PRESS PLAY: GETTING AND KEEPING BREAST CANCER SERVICES BACK ON TRACK
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PRESS PLAY REPORT 2020 FOREWORD Coronavirus is the biggest by the disease, but they have crisis that breast cancer been deeply affected. And the has faced in decades. fundraising that powers them has also been hit hard, too. So, to mark Breast Cancer Awareness Month 2020, this But, gradually, ‘play’ is being report shares what we are pressed for breast cancer services hearing and seeing about and research. The number of the impact of coronavirus on referrals continues to recover breast cancer, including from every month. Breast screening is breast cancer patients and restarting. The number of people healthcare professionals. beginning treatment is rising. Our researchers are back in the lab - As the number of cases of although we have had no option Baroness Delyth Morgan coronavirus begins to increase but to reduce the amount we CEO, Breast Cancer Now again the Prime Minister has spend on research. And we have warned that a second wave developed new online support is coming. The number of services to continue to be here for local lockdowns is increasing. anyone affected by breast cancer. There is speculation about further possible measures The resource and effort the which may be introduced to NHS has put into finding ways control the virus. And concerns to safely diagnose and treat over winter pressures on the cancer during the pandemic, NHS continue to grow. and the knowledge we have gained, will prove invaluable Earlier this year, at the height moving forwards. We must make of the pandemic, we saw a big sure we are well prepared for a drop in the number of people second wave. The progress that being referred to see a specialist we have made in breast cancer with suspected breast cancer. must not be allowed to stall. We Screening services were paused. cannot afford to pause again. Recruitment to many clinical trials was paused. And while many This report makes a number patient’s treatment continued of recommendations to help unchanged other patients saw ensure this does not happen. We delays and cancellations to their look forward to working with treatment alongside changes governments and the NHS across to the support they received. the UK to implement them. This has caused huge levels of anxiety - particularly for patients with incurable secondary breast cancer and their loved ones. Breast Cancer Now’s world- class research and life-changing community support services are here for anyone affected 3
PRESS PLAY REPORT 2020 INTRODUCTION THANK YOU… At the start of this year, as the July and 6 August. The survey was number of coronavirus cases conducted online and publicised TO EACH AND EVERY PERSON began to grow, it became very through our social media accounts AFFECTED BY BREAST clear, very quickly that the and other networks including pandemic would have a huge our Insight and Experience CANCER WHO TOOK THE impact on breast cancer. Panel and Breast Cancer Voices TIME TO COMPLETE ONE network. 2,124 people with OR BOTH OF OUR SURVEYS In March, to help us understand breast cancer responded. this impact, we asked people with breast cancer to tell us We also spoke to 12 healthcare how coronavirus had affected professionals from different parts their treatment and care. of the breast cancer pathway 580 people responded. Many including radiographers, surgeons, reported that they or their loved oncologists specialising in drug ones had experienced delays treatment and radiotherapy, and or cancellations to treatment clinical nurse specialists. We and monitoring scans. Others supplemented this by looking at had not experienced any the data available on the impact changes to their treatment. of the pandemic, for example on referrals to see a specialist. To understand how people’s experiences may have changed This report sets out what we and try to better quantify some of found, and what we think needs the impacts we heard about, we to happen next to tackle the ran a second survey between 9 challenges we have identified. Secondary breast cancer In Breast Cancer Awareness Month 2019 we launched a campaign calling for action to address the challenges experienced by patients with incurable, secondary breast cancer. These include receiving a prompt diagnosis, access to treatments, information about THANK YOU… TO THE HEALTHCARE PROFESSIONALS WHO GAVE THEIR TIME AND EXPERTISE SO WILLINGLY DURING SUCH A BUSY TIME FOR THE NHS 4
PRESS PLAY REPORT 2020 THE SURVEY IN clinical trials and support from NUMBERS a clinical nurse specialist. Breast 2124 Cancer Now is committed to campaigning to ensure these challenges are addressed. people with breast cancer Our analysis of responses to responded to the survey our survey on the impact of coronavirus did not find significant differences for patients with 1545 secondary breast cancer. Back in May we highlighted that the specific needs of patients with had primary breast cancer, secondary breast cancer must be and 472 had secondary identified and addressed in the breast cancer, also known as recovery plans for cancer that are advanced, stage 4 or metastatic being developed by governments breast cancer. The remainder and the NHS across the UK.1 chose to describe their However, this will be hampered breast cancer themselves. by the lack of available data on secondary breast cancer patients – including the number of people 354 living with the disease, which we highlighted in this campaign. This makes it extremely difficult to plan services. We are currently calling were diagnosed with for a national audit of secondary breast cancer between breast cancer to be funded as part of the Comprehensive Spending January and July 2020 226 Review expected in the Autumn. respondents from As part of our campaign we Scotland also highlighted that less than a third of secondary breast cancer patients said they regularly saw 43 a clinical nurse specialist (CNS).2 respondents Worryingly 41% of respondents from to our survey felt they had less Northern Ireland contact with their CNS during the coronavirus outbreak. We are 1708 also calling for funding to recruit and train more CNSs to meet respondents the needs of all people living from with breast cancer as part of the 147 England Comprehensive Spending Review. respondents from Wales 5
PRESS PLAY REPORT 2020 ACROSS THE UK THERE IS LIKELY TO HAVE BEEN NEARLY 107,000 FEWER REFERRALS The earlier breast cancer is A survey undertaken for NHS diagnosed, the more likely it is England suggested that the ‘The new way of triaging has that treatment will be successful. main reasons people were been positive for both staff and reluctant to come forward were those being referred. We simply As the number of referrals to see both concerns about catching don’t have the space or the a cancer specialist continues to coronavirus and giving it to their staff to go back to the previous recover and the breast screening family, as well as fears they way of dealing with referrals.’ programme restarts there is likely would burden the NHS.7 Some Nicky Roche, to be an influx in demand for GPs may also have been reluctant consultant breast surgeon imaging and diagnostics which to refer people to hospital. threatens to overwhelm these services. It is vital that that the Across the UK, the NHS launched recovery plans being developed by campaigns to encourage people to governments and the NHS across come forward with any symptoms the UK set out how this expected that might be cancer. Whilst the surge in demand will be managed number of referrals continues to so people are diagnosed and increase every month, they remain start treatment for their breast some way below what we would cancer as soon as possible. expect in England. It is therefore important that these campaigns Capacity in the diagnostic continue, particularly during any workforce must also be assessed, further peaks in the pandemic. and plans put in place to address shortages, backed up with During the pandemic referrals investment through the upcoming have been triaged. Those Comprehensive Spending Review. considered to be at high risk of having breast Referrals cancer are asked to come The number of people referred to in for assessment, whilst see a specialist with suspected those considered to be cancer declined dramatically at low risk of having during the peak of the coronavirus breast cancer may have outbreak in April, with a drop of a follow up by phone.8 around 70% across all cancers It is crucial that where being reported in some parts assessments are delayed of the UK.3 In England, between people are monitored March and July 2020 there were and followed up. over 95,000 fewer referrals by a GP for tests (whether breast cancer was initially suspected or not) compared with 2019.4 In Wales between March and July there were 2,500 fewer urgent suspected breast cancer referrals.5 Full data for this period has not yet been published for Scotland and Northern Ireland. However, we estimate that across the UK there is likely to have been nearly 107,000 fewer referrals.6 7 7
PRESS PLAY REPORT 2020 WE ESTIMATE THAT A SIGNIFICANT BACKLOG OF NEARLY A MILLION WOMEN REQUIRING SCREENING HAS BUILT UP ACROSS THE UK DURING THE PAUSE Waiting times Breast screening ‘I was diagnosed just before In England and Northern Ireland The breast screening programme lockdown. If I didn’t have those referred by their GP should was officially paused in Scotland, the screening I would still be have their first appointment with Wales and Northern Ireland, unaware of my diagnosis.’ a specialist within two weeks. and effectively paused in Survey respondent Since April, performance against England, in March. Screening is this standard has largely been now restarting, although this is Some measures have been maintained at pre-pandemic happening more quickly in some taken to try and ensure levels.9 The combination of far parts of the country than others. attendance at the reduced fewer people being referred, number of appointments and telephone triage counting We estimate that a significant available. In England, from the as a first appointment for the backlog of nearly a million end of September to the end purposes of the two-week wait women requiring screening has of March 2021 women will be will have helped achieve this. built up across the UK during the sent ‘open invitations’ to call pause.10 It is currently unclear and make an appointment for There is not currently a waiting how long it will take to catch up. screening, rather than a timed time target for diagnosis. 354 The number of appointments appointment. Although women respondents to our survey (17%) available has been reduced to may be more likely to attend an told us that they were diagnosed enable social distancing and appointment they have made, with breast cancer between infection prevention and control research shows that the number January and July: 306 of these measures to be implemented, of women making appointments (86%) told us they received and these arrangements will is significantly lower than those a diagnosis within 3-4 weeks need to be kept under review. attending timed appointments. of being referred for tests. We are concerned that this could worsen the persistent decline we have seen in uptake of breast ‘Screening diagnoses around screening in recent years. We are 19,000 breast cancers a year in particularly concerned about the England and there has been a impact this will have on groups delay of over 4 months in the amongst which uptake is already programme. To not only maintain low, such as women living in pre-pandemic levels of activity, deprived areas and some Black but also do a huge catch up with and Minority Ethnic (BAME) groups. inadequate workforce levels is an enormous mountain to climb.’ If open invitations are to be Mary Wilson, consultant adopted, then measures must be breast radiologist taken to mitigate the potential impact by implementing measures shown to improve uptake, such as appointment reminders and letters from GP practices endorsing screening. They should also be for a limited period, as proposed. Outcomes must be carefully monitored at a local level. We understand that several services will be early adopters of open invitations and it is essential that we learn from and share the 8
PRESS PLAY REPORT 2020 experience in these areas. For Combined with a reduction in the The new NHS People Plan for example, in Greater Manchester number of people that services 2020/21 in England recognised two members of NHS staff have will be able to see as a result of the severe pressures the NHS been appointed to undertake infection prevention and control workforce has been under during health promotion activities, measures, we are concerned the outbreak – which could be including calling women that have that this demand threatens to intensified if lack of access to been invited to make screening overwhelm services and may lead coronavirus testing means staff appointments, but have not, to people waiting longer to be must self-isolate - and set out targeting the most deprived areas. diagnosed and receive treatment broad ambitions to recruit more for their breast cancer. The cancer staff.12 However, further action Demand for imaging recovery plans being developed is urgently needed in the short and diagnostics by governments and the NHS and longer-term across the UK to The expected increase in referrals across the UK must set out how ensure there is an appropriately and backlog of women waiting for this demand will be managed resourced workforce. Without breast screening will lead to an so that this does not happen. this recovery plans could be increase in demand for diagnostic undermined and we risk failing to and imaging services in the achieve broader ambitions on early coming months. The workforce diagnosis, treatment and care. in these services was already stretched before the pandemic. For example, a quarter of trusts and health boards across the UK WHAT NEEDS TO have at least one vacant breast HAPPEN NOW? radiologist role, and vacancies are set to increase as a quarter of The NHS across the The UK Government must breast radiologists are expected UK should continue to take immediate action to retire over the next five years.11 encourage people who as part of the upcoming Many staff may also be suffering have symptoms that might Comprehensive Spending from burnout from the demands be cancer to contact Review to provide much- placed on them during this time. their GP surgery to get needed investment them checked out. for recruitment in the imaging and diagnostic The recovery plans for cancer workforce. cancer being developed ‘Across the board it has by governments and the If open invites are used been extremely challenging NHS across the UK must for the breast screening for the workforce. Ultimately, set out how the expected programme, uptake – we are significantly under- influx of demand for including amongst groups resourced. The People Plan doesn’t imaging and diagnostics already less likely to access go far enough, but if I’m being an will be safely managed. breast screening – must optimist, every little helps. The be monitored regularly and NHS can’t squeeze much more Governments and the NHS locally, and measures to out of us; more equipment can be across the UK must assess mitigate against a decline in given but you can’t run it without diagnostic capacity across uptake implemented. They a fully resourced workforce.’ breast cancer services should also be used for a Dr Caroline Rubin, and set out a demand-led, limited period, as proposed. clinical radiologist long-term plan to ensure the workforce has enough resource and support now and in the future. 9
