How has the COVID-19 pandemic impacted prescribing pancreatic enzyme replacement to people with unresectable pancreatic cancer?
In a recent study posted to the medRxiv* preprint server, researchers evaluated the impact of the coronavirus disease 2019 (COVID-19) pandemic on the rates of pancreatic enzyme replacement therapy (PERT) prescribing in England.
Studies have described the effects of the COVID-19 pandemic on cancer surgery, chemotherapy, and cancer research, including diagnostic, staging, and treatment delivery. There are over half a million new pancreatic cancer diagnoses every year globally. Due to late diagnoses in between 85 to 90% of cases, surgical resection becomes unfeasible. Therefore, pancreatic cancer has the lowest survival rate among all cancers.
For unresectable pancreatic cancer patients who suffer from extreme weight loss, malnutrition, and impaired quality of life via gastrointestinal symptoms, PERT can help to improve nutritional status and wellbeing. Subsequently, the National Institute for Health and Care Excellence (NICE) published a Quality Standard in December 2018 to ensure that all adults with unresectable pancreatic cancer receive PERT. Yet, PERT prescribing remains suboptimal across England. With the onset of the COVID-19 pandemic and associated healthcare disruption, there was a growing concern that this patient population would be further disadvantaged during the pandemic.
About the study
In the present study, researchers used the OpenSAFELY-TPP platform to conduct an automated audit of 24 million adults with unresectable pancreatic cancer receiving PERT between 1 January 2015 and 31 March 2022. The study dataset covered over 40% of England’s population and was pseudonymized, which means all primary care patient records included coded diagnoses, medications, and physiological parameters. OpenSAFELY-TPP offered several technical and organizational controls. Additionally, it facilitated the analysis of all data in real-time for regular updates.
SNOMED-CT codes indicated the presence of pancreatic cancer, whereas the absence of OPCS-4 codes indicated a surgical resection procedure after a pancreatic cancer diagnosis. The researchers adhered to codes from the National Health Service (NHS) Dictionary of Medicines and Devices. Likewise, they used a list of medications compiled from the British National Formulary (BNF) to define PERT. The team visualized the overall trends in PERT prescribing over time stratified by regions in England. They presented the proportion of individuals receiving PERT per 100 people with unresectable pancreatic cancer as monthly rates (in %).
To visualize change in rates over time, the team used time as a continuous variable in the study and used a generalized linear model (GLM). The study model accounted for the effect of COVID-19 and temporal shifts in prescribing trends to predict the expected rates in PERT prescribing. The researchers estimated the effect of the COVID-19 pandemic using the 95% confidence intervals of the predicted values.
The authors observed an insubstantial dip of around 3% in PERT prescribing to people with unresectable pancreatic cancer between March and July 2020, i.e., at the beginning of the COVID-19 pandemic. However, the rates again surged to normal levels by September 2020.
The authors observed that the COVID-19 pandemic worst affected the PERT prescribing rates in the West Midlands area. From 2018 onwards, this area had the highest PERT prescribing rates, between 50% and 60%, which dipped by nearly 10% in July 2020. The London region had the lowest rates of between 20% and 30% throughout the study.
Despite its proven benefits, PERT remained under-prescribed in all adults with unresectable pancreatic cancer even before the beginning of the COVID-19 pandemic.
The largest study in this area, receipt of curative resection or palliative care for hepatopancreatic biliary tumor (RICOCHET), relied on manual audits, which imposed a substantial resource burden on local teams collecting data. It was conducted between April and August 2018, six months after the introduction of the national pancreatic cancer guidelines. It demonstrated that PERT prescribing rates of 45% among patients with unresectable disease; additionally, these rates were highest within specialist sites, regardless of tumor stage and treatment intent.
The current study demonstrated that the pandemic did not impact PERT prescribing rates in England. It used OpenSAFELY tools that facilitated cost-effective, regular and nearly real-time audits and feedback to NHS organizations. Although increasing steadily over time by 1% each year, the rates remained under 50% in 2022, much below the recommended 100% quality standard. Future research should investigate the effect of COVID-19, the barriers to PERT prescribing, and geographic variations to improve the quality of care for pancreatic cancer patients. Indeed, the study data could help improve NHS services substantially across England.
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.