Sir, for those involved in cancer care it is clear that our patients have been the collateral damage of this pandemic. There have never been more patients waiting 104 days for their cancer treatment.1 This has consequences; even a four-week delay causes a 13% increase in mortality.2 To mitigate this, NHS England published guidance (P1, P2, P3 and P4 categories) for those with the greatest healthcare need. This has been to ensure P1 and P2 cancer surgery is prioritised alongside patients with COVID-19.3 However, this national strategy has been implemented at a local level, where there are substantial differences from region to region. This variation has not aligned with either cancer or COVID-19 demand. Instead, this has been due to the ability to escalate beds and surgical capacity.4

The main increases in capacity have been the independent sector and the creation of cancer hubs. Some regions have more private hospitals, so finding additional operative capacity is relatively easier.5 The development of cancer hubs has helped some regions, but not equitably. For instance, the North West region has seen a 188% increase in their 104 day breaches versus London at 98%.1 Between specialities, there exists a large difference in activity too, with head and neck cancer (HNC) being one of the greatest affected. Dentists, the largest referral base for HNC, have seen a reduction in activity to 25%, compared to 2019 resulting in a 55% decrease in such referrals in April 2020 compared to 33% for lower GI malignancies.6

Whilst the strategy for priority triaging of patients has been well intended and needed, it has failed to take into account regional variations of services and different specialities. The success of the vaccination programme makes it easy to believe that these are historic problems. However, the government has modelled for a further wave in the autumn.7 If this is the case, then we may well see further inequity between cancer patients.

How we go about tackling this is not straightforward, and there is no silver bullet. However, the time to have this conversation is now. National strategy and guidance is one thing, but without thinking local and speciality specific, we will fail to tackle this crisis.