PRESS PLAY REPORT 2020 78% OF ALL RESPONDENTS TOLD US THEY THOUGHT THE CORONAVIRUS PANDEMIC HAD AN IMPACT ON THEIR TREATMENT AND CARE The NHS moved quickly to issue In Wales performance is measured guidance on treating cancer safely against the target that patients ‘Cancer treatment didn’t stop for at the start of the pandemic. should receive their first treatment me during the outbreak, yes it within 62 days of being urgently impacted and altered it but I am A significant proportion of referred with a suspicion of cancer. still here thanks to the NHS still respondents to our survey did The number of patients starting working through such times.’ not experience changes to treatment in Wales dropped Survey respondent their treatment. Delays and by over a third in April and May cancellations to surgery, including compared to the same time last breast reconstruction, were the year, but has now recovered, biggest changes reported. Many although the percentage starting 95% of all respondents were respondents were concerned treatment within 62 days has not worried there would be continued about the potential impact of been recorded since February.14 pressure on the NHS in the next these changes. Recovery plans 12 months, and 88% were worried must set out how treatment there would be cancellations, will be safely restored to pre- Experience of treatment delays and disruption to breast pandemic levels, and deal with Although 78% of all respondents cancer treatment during this time. the backlog. Implementation told us they thought the of some beneficial treatment coronavirus pandemic had Surgery changes, like shorter courses of an impact on their treatment Surgery is usually the first radiotherapy, were accelerated by and care, 52% described their treatment that most patients with the pandemic, and these changes experience during this time as primary breast cancer will have. must be able to continue. positive or very positive. However, During the pandemic those with of the 1160 respondents receiving certain types of breast cancer Treatment waiting times or awaiting treatment only 43% (triple negative and HER2 positive) Patients should receive their first said they definitely felt as involved have been prioritised for surgery.16 treatment for cancer within 31 as they wanted to be in decisions Some patients with hormone days of being diagnosed, although about their treatment and care, receptor positive breast cancer the target for this varies across compared to 81% of breast were started on hormone therapy the UK from 95% in Scotland cancer patients responding to following research which showed to 96% in England and 98% in the Cancer Patient Experience that in the majority of cases Northern Ireland. In England the Survey in 2019 in England.15 this could safely delay surgery percentage of patients starting for at least six months.17 Risk- their first treatment within 31 days This may be related to the fact reducing mastectomies for women dropped from 97% in February, that many respondents felt they at increased risk of developing March and April, to 90% in May had less contact with healthcare breast cancer because of their but recovered to 95% in July. In professionals during this time. family history were suspended.18 Northern Ireland, 95% of patients started their first treatment within 31 days in May and June.13 Data for Scotland for this period has not yet been published. 43% Of the 354 respondents that SAID THEY DEFINITELY FELT AS INVOLVED told us they were diagnosed between January and July, 62% AS THEY WANTED TO BE IN DECISIONS said that they had started their ABOUT THEIR TREATMENT AND CARE first treatment for breast cancer within 3-4 weeks of receiving their diagnosis, with a further 17% starting within 4-6 weeks. 11 11
PRESS PLAY REPORT 2020 462 respondents to our survey Data from NHS England shows In the past, some Clinical told us they had received or that between March and June the Commissioning Groups (CCGs) were awaiting surgery during the number of people having breast in England have implemented pandemic. The majority of these cancer surgery was at 76.3% of restrictions on the time in (43%) told us there had been no the level in the same months which reconstruction should be change to their surgery. However, in 2019.19 The reduced numbers complete.23 There are already 27% told us they had experienced of people being referred and delays of 1 to 2 years for delayed cancellations or delays to their diagnosed during this time, as well reconstruction in many hospitals. surgery. Some of these delays or as some women being started Women waiting for delayed cancellations may be because on hormone therapy instead, are reconstruction should not be patients started on hormone likely to have contributed to this. prevented from having surgery as therapy - or chemotherapy - a result of any such restrictions. instead of surgery. Many patients Breast reconstruction told us they had their NHS surgery Breast reconstruction was Of those respondents that in a private hospital as a result suspended during the peak experienced changes to their of agreements between NHS and of the pandemic. Thirty per reconstructive surgery nearly healthcare providers to provide cent of women that have a half (48%) told us they were COVID-safe areas for treatment. mastectomy choose to have unhappy with their body image, breast reconstruction and this is and 59% were concerned that a crucial part of their treatment they would need more operations and recovery from breast cancer.20 as they were unable to have ‘My surgery happened quickly 21% of respondents that were reconstruction at the same as a slot in a private hospital receiving or awaiting surgery said time as their mastectomy.24 was found in April. I did not have their breast reconstruction had chemo beforehand but am happy been cancelled or delayed. We with surgery that went ahead.’ estimate that over 1000 women Survey respondent will have missed out on immediate ‘Patients requiring breast reconstruction, and around another reconstruction surgery, who 500 will have had their delayed are often really vulnerable, are reconstruction delayed further.21 at the end of the queue at the moment and could be waiting ‘Longer waiting times, location The British Association of a long time for their surgery’ changes, surgeon changes, Plastic Reconstructive and Ruth Waters, having to shield for two weeks Aesthetic Surgeons (BAPRAS) consultant plastic and before, not being allowed issued guidance in June reconstructive surgeon and company, and general uncertainty recommending that breast president elect of BAPRAS. has all had an impact.’ reconstruction be restarted, Survey respondent beginning with immediate reconstruction.22 BAPRAS told us that most hospitals performing reconstructive surgery are currently restricted to between 20% and 50% of pre-coronavirus activity. 12
