Socioeconomic inequalities in breast cancer survival persist in the UK. Area-based deprivation measures may underestimate socioeconomic effects by assigning average deprivation levels to all area inhabitants. This study investigated associations between house value (individual-level) and area-based deprivation with breast cancer outcomes in Northern Ireland. Women diagnosed with breast cancer from 2011 to 2021 were identified using the Northern Ireland Cancer Registry. House value was determined from Valuation and Lands Agency property valuation data, and area-based deprivation from the Northern Ireland Multiple Deprivation Measure. The primary outcome was breast cancer-specific mortality. Secondary outcomes were stage at diagnosis and all-cause mortality. Cox regression models calculated adjusted hazard ratios (HR) and 95

Baseline cardiovascular disease (CVD) has been linked with poorer outcomes for patients with cancer. The precise mechanisms underpinning that are poorly understood but may include reduced treatment receipt. We estimated the association between pre-existing CVD and cancer treatment receipt using population-based cancer registry records. Records of all adults diagnosed with cancer (excluding non-melanoma skin cancer) in Northern Ireland in 2009–2019 were linked with comorbidity and treatment data. The adjusted odds ratios (aOR) of receiving various cancer treatments for patients with previous cardiovascular diagnoses were estimated using multivariable logistic regression, adjusting for established confounders. Subgroup analyses were conducted for combinations of 24 tumour sites, 11 cardiovascular conditions, and 5 cancer treatment modalities. Kaplan-Meier curves and Cox proportional hazards model were used to analyse time to treatment. 81,341 cancer patients were included, with a mean age of 67.1 ± 14.1 years. The most common cancers included were breast (15.8%), lung (14.1%) and colorectal cancer (13.5%). Patients with pre-existing CVD (23.4%) were 30% less likely to receive any cancer treatment than patients without (aOR = 0.70 [95%CI 0.67, 0.73]). This reduction varied between treatment modalities with 30% for chemotherapy (aOR = 0.70 [95%CI 0.67, 0.73]), 28% for radiotherapy (aOR = 0.72 [95%CI 0.66, 0.79]), and 23% for surgery (aOR = 0.77 [95%CI 0.74, 0.80]). Hormone therapy showed no significant overall difference (aOR = 1.02 [95%CI 0.94, 1.11]). At 6 months post-diagnosis, patients with pre-existing CVD had a 14% (0.14 [95%CI 0.13, 0.15]) lower probability of initiating cancer treatment compared to those without. Pre-existing CVD was associated with an overall lower odds of cancer treatment, although the magnitude of this decrement varied according to the primary tumour, treatment modality and the type of CVD. These data present granular population-based insights into the impact of cardiovascular comorbidities on receiving cancer treatment and should be accounted for when reporting survival variations and healthcare policymaking.

Background Travel time has been associated with worse outcomes for several cancers. In breast cancer patients, we examined stage at diagnosis and mortality by travel time to General Practitioner (GP) practice and cancer treatment hospital. Methods Women newly diagnosed with breast cancer from 2011 to 2021 were identified using the Northern Ireland Cancer Registry. The travel times by car from home address to GP practice and to cancer treatment hospitals were determined. The primary outcome was time to breast cancer-specific mortality up to March 2023. Secondary outcomes included stage at diagnosis. Cox regression models calculated adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for breast cancer-specific mortality by travel time. Results The final cohort included 13,629 breast cancer patients. Among women living greater than 15 min by car from their GP practice, compared with less than 5 min, there was no association with later stage (5% versus 6% stage 4; adjusted odds ratio = 0.83 95% CI 0.61, 1.12) or breast cancer-specific mortality (adjusted HR = 1.10 95% CI 0.93, 1.10). Also, breast cancer-specific mortality was similar in women living greater than 60 min by car, compared with less than 15 min, from the hospital of their surgery (adjusted HR = 1.04 95% CI 0.88, 1.23), radiotherapy (adjusted HR=1.21 95% CI 0.99, 1.48) and systemic anti-cancer therapy (adjusted HR = 0.94 95% CI 0.75, 1.16). Conclusions In our population-based cohort of breast cancer patients, longer travel times were not associated with worse outcomes or later stage at diagnosis.

