Abstract

Background: Cancer treatments were variably disrupted during the COVID-19 pandemic. Despite UK national guidelines recommending pancreatic enzyme replacement therapy to all people with unresectable pancreatic cancer, observational studies demonstrate under-prescribing

Aim: To investigate the impact of the COVID-19 pandemic on the prescribing of pancreatic enzyme replacement to people with unresectable pancreatic cancer.

Methods: With the approval of NHS England, we conducted a cohort study using 24 million health records through the OpenSAFELY-TPP research platform. We modelled prescribing rates from January 2015 and investigated the effect of the pandemic with multivariable linear regression.

Results We found no reduction in pancreatic enzyme replacement therapy during the COVID-19 pandemic. Overall, since 2015, the rates of prescribing increased steadily over time by 1% every year. The national rates ranged from 41% in 2015 to 50% in 2024. There was substantial regional variation. The highest rates of 50% to 60% were in the West Midlands.

Conclusions: The COVID-19 pandemic did not affect PERT prescribing in unresectable pancreatic cancer. Although overall rates increased over time, substantial under-prescribing persisted. At around 50% in 2024, the rates were still below the recommended 100% standard. Despite the national guidelines, under-prescribing of PERT continued and has improved only marginally since their publication. This could be an important missed opportunity to reduce morbidity for patients with pancreatic cancer. The research into barriers to prescribing of PERT and geographic variation is urgently needed to improve quality of care.

Figure 1. Study flowchart explaining inclusion and exclusion criteria. Each month the rate was calculated of people receiving pancreatic enzyme replacement therapy (numerator) among people with unresectable pancreatic cancer (denominator).

National rates

Figure 2 shows the rates in prescribing over time in England. Overall, the COVID-19 pandemic did not affect PERT prescribing to people with unresectable pancreatic cancer.

In view of the national target rate of 100%, at around 50% in 2024, the prescribing rates were still below the recommended standard. (Figure 2).

Figure 2. Prescribing rates in England

Regional rates

Figure 3 shows the rates in prescribing by regions in England. The highest rates, achieving values between 50% and 60% from 2018 onwards were in the West Midlands region. Please note, data for London is limited in this dataset and therefore the representativeness of figures for London is limited and difficult to assess.

Figure 3. Prescribing rates in Regions in England