PRESS PLAY REPORT 2020 12% experienced delays in accessing their drug treatment, 12% EXPERIENCED DELAYS IN ACCESSING THEIR DRUG TREATMENT DURING THE PANDEMIC Overall, of those respondents Guidance on the delivery of who experienced changes to drug treatment and interim ‘My treatment was stopped at their surgery, 61% said this had a treatment options to provide the beginning of lockdown but negative impact on their emotional greater flexibility in managing now I’m having a new chemo and mental health, and 62% that cancer was quickly introduced.27 after eventually having a CT scan it had increased their anxiety. This included reducing the that showed my worst fears Just over a third were worried course of adjuvant trastuzumab of cancer spreading…Not only about their cancer growing or treatment from 12 months to 6 has this affected me physically spreading (34%) and that they months which had already been but the emotional and mental may now need more extensive shown to be as effective, whilst stress has been immense too.’ surgery (35%). 41% were worried potentially reducing the risk of Survey respondent that the changes would impact on patients having to stop treatment their long-term outcomes from due to heart problems.28 breast cancer. Many people also told us how daunting it was to Guidance also suggested how ‘I think despite the shock and have to go for treatment alone.25 patients should be prioritised for anxiety of being diagnosed with drug treatment if this became secondary breast cancer, I’ve Drugs necessary. Patients having non- been most fortunate in having Drug treatment is a cornerstone curative treatment, such as those chemotherapy on time….. of the breast cancer pathway. with secondary breast cancer, Others haven’t been so lucky.’ This is particularly the case for were generally given a lower Survey respondent patients with secondary breast priority than those having curative cancer for whom drugs can extend treatment.29 This was hugely the time before their disease concerning and we raised this progresses and extend their lives. with governments and the NHS 969 respondents to our survey who reiterated the importance told us they were receiving or During the pandemic some of decisions being made on an awaiting drug treatment during patients with both primary and individual basis according to the the pandemic. The majority (56%) secondary breast cancer had risks and benefits of treatment. experienced no change to their their chemotherapy or targeted drug treatment. 12% experienced treatments changed or temporarily However, the extent to which this delays in accessing their drug paused, primarily to protect guidance was used in practice treatment, 9% people received it their immune systems. Data is unclear. It is essential that in a different setting, for example from NHS England suggests that the needs of secondary breast at home rather than hospital, and in April the number of people cancer patients are identified 7% experienced changes to the starting chemotherapy for breast and addressed in the cancer drugs they would normally use. cancer fell to 61% of levels in recovery plans that are being April 2019. By June this had developed, including recognising returned to 92% of 2019 levels.26 the importance of drug treatment for these patients. 13
PRESS PLAY REPORT 2020 47% FELT THAT CHANGES TO THEIR DRUG TREATMENT INCREASED THEIR ANXIETY, WITH 41% STATING THE CHANGES HAD A NEGATIVE IMPACT ON THEIR EMOTIONAL AND MENTAL WELLBEING Bisphosphonates Radiotherapy ‘Locally we’ve still carried on Post-menopausal women with Radiotherapy is most often given with treatment for breast cancer primary breast cancer may also be in 15 doses, five days a week patients but there does seem to offered bisphosphonates to help for three weeks. Recent results have been some variation across reduce the risk of breast cancer from the FAST and FAST-Forward regions. We changed a small spreading to other parts of the trials showed that radiotherapy number of drug treatments after body. Stopping bisphosphonates could be just as effective for discussions with patients, but for this purpose was included certain patients given in fewer for the vast majority treatment in the guidance on interim but higher doses either every day didn’t change. For chemotherapy treatment options during the for five days, or once a week for we took over a private hospital in pandemic issued by NICE and NHS five weeks.32 The Royal College order for people to attend their England to reduce the number of of Radiologists recommended outpatient appointments which people coming into hospital. 31 in March that the results of helped patients feel safer’. these trials be implemented Mark Beresford, Of the 207 women who told us in response to the pandemic.33 clinical oncologist they were receiving or awaiting 80% of respondents to a survey treatment with bisphosphonates, of radiotherapy units by Action 50% told us there had been no Radiotherapy in April said they had change in their treatment. Given implemented these changes. 34 Of those whose drug treatment the most popular frequency for was affected as a result of the giving IV bisphosphonates is six- pandemic, 39% were worried monthly, it may be that this has changes would impact on the not impacted many women. 29% effectiveness of their drug said their treatment had been treatment, and that their delayed. This will likely have been cancer would grow or spread the case for new patients as as a result, with this being a they should have a dental check- bigger worry for patients with up before starting treatment secondary breast cancer. 43% to help avoid a rare but serious of those affected by changes side effect, osteonecrosis of the were worried it would impact on jaw, and dental services were their long-term outcomes from suspended during lockdown. breast cancer. Nearly half (47%) felt that changes to their drug treatment increased their anxiety, with 41% stating the changes had a negative impact on their emotional and mental wellbeing.30 14
PRESS PLAY REPORT 2020 409 respondents to our survey The breast radiotherapy told us that they were receiving WHAT NEEDS TO community has embraced or awaiting radiotherapy during HAPPEN NOW? the use of five doses of the pandemic. 31% of these said radiotherapy rather than 15. that there had been changes We saw a very quick move in to the timeframe in which their Recovery plans for April and May towards this. radiotherapy was being delivered, cancer being developed There are clear patient benefits and 10% that their dosage had by governments and the – fewer visits to hospital, been changed. 12% said that their NHS across the UK must with equivalent outcomes radiotherapy had been delayed. set out how treatment and no worse side effects. NHS England data suggests that will be safely restored to Dr Imogen Locke, the number of people starting pre-pandemic levels, and consultant clinical oncologist radiotherapy for breast cancer the backlog dealt with. between March and June remained This includes women at over 90% of levels during who were unable to have the same period of 2019.35 breast reconstruction during this time. Of those that experienced changes to their radiotherapy, just over a These plans must also quarter (26%) were worried that identify and address their cancer would grow or spread, the needs of secondary and just over third (34%) that this breast cancer patients, would impact on their long-term including recognising outcomes from breast cancer. 28% the importance of said that changes had a negative drug treatment for impact on their emotional and these patients. mental health, and 33% that it had increased their anxiety. 36 Women must not be prevented from having breast reconstruction because of any time limits imposed on these operations by CCGs in England. Some treatment changes introduced during the pandemic, including the reduction in the number of doses of radiotherapy and cycles of adjuvant trastuzumab, have benefits for patients and the NHS and should be enabled to continue with these. 15