We examined the stage at diagnosis and breast cancer-specific mortality in a cohort of breast cancer patients prescribed medications used for mental health conditions before diagnosis. Women newly diagnosed with breast cancer from 2011 to 2021 were identified from the Northern Ireland Cancer Registry. The primary outcome was time to breast cancer-specific mortality up to March 2023. The secondary outcomes included stage at diagnosis. We identified anxiolytic, antidepressant, and antipsychotic prescriptions dispensed in the year before breast cancer diagnosis from the Northern Ireland Enhanced Prescribing Database. Cox regression models were used to calculate adjusted hazard ratios (aHR) and 95

The COVID-19 pandemic had a major impact on cancer patients and services but has been difficult to quantify. We examined how the entire cancer pathway-from incidence, presentation, diagnosis, stage, treatment and survival-was affected in Northern Ireland during April-December 2020 compared to equivalent 2018-2019 periods using retrospective, observational cancer registry data from the Northern Ireland Cancer Registry (NICR). There were 6748 cancer cases in April-December 2020 and an average 7724 patients in April-December 2018-2019. Incident cases decreased by 13% (almost 1000). Significant differences were found across age cohorts and deprivation quintiles, with reductions greatest for younger people (<55 years; 19% decrease) and less deprived (22% decrease). A higher proportion had emergency admission (16%-to-20%) with lower proportions diagnosed pathologically (85%-to-83%). There was a significant stage shift, with lower proportions of early stage (29%-to-25%) and higher late-stage (21%-to-23%). Lower proportions received surgery (41%-to-38%) and radiotherapy (24%-to-22%) with a higher proportion not receiving treatment (29%-to-33%). One-year observed-survival decreased from 73.7% to 69.8% and 1-year net-survival decreased from 76.1% to 72.9%, with differences driven by five tumours; Lung (40.3%-to-35.0%), Head-and-Neck (77.4%-to-68.4%), Oesophageal (53.5%-to-42.3%), Lymphoma (81.1%-to-75.2%) and Uterine cancer (87.4%-to-80.4%). Our study reveals profound adverse impact of COVID-19 on the entire cancer patient pathway, with 13% fewer cases, greater emergency admissions and significant stage-shift from early to more advanced-stage disease. There was major treatment impact with lower rates of surgery and radiotherapy and higher proportions receiving no treatment. There were significant reductions in 1-year survival. Our study will support service recovery and protect cancer services in future pandemics or disruptions.

The COVID-19 pandemic brought unplanned service disruption for breast cancer diagnostic, treatment and support services. This scoping review describes these changes and their impact in the UK and the Republic of Ireland based on studies published between January 2020 and August 2023. Thirty-four of 569 papers were included. Data were extracted and results thematically organized. Findings include fewer new cases; stage shift (fewer early- and more late-stage disease); and changes to healthcare organization, breast screening and treatment. Examples are accepting fewer referrals, applying stricter referral criteria and relying more on virtual consultations and multi-disciplinary meetings. Screening service programs paused during the pandemic before enacting risk-based phased restarts with longer appointment times to accommodate reduced staffing numbers and enhanced infection-control regimes. Treatments shifted from predominantly conventional to hypofractionated radiotherapy, fewer surgical procedures and increased use of bridging endocrine therapy. The long-term impact of such changes are unknown so definitive guidelines for future emergencies are not yet available. Cancer registries, with their large sample sizes and population coverage, are well placed to monitor changes to stage and survival despite difficulties obtaining definitive staging during diagnosis because surgery and pathological assessments are delayed. Multisite longitudinal studies can also provide guidance for future disaster preparedness.

