown. Moreover, the duration of the outbreak could impact the prognostic of several patients. Furthermore, medical societies have also implemented during Covid-19 outbreak low-evidence based but convenient recommendations to balance standard-of-care requirements and healthcare accessibility. Awareness of oncologists could help limiting the impact of coronavirus outbreak on cancer mortality.

1. Post Covid-19-outbreak
impact on cancer mortality
Prof Eric Raymond
Head of Medical Oncology – Paris Saint-Joseph Hospital
France

2. The evolution of data from China gives insight
on the duration of the COVID-19 infection
Hit wave Recovery wave
https://www.worldometers.info/coronavirus/#countries

3. Data from China show several active cases at
3 months, about 23% being severe or critical
Remnant active cases
https://www.worldometers.info/coronavirus/#countries
Hit wave Recovery wave

4. The durations of COVID-19 outbreak may be
longer than anticipated (south Korea data)
Home containment aiming to mitigate the
impact of COVID-19 outbreak on intensive
care requirements and limit casualty may
prolong epidemic duration
Infestations from infected non-symptomatic
reservoirs occurring after the initial epidemic
peak may result in the maintenance of
COVID-19 infection for several weeks
Hit wave
Remnant waves
https://www.worldometers.info/coronavirus/#countries

5. Models incorporating transient releases of
home containment suggest occurrence of
multiple remnant waves (UK model)
GRAPHIC: IMPERIAL COLLEGE COVID-19 RESPONSE TEAM, ADAPTED BY C. BICKEL/SCIENCE
Long lockdowns to slow a disease may have
catastrophic economic impacts and may
devastate public health
It's a three-way tussle between protecting
health, protecting the economy, and
protecting people's well-being and emotional
health
Science 27 Mar 2020:
Vol. 367, Issue 6485, pp. 1414-1415
Remnant waves

6. Each country (one after another)
is foreseeing multiple step crises
Acute
healthcare
crisis
Social & economic crisis
3 months 12-18 months ‘X’-years
Healthcare
Recovery
crisis
Home containment
Healthcare system and hospital difficulties
Psychological and economical impacts on the global society

7. Immediate consequences of COVID-19
outbreak on cancer mortality
• About 1% of patients with cancer have been hospitalized (Chinese
data) provided that all patients have been identified in the databases
• Worldwide mortality rate ranges up to 5.0% of newly diagnosed COVID-
19 patients
• Patients with cancer (past/present) represents about 6% of casualties
• Cancer incidence is estimated to about 18 millions new cases yielding
9.6 million deaths every year (WHO 2018)
• A crude estimate of direct impact on COVID-19 infection on cancer
mortality may account for an additional 30,000 deaths in 2020

8. Post COVID-19 outbreak with potential
impact on mid-term cancer mortality
• Shortages of hospital beds and availability of the healthcare workforces
• Postpone cancer prevention, screening, diagnosis, and treatments
• Restrictions in-hospital visits aimed to avoid contagious contacts for cancer patients is resulting
in postponing primary diagnosis and delay therapies such as surgery, radiotherapy and
chemotherapy/immunotherapy
• Normalization of cancer diagnostic and therapy after the Covid-19 outbreak will be highly
dependent of the ability of healthcare systems to resume standard activities without being
overflooded by delayed cancer care
• The duration of the outbreak is likely to last for >3 months, a duration that may be
associated with cancer progression that could impact the prognostic of several
patients
• Medical societies have also implemented during Covid-19 outbreak low-evidence
based but convenient recommendations to balance standard-of-care
requirements and healthcare accessibility

9. Lessons learned from the recent
subprime mortgage crisis
Looking at the impact of economic crisis on mid-term cancer mortality

10. Lessons learned from the U.S. Great
Recession (subprime mortgage crisis)
Yearly cancer incidence rate
decline was 3.3% among
males, 1.4% among females
during the recession/recovery

11. Types of cancer impacted by the U.S.
Great Recession

12. Impact of economic downturns on
cancer mortality

13. Unemployment is associated an increased
all-cancer specific mortality

14. Effects of economic crisis on cancer
mortality
• Post subprime mortgage crisis increases all-cancer mortality and
all specific cancers except lung cancer in women
• The 2008–10 economic crisis was associated with about 260 000
excess cancer-related deaths in the Organization for Economic
Co-operation and Development alone
• All-cancer, treatable cancer, and specific cancer mortalities
significantly decreased as public-sector expenditure on health
care increased

15. Summary
•The COVID-19 outbreak may directly impact the
short-term cancer mortality
•Mid-term increase in cancer mortality resulting from
the healthcare and economic breakdown is expected
•Public-sector expenditure on health care may, at
least in part, counteract the impact of the COVID-19
induced crisis on cancer death

16. Recommendations to reduce the impact of
COVID-19 outbreak consequences on cancer
mortality
• Keep oncology wards free from potential COVID-19 infection and maintain
COVID-19 specific care units to manage the care of cancer patients during the
remnant waves of infection
• Reorganize promptly the hospital organization to prioritize the rescheduling
of patients postponed for diagnosis and treatments during the hit wave of
COVID-19 infection
• Reinforce and facilitate the access of cancer facilities to patients who may
have develop symptoms during the COVID-19 home confinement
• Information to patients (some may fear to access hospital after COVID-19 outbreak)
• Information to primary care physicians (many may stay focus on COVID-19 infection)
• Short cut in-hospital organizations to speed up diagnosis and treatments