PRESS PLAY REPORT 2020 CLINICAL TRIALS AND RESEARCH 16
PRESS PLAY REPORT 2020 85% OF RESPONDENTS WERE ALSO CONCERNED ABOUT DELAYS AND DISRUPTION TO CLINICAL RESEARCH INTO BREAST CANCER Clinical trials provide a vital Of 92 breast cancer trials that the at least 30%. We have also had to opportunity for patients to access NIHR Clinical Research Network cancel our latest round of project potential new treatments at an was supporting in March 2020, grants and PhD studentships. early stage of their development. 50% paused recruitment, 45% Cuts to research may in the continued and 5% closed.39 This long-term lead to charities losing This is particularly important for suggests that there may have the capacity they have built in women with secondary breast been relatively little disruption their research areas, including cancer, who often have limited for patients that were already being unable to support the next treatment options available on trials. Of the 118 respondents generation of researchers. to them and for whom clinical who were receiving, or expecting trials provide precious hope to receive, treatment as part of To ensure that vital research of more time with loved ones. a clinical trial during this time, progress does not stall we are Whilst there was relatively little just under a quarter (22%) told supporting the Association of disruption for breast cancer us they had experienced such Medical Research Charities (AMRC) patients already on clinical disruption. However, this pause call for match-funding from the trials, the pause in recruitment in recruitment will have made it Government for future charity to many trials will have made more difficult to access trials, research through the upcoming it difficult for other patients to and 59% of all respondents Comprehensive Spending Review. access them. The pace at which were concerned about this. clinical trials restart must be closely monitored with further In conversations with secondary measures to assist with restarting breast cancer patients they considered if necessary. The have pointed to the speed with WHAT NEEDS TO Government should provide match which trials for coronavirus have HAPPEN NOW? funding through the upcoming been set up and are keen for the Comprehensive Spending review lessons from this to be applied to The NIHR and equivalent to protect vital charity research. setting up clinical trials for cancer bodies in the nations and other health conditions. should continue to In March, the National Institute closely monitor the of Health Research (NIHR) The NIHR published a framework restart of clinical trials suggested that many NIHR funded to support restarting clinical trials and publish information or supported studies may have in May, which is being used across on them, and consider to be paused as healthcare the UK.40 As of September 40% if, and what, further professionals were asked to of non-commercial and 57% of measures could be taken prioritise frontline care and make commercial studies were open to assist with this. research facilities available for for recruitment in the UK.41 this if asked to do so by their The Government should employer. It also paused the site 85% of respondents were also match fund future set up of new and ongoing trials.37 concerned about delays and charity research over disruption to clinical research the next three years The Medical and Healthcare into breast cancer more broadly. via a Life Sciences- products Regulatory Agency Like many other medical research Charity Partnership (MHRA) issued guidance charities, the research that Breast Fund for medical on managing trials during Cancer Now funds has been research charities. the outbreak, including impacted by the estimated drop in recommendations on remote our income. Though all our long- The NIHR and MHRA monitoring.38 48% of respondents term research will continue, we should consider how to our survey who were receiving have had to reduce the amount the speed with which treatment through a clinical trial of funding to the Breast Cancer clinical trials for vaccines said they were having telephone Now Toby Robins Research Centre, and treatments for follow up and interaction Tissue Bank, Generations Study coronavirus have been instead of face-to-face. and King’s College London Unit by set up could be applied to cancer trials. 17
PRESS PLAY REPORT 2020 CARE AND SUPPORT 18
PRESS PLAY REPORT 2020 82% OF RESPONDENTS EXPERIENCED TELEPHONE APPOINTMENTS INSTEAD OF FACE TO FACE Living with breast cancer can be incredibly difficult at the best ‘Although treatment wasn’t ‘Doing clinics in a mask and telling of times. Good care and support changed, the lack of supporting someone they have cancer is can make a real difference. services have made it very very impersonal and not being stressful. Also, I have been able to maybe put a hand on The pandemic and resulting unable to see the oncologist their shoulder or offer proper changes to treatment and care which would have been a empathy is not very nice.’ have been a real source of anxiety key point of reassurance.’ Nicky Roche, for many people with breast Survey respondent consultant breast surgeon cancer. Whilst the majority of respondents that accessed By far the biggest change in support did so through a clinical people’s care was the move from nurse specialist (CNS), many felt The face-to-face support services face-to-face appointments to they had less contact with them provided by Breast Cancer Now telephone appointments, with 82% during this period. It is vital that were suspended at the start of the of respondents saying they had support services are included in pandemic, although we have been experienced this.43 Whilst some recovery plans. Additional funding offering online alternatives for our preferred this as it was quicker to recruit and train more CNSs to Moving Forward programme for and easier than travelling into meet the needs of people living primary breast cancer, and Living hospital, others were concerned with breast cancer, including with Secondary Breast Cancer that they had not been seen in secondary breast cancer, both programme, as well as opening person. Moving forward it will now and in the future, must be up our Someone Like Me service be important to remember that provided through the upcoming to provide one-to-one support virtual appointments will not Comprehensive Spending Review. for anyone with breast cancer be the right way of interacting feeling isolated or anxious as a with everyone, every time and Respondents to our survey result of the pandemic. We will the healthcare professionals felt the coronavirus outbreak also be rolling out personalised we spoke to recognised this. had impacted on their care in direct referrals to our services several ways. These included later this year, to ensure people being unable to access services are aware of the services Breast such as counselling and therapy Cancer Now provides from ‘Just because appointments (48%) a lack of appropriate diagnosis onwards. Our Helpline by phone are convenient for follow-up support (39%) and and Ask Our Nurse services doctors, it doesn’t mean it is being unable to access scans continued to operate as normal. best for patients. We need to to monitor their breast cancer get back to seeing patients (35%).42 However, access to – not all of them – some of some types of support, including them, including new patients. counselling, may have been At some stage, we all need to difficult before the pandemic. think about which appointments can be done appropriately by telephone and which patients need to come into hospital.’ Andreas Makris, consultant clinical oncologist 19