BACKGROUND:There is little evidence on variation in radiotherapy use in different countries, although it is a key treatment modality for some patients with cancer. Here we aimed to examine such variation. METHODS:This population-based study used data from Norway, the four UK nations (England, Northern Ireland, Scotland, and Wales), nine Canadian provinces (Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Ontario, Prince Edward Island, and Saskatchewan), and two Australian states (New South Wales and Victoria). Patients aged 15-99 years diagnosed with cancer in eight different sites (oesophageal, stomach, colon, rectal, liver, pancreatic, lung, or ovarian cancer), with no other primary cancer diagnosis occurring within the 5 years before to 1 year after the index cancer diagnosis or during the study period were included in the study. We examined variation in radiotherapy use from 31 days before to 365 days after diagnosis and time to its initiation, alongside related variation in patient group differences. Information was obtained from cancer registry records linked to clinical or patient management system data, or hospital administration data. Random-effects meta-analyses quantified interjurisdictional variation using 95% prediction intervals (95% PIs). FINDINGS:Between Jan 1, 2012, and Dec 31, 2017, of 902 312 patients with a new diagnosis of one of the studied cancers, 115 357 (12·8%) did not meet inclusion criteria, and 786,955 were included in the analysis. There was large interjurisdictional variation in radiotherapy use, with wide 95% PIs: 17·8 to 82·4 (pooled estimate 50·2%) for oesophageal cancer, 35·5 to 55·2 (45·2%) for rectal cancer, 28·6 to 54·0 (40·6%) for lung cancer, and 4·6 to 53·6 (19·0%) for stomach cancer. For patients with stage 2-3 rectal cancer, interjurisdictional variation was greater than that for all patients with rectal cancer (95% PI 37·0 to 84·6; pooled estimate 64·2%). Radiotherapy use was infrequent but variable in patients with pancreatic (95% PI 1·7 to 16·5%), liver (1·8 to 11·2%), colon (1·6 to 5·0%), and ovarian (0·8 to 7·6%) cancer. Patients aged 85-99 years had three-times lower odds of radiotherapy use than those aged 65-74 years, with substantial interjurisdictional variation in this age difference (odds ratio [OR] 0·38; 95% PI 0·20-0·73). Women had slightly lower odds of radiotherapy use than men (OR 0·88, 95% PI 0·77-1·01). There was large variation in median time to first radiotherapy (from diagnosis date) by cancer site, with substantial interjurisdictional variation (eg, oesophageal 95% PI 11·3 days to 112·8 days; pooled estimate 62·0 days; rectal 95% PI 34·7 days to 77·3 days; pooled estimate 56·0 days). Older patients had shorter median time to radiotherapy with appreciable interjurisdictional variation (-9·5 days in patients aged 85-99 years vs 65-74 years, 95% PI -26·4 to 7·4). INTERPRETATION:Large interjurisdictional variation in both use and time to radiotherapy initiation were observed, alongside large and variable age differences. To guide efforts to improve patient outcomes, underlying reasons for these differences need to be established. FUNDING:International Cancer Benchmarking Partnership (funded by the Canadian Partnership Against Cancer, Cancer Council Victoria, Cancer Institute New South Wales, Cancer Research UK, Danish Cancer Society, National Cancer Registry Ireland, The Cancer Society of New Zealand, National Health Service England, Norwegian Cancer Society, Public Health Agency Northern Ireland on behalf of the Northern Ireland Cancer Registry, DG Health and Social Care Scottish Government, Western Australia Department of Health, and Public Health Wales NHS Trust).

BACKGROUND:The majority of Northern Irish uveal melanoma (UM) patients are diagnosed in Sheffield. This study aims to present incidence and survival outcomes for UM patients from Northern Ireland (NI). METHODS:Collaborative retrospective study between Sheffield and Northern Ireland Cancer Registry (NICR). For UM cases not on both databases, outcomes and survival rates (via Kaplan-Meier analysis) were compared. Anonymised NICR data were used to calculate whole-population incidence of UM for NI. RESULTS:In total, 161 patients from NI were diagnosed in Sheffield, 90 of which were not registered with NICR at the start of this study. Data-omissions were not consistent across patient groups, leading to significant differences between those patients registered and those not. Registered patients had an all-cause 5-year survival rate of only 68.9% compared to 92.5% of those not registered (p < 0.01) and were >17x more likely to have systemic metastases than those not registered (p < 0·001). Following rectification of data-omissions, the European age-standardised incidence rate of UM for NI was 8·6 per million. CONCLUSIONS:This study illustrates the impact of incomplete population-wide data, serving as a real-world lesson in case-identification bias. Rare cancers are at higher risk of omission due to systemic failures as the small numbers involved are not detected by system-wide validation procedures. Following this study, data-transfer agreements between England and NI were actioned, preventing future data-omissions. We present survival and incidence data for UM in NI for the first time, showing the incidence is amongst the highest in Europe, with good survival rates.

