Deaths are soaring - but not from cancer. What's going on?

In reality, it is at best perplexing and, at worst, a signal that more cases are tending to be detected at a later stage - especially among better off patients.

So what is really going on?

Much has been made of the pandemic’s impact on cancer - Scotland’s leading cause of death - with warnings that everything from pauses in screening programmes to spiralling waits for CT scans and colonoscopies threatens to reverse the steady progress made in cutting mortality rates from the disease.

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Right now, however, the picture is somewhat puzzling.

Since the beginning of January, there have been 160 fewer cancer deaths in Scotland than might be expected, based on the five-year average (which National Record of Scotland counts as 2016-19 plus 2021 when calculating comparisons for 2022; 2020 is discounted as an aberration).

Overall, this is not massively out of whack.

In a typical year, Scotland would have recorded around 13,060 cancer deaths by now - so 160 fewer than normal is only 1.2 per cent out.

What is peculiar, however, is that this deficit has been occurring at a time when the total number of people dying in Scotland has been consistently running at 10% above average.

For most of the time since July 2021, significantly more people have been dying in Scotland compared to the pre-pandemic average. Cancer deaths remain an outlier, however (Image: PHS)

Since mid-April, there have been 2,828 excess deaths.

Covid is no longer the main cause; it was directly responsible for just 30% of these deaths compared to 81% during 2021.

Of the remainder, around a quarter (23%) combined were due to dementia/Alzheimer's, other respiratory diseases, and circulatory diseases (strokes, heart attacks, brain haemorrhages and so on).

Nearly half (47%) are simply categorised as "other", which could cover everything from suicides and road traffic accidents to sepsis.

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Against this backdrop, the dip in cancer deaths stands out as an anomaly.

And it's not just numbers; a report on cancer mortality in Scotland published earlier this week also noted that the pandemic appeared to have had no adverse effect on death rates from the disease either during 2021.

Adjusted for age and calculated per 100,000, Scotland's cancer mortality rates during 2021 "were lower than those before the pandemic and within the expected range of the long-term trend".

Scotland's cancer mortality rate has remained with expected thresholds based on the downward trend pre-pandemic, and was lower in 2021 than it was in 2019 (Image: PHS)

Furthermore, the report added that "it would appear, at this very early stage, that inequalities in overall cancer mortality did not widen in year one and narrowed in year two of the pandemic".

It is a long-standing tragedy that people living in the poorest areas in Scotland are substantially more likely to die from cancer, and they still are.

But when Public Health Scotland (PHS) compared 2015-19 against 2021, they found that the gap in cancer mortality rates between the most and least deprived had actually shrunk from 79% to 64% last year.

Shortages of radiologists who diagnose cancer from scans has led to concerns that patients are facing lengthy delays before being referred on for treatment (Image: PA)

A separate report cautioned that this is not really the "positive outcome" it might seem.

When PHS examined breast cancer diagnoses, for example, they found that the pre-pandemic inequality gap had virtually disappeared in 2021 - but only because fewer affluent women were having the disease detected at an early stage.

Before Covid, 42% of women living in the least deprived areas were diagnosed with breast cancer at stage 1, when it is most treatable, compared to 35.5% in the most deprived areas.

In 2021, 36% of cases among the most deprived women were found at stage 1 - effectively unchanged - but a significantly lower proportion (37.6%) were picked up at stage 1 for the least deprived patients.

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PHS noted that this "this likely reflects the effect of the screening programme being paused for four months in 2020", given that uptake of routine mammograms is traditionally higher among the better-off.

Overall, statistics show that there were around 2,700 fewer cancer diagnoses during 2020 compared to 2019.

That is unlikely to reflect an actual drop-off in incidence so the expectation is that these "missed" cases, once they are detected, will be more advanced and less treatable.

This corresponds with figures showing both a 9% increase in the number of patients referred for key cancer tests in April-June this year versus 2019 and longer waits once they join the queue - both of which auger badly for future mortality trends.

After falling during 2020, the number of cancer patients being referred for diagnostic tests has crept up and now exceeds pre-pandemic levels (Source: PHS) (Image: PHS)

In this sense then, the cancer timebomb is probably ticking; it just hasn't gone off yet. The risk of death from colon cancer, for example, increases by 6% for every four weeks that surgery is delayed.

Nonetheless, it is not entirely clear why cancer deaths are where they are now - but Scotland is not alone.

Charity, The Health Foundation, noted that there had been a 7% reduction in lung cancer deaths in England between January and June 2021.

At first glance, the most obvious explanation might seem to be "displaced mortality": that people who would otherwise have died from lung cancer in 2021 had died instead, earlier, from Covid.

Similar patterns can be seen after a "bad flu year", for example: there are often fewer deaths among older people in the post-winter months as some died prematurely from flu.

However, the Health Foundation estimated that displaced mortality due to Covid was likely to explain only a "small proportion" of the reduction in lung cancer deaths - maybe as little as 1% - based on the age-specific risk of dying from Covid.

Patients are waiting longer now on average for scans and investigations, such as endoscopies, to diagnose cancer (Image: PA)

Even taking into account that cancer patients are at higher risk from Covid than the general population still could not explain the drop off.

Since lung cancer is particularly aggressive (60% of patients die within a year of diagnosis), they suggest that pandemic-related disruption may have resulted in more people dying before the condition was ever diagnosed - meaning that other causes were recorded instead.

"In reality, it likely foretells an increase in mortality in future years, as delays in diagnosis catch up," it added.

As always, if it seems to good to be true, unfortunately, it probably is.