PRESS PLAY REPORT 2020 41% OF RESPONDENTS FELT THEY HAD LESS CONTACT WITH THEIR CNS DURING THIS PERIOD Personalised care Access to clinical nurse specialists ‘The total lack of face to face Everyone with cancer should Clinical nurse specialist’s (CNSs) appointments has been very have access to personalised care, play a crucial role in co-ordinating challenging to come to terms including a needs assessment, care and providing the information with. Telephone consultations care plan and health and wellbeing and support patients need to didn’t answer questions and were information. NHS England’s Long- manage their diagnosis and often at unexpected times.’ Term Plan includes an aspiration treatment. Access to a CNS can Survey respondent that this will happen by 2021.44 make a big difference to the way The Scottish Government has people experience their care. Being diagnosed and treated for committed to this happening by This is particularly important for breast cancer can be anxious 2023 and made good progress patients with secondary breast and stressful at any time. by funding the Transforming cancer who will be on lifelong Many patients told us that Cancer Care programme with treatment and have complex coronavirus had an impact on their Macmillan Cancer Support to emotional and support needs. emotional wellbeing, with 60% provide access to a support of all respondents to the survey worker to assess patient’s needs However, in a Breast Cancer Now feeling stressed or anxious, 58% and link with relevant support survey of secondary breast cancer being worried about the future, services.45 Actions in the Wales patients in 2019 only 30% said 38% feeling isolated and 35% Cancer Delivery Plan to support they regularly saw a CNS, and only unable to plan for the future. the delivery of person-centred 65% said their CNS had enough care include undertaking needs time to spend with them.47 A assessments and care planning.46 Breast Cancer Now survey of CNSs Progress towards implementing in early 2020 found that only 35% this must continue. Northern felt that they have enough time Ireland is currently developing to offer each secondary breast I have really noticed the impact of a new cancer strategy and this cancer patient the opportunity the current situation on patient’s should also include commitments to discuss their wider concerns emotional wellbeing which is on personalised care. and needs in the weeks following really difficult. Patients may be diagnosis, and even less (31%) have out in the community and may Both changes to treatment and the time to offer this as treatment not be supported in the same way care as a result of the coronavirus changes or the cancer progresses. they usually are or it may have outbreak, and the emotional exacerbated previous issues. impact this is having on people Amongst the 446 respondents Mark Beresford, with breast cancer make access to our survey who told us they clinical oncologist to a clinical nurse specialist accessed support during this (CNS) and support services more period, the most popular way of important than ever. The cancer doing so was from a CNS (30%). recovery plans being developed However, 41% of respondents also across the UK must ensure felt they had less contact with that patient’s care and support their CNS during this period.48 needs are being met during this period, alongside restoring cancer diagnostics and treatment to pre- pandemic levels. Some services, such as monitoring scans, will be using the same equipment and staff as diagnostic scans. 20
PRESS PLAY REPORT 2020 Shielding ‘BCNs [breast care nurses] are In March people who were WHAT NEEDS TO a critical point of contact…..I identified by their clinical team was lucky my treatment as extremely clinically vulnerable HAPPEN NOW? continued, but it shouldn’t were advised to ‘shield’. Those be forgotten that support is with breast cancer having The cancer recovery still needed for those who are treatment that suppresses the plans being developed still undergoing treatment.’ immune system were likely to by governments and Survey respondent be advised to shield. Just over the NHS across the half of respondents to our survey UK must ensure that (52%) were advised to shield. the care and support needs of patients are There was already a shortage Over the course of the pandemic met during this period. of CNSs before the pandemic. guidance on shielding has varied Our survey of CNSs found that across the nations, with each The upcoming only one in three believed their lifting shielding gradually. In Comprehensive Spending hospital had enough specialist August the shielding programme Review must provide nurses to give secondary breast was paused across the UK the necessary additional cancer patients the support and as a result of the decrease in funding to recruit and care they need, with 82% saying coronavirus cases. However, nearly train more clinical nurse this was because there are not two thirds (65%) of respondents specialists to ensure enough nursing posts. In common who were advised to shield were that everyone with with other parts of the workforce, concerned about this decision. breast cancer- including many CNSs were redeployed those with secondary elsewhere in the NHS during breast cancer - is the peak of the pandemic. For supported by a CNS. example, over 400 Macmillan NHS professionals including Macmillan Progress towards funded CNSs were redeployed.49 ensuring that everyone with breast cancer The recent NHS People Plan for has personalised care 2020/21 in England included must continue, and 350 training grants for nurses commitments on this to become cancer CNSs should be included in and chemotherapy nurses.50 the new cancer strategy However, additional funding being developed in is needed to recruit and train Northern Ireland. more CNSs to meet the needs Care plans should be of people living with breast reconsidered where cancer across the UK, now and necessary to take in the future. The upcoming account of changes Comprehensive Spending Review to people’s treatment must provide this funding. during the pandemic. If patients are advised to shield again then the shielding programme should ensure patients are sign posted to relevant emotional, practical and financial support services. 21
PRESS PLAY REPORT 2020 CONCLUSION 22
PRESS PLAY REPORT 2020 Coronavirus has affected every The breast cancer workforce have been. And for some part of the breast cancer pathway. will be critical to addressing patients, virtual consultations these challenges. The imaging have freed up time and removed What we have seen and and diagnostics workforce was the anxiety of going to hospital heard about the impact of stretched before the pandemic. during this period. We need to coronavirus on breast cancer, clinical nurse specialists did make sure that these positive including through our survey not have enough time to spend changes are carried forward. and discussions with healthcare with patients with secondary professionals, suggests there are breast cancer. The upcoming The recommendations that we many challenges that need to Comprehensive Spending Review have made seek to address the be addressed moving forward. must provide investment for challenges that have arisen recruitment both now and and ensure the most is made These include: ensuring that there for the longer term - as well of the positive changes, as are clear plans in place to safely as match funding to protect well as helping to ensure that manage the likely surge of demand future charity research. we are well prepared for any for diagnostics and imaging as further peaks of coronavirus. referrals continue to recover and The pandemic has resulted in breast screening restarts; that some positive changes. The NHS Coronavirus has placed huge treatments are safely restored to moved quickly to issue guidance additional strain on people pre-pandemic levels and demand on safely diagnosing and treating affected by breast cancer. With dealt with; that progress in breast cancer. Some changes to drug more challenges ahead, we cancer research, including through treatment and radiotherapy – must act now to ensure that clinical trials, does not stall; and which benefit both patients and breast cancer services do not that patients have the care and the NHS – were implemented more have to be paused again. support they need at this time. quickly than they would otherwise 23
