New Approaches to Cancer Care in a COVID-19 World—The Role of Health and Social Protection Policies | Oncology | JAMA Oncology | JAMA Network
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Comment & Response
November 25, 2020

New Approaches to Cancer Care in a COVID-19 World—The Role of Health and Social Protection Policies

Author Affiliations
  • 1St George’s Medical School, University of London, London, United Kingdom
  • 2The Royal Marsden NHS Foundation Trust, London, United Kingdom
  • 3Department of Oncology, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
JAMA Oncol. 2021;7(1):137-138. doi:10.1001/jamaoncol.2020.5853

To the Editor In their recent Viewpoint in JAMA Oncology, Gyawali and colleagues1 asked if new initiatives to reduce in-person visits, testing, and low-value treatments would provide lasting benefits to cancer care beyond the pandemic period. They considered how a priority-based approach and the transition to telehealth have been adopted in attempts to control the spread of coronavirus disease 2019 (COVID-19), suggesting that the economic ramifications of lockdown will force prioritization of health care resources in an overstretched cancer care system.

World Bank estimates2 indicate that the pandemic will contract the global economy by 5.2%, representing the deepest recession since World War II, pushing 60 million people into extreme poverty. Maruthappu and colleagues3 attributed 263 211 excess cancer deaths between 2008 and 2010 to the global recession. A 1% unemployment rise was associated with significantly higher age-standardized mortality in “treatable” cancers, lasting up to 5 years with lag-time analyses. A comparison of cancer mortality during and after the recession identified a significant decrease with increased health care expenditure as a percentage of gross domestic product. This provides valuable insight into how macro-level multinational policy affects cancer mortality at a population level.

Cancer mortality has been shown to be more sensitive to financial strain, social isolation, and restricted health care access than other diseases.4 Notwithstanding that England’s urgent referrals for cancer have dropped by 60% in April 2020 year-on-year, further changes in accessibility due to financial pressures may contribute to reduced health care utilization, manifesting as reduced screening adherence, higher rates of late-stage cancer diagnoses, lower rates of treatment commencement after diagnosis, or higher discontinuation rates.

Some public health economists argue that austerity measures had a greater influence on health care access and excess deaths than the recession itself. A review of European countries’ economic responses found that policies consolidating countercyclical expenditure on public health and social protection, comprehensive health coverage, reduction of out-of-pocket payments, and selective investments made health systems more resilient.5 Conversely, austerity measures directly reduced health coverage, while indirectly cutting social protection programs for unemployment, poverty, homelessness, food security, and social care that mitigate public health risk.

Value-based cancer care will inevitably become more important in the coming years. While clinicians must critically appraise whether decisions deliver meaningful patient outcomes in a resource-limited setting,1 so too must comprehensive health and social protection policies in response to the COVID-19 era be carefully considered to mitigate for the adverse long-term health effects of an approaching global recession and protect the progress made in cancer care.

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Article Information

Corresponding Author: Mehran Afshar, MBBS, PhD, Department of Oncology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Rd, London SW17 0QT, United Kingdom (

Published Online: November 25, 2020. doi:10.1001/jamaoncol.2020.5853

Conflict of Interest Disclosures: None reported.

Editorial Note: This letter was shown to the corresponding author of the original article, who declined to reply on behalf of the authors.

Gyawali  B, Poudyal  BS, Eisenhauer  EA.  COVID-19 pandemic—an opportunity to reduce and eliminate low-value practices in oncology?   JAMA Oncol. Published online July 2, 2020. doi:10.1001/jamaoncol.2020.2404PubMedGoogle Scholar
World Bank.  Global Economic Prospects, June 2020. World Bank; 2020.
Maruthappu  M, Watkins  J, Noor  AM,  et al.  Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis.   Lancet. 2016;388(10045):684-695. doi:10.1016/S0140-6736(16)00577-8PubMedGoogle ScholarCrossref
Ruhm  CJ.  Recessions, healthy no more?   J Health Econ. 2015;42:17-28. doi:10.1016/j.jhealeco.2015.03.004PubMedGoogle ScholarCrossref
Thomson  S, Figueras  J, Evetovits  T,  et al.  Economic Crisis, Health Systems and Health in Europe: Impact and Implications for Policy. World Health Organization Regional Office for Europe; 2014.
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