Abstract Background The COVID-19 pandemic was managed in Aotearoa New Zealand (NZ) by a COVID-19 elimination policy, involving border closure and an initial national lockdown. This was different to most other countries including Northern Ireland (NI) and the Netherlands (NED). We quantify the effect of these policies on the diagnosis of three major cancers, comparing NZ with these two European countries. Method Data from NED, NZ and NI population-based cancer registries were used to assess trends in all pathologically diagnosed (PD) lung, breast, and colorectal cancers from March to December 2020 (pandemic period) and compared to the similar pre-pandemic period (2017–2019). Trend data were also collated on COVID-19 cases and deaths per 100,000 in each population. Results Comparing the pre-pandemic period to the pandemic period there were statistically significant reductions in numbers of lung (↓23%) and colorectal (↓15%) PD cancers in NI and numbers of breast (↓18%) and colorectal cancer (↓18.5%) diagnosed in the NED. In NZ there was no significant change in the number of lung (↑10%) or breast cancers (↑0.2%) but a statistically significant increase in numbers of colorectal cancer diagnosed (↑5%). Conclusion The impact of COVID-19 on cancer services was mitigated in NZ as services continued as usual reflecting minimal healthcare disruption and protected cancer services linked with the elimination approach adopted. The reduction in PD cases diagnosed in NED and NI were linked with higher COVID-19 rates and reflect societal restrictions which resulted in delayed patient presentation to primary and secondary care, disruption to screening and healthcare services as a result of COVID-19 infections on staff and the need to shift intensive care to COVID-19 patients. Reductions in PD cancers in NI and the NED and in particularly lung cancers in NI, highlight the need for targeted public health campaigns to identify and treat ‘missing’ patients. Protecting cancer services should be a priority in any future pandemic or systemic healthcare system disruption.

Cancer is a leading cause of death. This paper examines the utilisation of unscheduled emergency end-of-life healthcare and estimates expenditure in this domain. We explore care patterns and quantify the likely benefits from service reconfigurations which may influence rates of hospital admission and deaths. Using prevalence-based retrospective data from the Northern Ireland General Registrar’s Office linked by cancer diagnosis to Patient Administration episode data for unscheduled emergency care (1st January 2014 to 31st December 2015), we estimate unscheduled-emergency-care costs in the last year of life. We model potential resources released by reductions in length-of-stay for cancer patients. Linear regression examined patient characteristics affecting length of stay. A total of 3134 cancer patients used 60,746 days of unscheduled emergency care (average 19.5 days). Of these, 48.9