PRESS PLAY REPORT 2020 SUMMARY OF RECOMMENDATIONS Overarching The UK Government must take Diagnosis The recovery plans for immediate action as part of The NHS across the UK should cancer being developed by the upcoming Comprehensive continue to encourage people governments and the NHS Spending Review to provide: who have symptoms that might across the UK must set out: be cancer to contact their GP much-needed investment for surgery to get them checked out. how the expected influx recruitment in the imaging and of demand for imaging diagnostic cancer workforce. Governments and the NHS across and diagnostics will be the UK must assess diagnostic safely managed; the necessary additional capacity across breast cancer funding to recruit and train services and set out a demand- set out how treatment more clinical nurse specialists led, long-term plan to ensure the will be safely restored to to ensure that everyone with workforce has enough resource pre-pandemic levels, and breast cancer- including those and support now and in the future. the backlog dealt with. with secondary breast cancer This includes women who - is supported by a CNS. If open invites are used for the were unable to have breast breast screening programme, reconstruction during this match funding for future uptake – including amongst time, who should not be charity research over groups already less likely to prevented from having these the next three years via access breast screening – must operations as a result of a Life Sciences-Charity be monitored regularly and locally, any time limits imposed on Partnership Fund for medical and measures to mitigate against them by CCGs in England; research charities. a decline in uptake implemented. They should also be used for a identify and address the limited period, as proposed. needs of secondary breast cancer patients, including recognising the importance of drug treatment for these patients; and ensure that the care and support needs of patients are met during this period. 24
PRESS PLAY REPORT 2020 ‘THE NHS ACROSS THE UK Treatment and clinical trials Care and Support Some treatment changes Progress towards ensuring that SHOULD CONTINUE TO introduced during the pandemic, everyone with breast cancer has ENCOURAGE PEOPLE WHO including the reduction in the personalised care must continue, HAVE SYMPTOMS THAT number of doses of radiotherapy and commitments on this should and cycles of adjuvant be included in the new cancer MIGHT BE CANCER TO trastuzumab, have benefits for strategy being developed in CONTACT THEIR GP SURGERY patients and the NHS and should Northern Ireland. Care plans TO GET THEM CHECKED OUT.’ be enabled to continue with these. should be reconsidered where necessary to take account of The NIHR and equivalent bodies changes to people’s treatment in the nations should continue during the pandemic. to closely monitor the restart of clinical trials and publish If patients are advised to information on them, and consider shield again then the shielding if, and what, further measures programme should ensure could be taken to assist with this. patients are sign posted to relevant emotional, practical The NIHR and MHRA should and financial support services. consider how the speed with which clinical trials for vaccines and treatments for coronavirus have been set up could be applied to cancer trials. 25
PRESS PLAY REPORT 2020 ENDNOTES 1 Thousands of women with secondary breast cancer 12 We are the NHS: People Plan 2020/21 – action for us all, ‘fearing for survival’ amid delays to treatments, scans NHS England, August 2020. Available at: www.england.nhs. and access to trials, Breast Cancer Now, May 2019. uk/wp-content/uploads/2020/07/We_Are_The_NHS_Action_ Available at: breastcancernow.org/about-us/media/press- For_All_Of_Us_FINAL_24_08_20.pdf releases/thousands-women-incurable-breast-cancer- %E2%80%98fearing-survival%E2%80%99-amid-delays- 13 Monthly Provider Based Data and Summaries, Cancer treatment-scans-access-trials Waiting Times, NHS England. Available at: www.england.nhs. uk/statistics/statistical-work-areas/cancer-waiting-times/ 2 The Unsurvivors, Breast Cancer Now, October 2019. monthly-prov-cwt/ Available at: breastcancernow.org/sites/default/files/bcn_ theunsurvivors_campaignreport_oct2019.pdf 14 Monthly cancer waiting times, StatsWales, Welsh Government. Available at: statswales.gov.wales/Catalogue/ 3 NHS urges people to get cancer symptoms checked as GP Health-and-Social-Care/NHS-Hospital-Waiting-Times/ referrals drop by 73%, NHS England, May 2020. Available Cancer-Waiting-Times/Monthly at: www.england.nhs.uk/midlands/2020/05/01/nhs- urges-people-to-get-cancer-symptoms-checked-as-gp- 15 Cancer Patient Experience Survey 2019, 2019 national level referrals-drop-by-73/#:~:text=Latest%20figures%20have%20 results, Picker. Available at: www.ncpes.co.uk/2019-national- revealed%20that,week%20ending%201%20March%202020 level-results and Urgent medical help still available, Scottish Government, April 202. Available at: www.gov.scot/news/urgent-medical- 16 Association of Breast Surgery Statements on COVID19. help-still-available/ Available at: associationofbreastsurgery.org.uk/for-members/ covid-19-resources/ 4 Monthly Provider Based Data and Summaries, Cancer Waiting Times, NHS England. Available at: www.england.nhs.uk/ 17 Dowsett, M et al, Evidence-based guidelines for managing statistics/statistical-work-areas/cancer-waiting-times/ patients with primary ER+ HER2− breast cancer deferred monthly-prov-cwt/ from surgery due to the COVID-19 pandemic. npj Breast Cancer 6, 21 (2020). Available at: doi.org/10.1038/s41523-020- 5 Monthly cancer waiting times, StatsWales, Welsh 0168-9 Government. Available at: statswales.gov.wales/Catalogue/ Health-and-Social-Care/NHS-Hospital-Waiting-Times/ 18 Association of Breast Surgery Statements on COVID19. Cancer-Waiting-Times/Monthly Available at: associationofbreastsurgery.org.uk/for-members/ covid-19-resources/ 6 Estimate based on cancer waiting times data in England and Wales. For Scotland and Northern Ireland the average 19 Data provided by NHS England and NHS Improvement. percentage drop in referrals in England between March and July 2020 was applied to referrals between March and July 20 National Mastectomy and Breast Reconstruction Audit 2011, 2019. The Royal College of Surgeons of England. Available at: www. rcseng.ac.uk/library-and-publications/rcs-publications/docs/ 7 NHS urges people to get cancer symptoms checked as GP mastectomy-breast-4/ referrals drop by 73%, NHS England, May 2020. Available at: www.england.nhs.uk/midlands/2020/05/01/nhs-urges- 21 Estimate based on data from the Audit on the number of people-to-get-cancer-symptoms-checked-as-gp-referrals- women having immediate and delayed reconstruction and drop-by-73/#:~:text=Latest%20figures%20have%20 updated to 2020. revealed%20that,week%20ending%201%20March%202020. 