Introduction: Radiation cardiotoxicity is a dose-limiting toxicity and major survivorship issue for patients with non-small cell lung cancer (NSCLC) completing curative-intent radiotherapy, however patients' car-diovascular baseline is not routinely optimised prior to treatment. In this study we examined the impact of statin therapy on overall survival and post-radiotherapy cardiac events. Methods: Patients treated between 2015-2020 at a regional center were identified. Clinical notes were interrogated for baseline patient, tumor and cardiac details, and both follow-up cancer control and car-diac events. Three cardiologists verified cardiac events. Radiotherapy planning scans were retrieved for application of validated deep learning-based autosegmentation. Pre-specified Cox regression analyses were generated with varying degrees of adjustment for overall survival. Fine and Gray regression for the risk of cardiac events, accounting for the competing risk of death and cardiac covariables was under-taken. Results: Statin therapy was prescribed to 59% of the 478 included patients. The majority (88%) of patients not prescribed a statin had at least one indication for statin therapy according to cardiovascular guide -lines. In total, 340 patients (71%) died and 79 patients (17%) experienced a cardiac event. High-intensity (HR 0.68, 95%CI 0.50-0.91, p = 0.012) and medium-intensity (HR 0.70, 95%CI 0.51-0.97, p = 0.033) statin therapy were associated with improved overall survival after adjustment for patient, cancer, treatment, response and cardiovascular clinical factors. There were no consistent differences in the rate or grade of cardiac events according to statin intensity. Conclusions: Statin therapy is associated with improved overall survival in patients receiving curative-intent radiotherapy for NSCLC, and there is evidence of a dose-response relationship. This study high-lights the importance of a pre-treatment cardiovascular risk assessment in this cohort. Further studies are needed to examine if statin therapy is cardioprotective in patients undergoing treatment for NSCLC with considerable incidental cardiac radiation dose and a low baseline cardiac risk.& COPY; 2023 The Authors. Published by Elsevier B.V. Radiotherapy and Oncology 186 (2023) 1-9 This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background Syndemics (synergistic epidemics) have traditionally been studied using a mixed methods approach in which qualitative analysis precedes quantitative analysis. Typically, scholars first develop hypotheses about interactions between two or more health problems and the social conditions in which they exist via qualitative fieldwork. Subsequently, the synergistic interaction may be validated quantitatively. However, qualitative studies are time-consuming, opportunistic and may offer limited guidance on probabilities between diseases and social conditions. We propose an alternative method to detect potential syndemics at scale using machine learning and big data that could guide subsequent detailed qualitative investigation. Methods Records of 99,847 cancer patients from the ethically approved Northern Ireland Cancer Registry were linked with 1.1 million diagnostic hospital records which provided information on comorbidities between 2009–2019. We used an association rule mining algorithm, ECLAT, to find most frequent clusters of diagnoses for each cancer site and calculated Synergy Factor (SF) for each cluster. We compared comorbidity patterns of cancer patients from different social groups, defined using the Northern Ireland Multiple Deprivation Index. The analysis is implemented in Python. Results We detected significant indications of synergies within several disease clusters. Essential hypertension & disorders of lipoprotein metabolism showed synergy among patients with breast cancer (SF=1.2), lymphoma (SF=1.3), melanoma (SF=1.4), leukaemia (SF=1.5), oesophageal cancer (SF=1.4), brain and central nervous system cancer (SF=1.6). Essential hypertension & chronic ischaemic heart disease showed synergy among patients with lymphoma (SF=1.3), head and neck cancer (SF=1.4), melanoma (SF=1.8), leukaemia (SF=1.4). Essential hypertension & diverticular disease of intestine showed synergy among patients with colorectal cancer (SF=1.2), kidney cancer (SF=1.3), gallbladder and other biliary cancer (SF=1.7). Disorders of lipoprotein metabolism & chronic ischaemic heart disease showed synergy among prostate cancer patients (SF=1.2). For liver cancer patients dyads of hypertension & gastritis/duodenitis (SF=1.5), type 2 diabetes mellitus & gastritis/duodenitis (SF=1.7), type 2 diabetes mellitus & disorders of lipoprotein metabolism (SF=1.4) showed synergy. SF varied across deprivation indices. Conclusion The proposed method provides a proof of principle for detection of potential syndemics relationships at scale using readily available electronic health records. Although qualitative studies are still necessary to understand the interaction between health problems and social conditions, this method enables efforts to identify such work to be targeted more efficiently. Findings, in this case, warrant further research on synergistic relationships between cancer, cardiovascular and metabolic diseases and in areas beyond cancer.

Upon the COVID-19 pandemic onset in Ireland, cancer service disruptions occurred due to prioritisation of COVID-19 related care, redeployment of staff, initial pausing of screening, diagnostic, medical and surgical oncology procedures, staff shortages due to COVID-19 infection and impacts on the physical and mental health of cancer healthcare workers. This was coupled with reluctance among people with symptoms suspicious for cancer to attend for clinical evaluation, due to concerns of contracting the virus. This was further compounded by a cyber-attack on national health service IT systems on May 14th 2021. The Irish Cancer Society, a national cancer charity with a role in advocacy, research and patient supports, convened a multi-disciplinary stakeholder group (COVID-19 and Cancer Working Group) to reflect on and understand the impact of the pandemic on cancer patients and services in Ireland, and discuss potential mitigation strategies. Perspectives on experiences were gathered across domains including timeliness of data acquisition and its conversion into intelligence, and the resourcing of cancer care to address cancer service impacts. The group highlighted aspects for future research to understand the long-term pandemic impact on cancer outcomes, while also highlighting potential strategies to support cancer services, build resilience and address delayed diagnosis. Additional measures include the need for cancer workforce recruitment and retention, increased mental health supports for both patients and oncology professionals, improvements to public health messaging, a near real-time multimodal national cancer database, and robust digital and physical infrastructure to mitigate impacts of the current pandemic and future challenges to cancer care systems.