22 Re-establishing breast reconstruction services, British 8 Association of Breast Surgery Statements on COVID19. Association of Plastic Reconstructive and Aesthetic Available at: associationofbreastsurgery.org.uk/for-members/ Surgeons, June 2020. Available at: www.bapras.org.uk/ covid-19-resources/ media-government/news-and-views/view/re-establishing- breast-reconstruction-services 9 Monthly Provider Based Data and Summaries, Cancer Waiting Times, NHS England. Available at: www.england. 23 Rebuilding my body: Breast reconstruction in nhs.uk/statistics/statistical-work-areas/cancer-waiting- England, Breast Cancer Now, June 2018. Available at: times/monthly-prov-cwt/, and Northern Ireland Waiting breastcancernow.org/sites/default/files/rebuilding_my_ Times Statistics: Cancer Waiting Times (April - June 2020, body_report_ june_2018.pdf Department of Health, September 2020. Available at: www. health-ni.gov.uk/sites/default/files/publications/health/hs- 24 We asked respondents that were receiving or awaiting niwts-cancer-waiting-times-q1-20-21.pdf surgery how much they agreed or disagreed with a set of statements about changes to their surgery. Those who 10 Estimate based on the average number of women screened said that the statement was not applicable to them were per month, and the approximate length of time the screening excluded from this analysis. programme was suspended, in each part of the UK. 25 Ibid. 11 Clinical Radiology: UK workforce census 2019, Royal College of Radiologists, April 2020. Available at: www.rcr.ac.uk/ system/files/publication/field_publication_files/clinical- radiology-uk-workforce-census-2019-report.pdf 26
PRESS PLAY REPORT 2020 26 Data provided by NHS England and NHS Improvement. 37 DHSC issues guidance on the impact of COVID-19 on research funded or supported by NIHR, National Institute for 27 Clinical guide for the management of non-coronavirus Health Research, March 2020. Available at: www.nihr.ac.uk/ patients requiring acute treatment: cancer, NHS England, news/dhsc-issues-guidance-on-the-impact-of-covid-19-on- March 2020. Available at www.england.nhs.uk/coronavirus/ research-funded-or-supported-by-nihr/24469 wp-content/uploads/sites/52/2020/03/specialty-guide- acute-treatment-cancer-23-march-2020.pdfand NHS England 38 Managing clinical trials during Coronavirus (COVID-19), interim treatment options during the COVID19 pandemic, May Medicines and Healthcare products Regulatory Agency, March 2020. Available at: www.nice.org.uk/guidance/ng161/resources/ 2020 Available at: www.gov.uk/guidance/managing-clinical- interim-treatment-change-options-during-the-covid19- trials-during-coronavirus-covid-19 pandemic-endorsed-by-nhs-england-pdf-8715724381. 39 Answer to UK parliamentary question provided by Helen 28 Earl, Prof HM et al, 6 versus 12 months of adjuvant Whately MP on 18 June 2020. trastuzumab for HER2-positive early breast cancer (PERSEPHONE); 4-year disease-free survival results of a 40 A framework for restarting NIHR research activities which randomized phase 3 non-inferiority trial, The Lancet, June have been paused due to COVID-19, National Institute for 2019. Available at: doi.org/10.1016/S0140-6736(19)30650-6 . Health Research, May 2020 Available at: www.nihr.ac.uk/ documents/restart-framework/24886 29 Clinical guide for the management of non-coronavirus patients requiring acute treatment: cancer, NHS England, 41 NIHR shares third monthly update on implementation of the March 2020. Available at www.england.nhs.uk/coronavirus/ Restart Framework, National Institute for Health Research, wp-content/uploads/sites/52/2020/03/specialty-guide- September 2020. Available at: www.nihr.ac.uk/news/nihr- acute-treatment-cancer-23-march-2020.pdf and Coronavirus shares-third-monthly-update-on-implementation-of-the- (COVID19); national guidelines for cancer treatment, restart-framework/25650. Scottish Government, April 2020.Available at: www.gov.scot/ publications/coronavirus-covid-19-clinical-guidelines-for- 42 We asked respondents how much they agreed or disagreed cancer-treatment/ with a set of statements about their care during the pandemic. Those who said that the statement was not 30 We asked respondents that were receiving or awaiting drug applicable to them were excluded from this analysis. treatment how much they agreed or disagreed with a set of statements about changes to their drug treatment. Those 43 We asked respondents how much they agreed or disagreed who said that the statement was not applicable to them were with a set of statements about their care during the excluded from this analysis. pandemic. Those who said that the statement was not applicable to them were excluded from this analysis. 31 NHS England interim treatment options during the COVID19 pandemic, May 2020. Available at: www.nice.org.uk/guidance/ 44 Long Term Plan, NHS England, January 2019. Available at ng161/resources/interim-treatment-change-options- www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs- during-the-covid19-pandemic-endorsed-by-nhs-england- long-term-plan-version-1.2.pdf pdf-8715724381. 45 £18 million funding for cancer support workers, Scottish 32 Brunt, A M et al, Hypofractionated breast radiotherapy for Government, August 2019. Available at: www.gov.scot/news/ 1 week versus 3 weeks (FAST-Forward): Five year efficacy gbp-18-million-funding-for-cancer-support-workers-1/ and late normal tissue effects results form a multicentre, randomized, non-inferiority phase 3 trial, The Lancet, April 46 Cancer Delivery Plan for Wales 2016-2020, Welsh 2020, Available at: doi.org/10.1016/S0140-6736(20)30932-6 Government, November 2016. Available at: www.walescanet. and FAST Phase III RCT of Radiotherapy Hypofractionation wales.nhs.uk/sitesplus/documents/1113/161114cancerplanen. for Treatment of Early Breast Cancer: 10 Year Results pdf (CRUKE/04/015), International Journal of Radiation Oncology, December 2018. Available at: doi.org/10.1016/j. 47 The Unsurvivors, Breast Cancer Now, October 2019. ijrobp.2018.08.049 Available at: breastcancernow.org/sites/default/files/bcn_ report1_1019v2_-_final_22.11.19_0.pdf 33 Guidelines on radiation therapy for breast cancer during the COVID-19 pandemic, The Royal College of Radiologists, March 48 We asked respondents how much they agreed or disagreed 2020. Available at: www.rcr.ac.uk/sites/default/files/breast- with a set of statements about their care during the cancer-treatment-covid19.pdf pandemic. Those who said that the statement was not applicable to them were excluded from this analysis. 34 Impact of COVID19 on UK Radiotherapy, Action Radiotherapy. Available at: ebf9be9c-890d- 49 Written evidence submitted by Macmillan Cancer Support 4dca-b67e-2c40c584e614.filesusr.com/ugd/ for Health and Social Care Committee’s inquiry on Delivering b68571_5a27d1bd9d434ebb898facc3199de2e8.pdf Core NHS and Care Services during the Pandemic and Beyond, Macmillan Cancer Support. Available at: committees. 35 Data provided by NHS England and NHS Improvement. parliament.uk/writtenevidence/4582/pdf/ 36 We asked respondents that were receiving or awaiting 50 We are the NHS: People Plan 2020/21 – action for us all, NHS radiotherapy how much they agreed or disagreed with a set England, August 2020. Available at: www.england.nhs.uk/wp- of statements about changes to their radiotherapy. Those content/uploads/2020/07/We_Are_The_NHS_Action_For_All_ who said that the statement was not applicable to them were Of_Us_FINAL_24_08_20.pdf excluded from this analysis. 27
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