Population-based cancer registries are responsible for collecting incidence and survival data on all reportable neoplasms within a defined geographical area. During the last decades, the role of cancer registries has evolved beyond monitoring epidemiological indicators, as they are expanding their activities to studies on cancer aetiology, prevention, and quality of care. This expansion relies also on the collection of additional clinical data, such as stage at diagnosis and cancer treatment. While the collection of data on stage, according to international reference classification, is consolidated almost everywhere, data collection on treatment is still very heterogeneous in Europe. This article combines data from a literature review and conference proceedings together with data from 125 European cancer registries contributing to the 2015 ENCR-JRC data call to provide an overview of the status of using and reporting treatment data in population-based cancer registries. The literature review shows that there is an increase in published data on cancer treatment by population-based cancer registries over the years. In addition, the review indicates that treatment data are most often collected for breast cancer, the most frequent cancer in women in Europe, followed by colorectal, prostate and lung cancers, which are also more common. Treatment data are increasingly being reported by cancer registries, though further improvements are required to ensure their complete and harmonised collection. Sufficient financial and human resources are needed to collect and analyse treatment data. Clear registration guidelines are to be made available to increase the availability of real-world treatment data in a harmonised way across Europe.

Introduction: The COVID-19 epidemic interrupted normal cancer diagnosis procedures. Population-based cancer registries report incidence at least 18 months after it happens. Our goal was to make more timely estimates by using pathologically confirmed cancers (PDC) as a proxy for incidence. We compared the 2020 and 2021 PDC with the 2019 pre-pandemic baseline in Scotland, Wales, and Northern Ireland (NI).Methods: Numbers of female breast (ICD-10 C50), lung (C33-34), colorectal (C18-20), gynaecological (C51-58), prostate (C61), head and neck (C00-C14, C30-32), upper gastro-intestinal (C15-16), urological (C64-68), ma-lignant melanoma (C43), and non-melanoma skin (NMSC) (C44) cancers were counted. Multiple pairwise comparisons generated incidence rate ratios (IRR).Results: Data were accessible within 5 months of the pathological diagnosis date. Between 2019 and 2020, the number of pathologically confirmed malignancies (excluding NMSC) decreased by 7315 (14.1 %). Scotland experienced early monthly declines of up to 64 % (colorectal cancers, April 2020 versus April 2019). Wales experienced the greatest overall change in 2020, but Northern Ireland experienced the quickest recovery. The pandemic's effects varied by cancer type, with no significant change in lung cancer diagnoses in Wales in 2020 (IRR 0.97 (95 % CI 0.90-1.05)), followed by an increase in 2021 (IRR 1.11 (1.03-1.20).Conclusion: PDC are useful in reporting cancer incidence quicker than cancer registrations. Temporal and geographical differences between participating countries mirrored differences in responses to the COVID-19 pandemic, indicating face validity and the potential for quick cancer diagnosis assessment. To verify their sensitivity and specificity against the gold standard of cancer registrations, however, additional research is required.

Supplementary Table 1. Sensitivity analysis excluding 1 year follow-up

Abstract Background The COVID-19 pandemic was managed in Aotearoa New Zealand (NZ) by a COVID-19 elimination policy, involving border closure and an initial national lockdown. This was different to most other countries including Northern Ireland (NI) and the Netherlands (NED). We quantify the effect of these policies on the diagnosis of three major cancers comparing NZ with these two European countries. Methods Data from NED, NZ and NI population-based cancer registries were used to assess trends in all pathologically diagnosed (PD) lung, breast, and colorectal cancers from March to December 2020 (COVID period) and compared to the similar pre-pandemic period 2017-2019. Trend data were also collated on COVID-19 cases and deaths per 100,000 in each population. Results Comparing the pre-pandemic period to the COVID-19 period there were statistically significant reductions in numbers of lung (↓23%) and colorectal (↓15%) PD cancers in NI and numbers of breast (↓18%) and colorectal cancer (↓18.5%) diagnosed in the NED. In NZ there was no significant change in the number of lung (↑10%) or breast cancers (↑0.2%) but a statistically significant increase in numbers of colorectal cancer diagnosed (↑5%). Conclusions The impact of COVID-19 on cancer services was mitigated in NZ as services continued as usual reflecting minimal healthcare disruption and protected cancer services linked with the elimination approach adopted. The reduction in PD cases diagnosed in NED and NI were linked with higher COVID-19 rates and reflect societal restrictions which resulted in delayed patient presentation to primary and secondary care, disruption to screening and healthcare services because of COVID-19 infections on staff and the need to shift intensive care to COVID-19 patients. Key messages • Reductions in PD cancers in NI and the NED and in particularly lung cancers in NI, highlight the need for targeted public health campaigns to identify and treat ‘missing’ patients. • Protecting cancer services should be a priority in any future pandemic or systemic healthcare system disruption.