Cancer and COVID-19: What Patients Need to Know
In November 2019, the first case of novel coronavirus infection was detected in a country 7000 miles away from the United States. Over the following months, the number of cases and deaths rose dramatically, peaking at ~81,000. Today, four months after the world’s first known COVID-19 infection, the U.S. has surpassed China – and the world – in the number of COVID-19 cases at >94,000.
This global pandemic is impacting different populations in different ways. Individuals with cancer are a unique group of people who are at high risk for becoming seriously ill from infection. Their immune systems are often weakened by the cancer itself as well as the different treatment regimens, including chemotherapy.
“Patients with cancer, especially those undergoing treatments that suppress the immune system and bone marrow, are particularly susceptible to the severe complications of flu and likely also corona virus 19,” said Bruce Chabner, MD, Director of Clinical Research, Massachusetts General Hospital Cancer Center.
The former longtime National Institutes of Health Clinical Oncology Director and researcher added, “These patients need to limit personal exposure to others, need to avoid exposure to the hospital environment as much as is consistent with essential treatment, and may be asked to have ‘virtual’ appointments with caregivers on Skype or FaceTime for routine follow-up. ”
In response to the growing concerns voiced by cancer patients, their families and caregivers, the American Society of Clinical Oncology (ASCO) posted information related to COVID-19 on their website. Much of the information defers to the CDC guidelines in terms of precautions. Other reliable resources include the American Cancer Society.
According to Jeffrey Van Deusen, MD, Medical Director, James Cancer Network, Ohio State University, “The ASCO guidance on therapy has been understandably vague by necessity.” The breast cancer specialist continued: “We’re all trying to navigate these difficult waters with somewhat limited information.”
Actress Sheetal Sheth Talks Cancer and Coronavirus
In June 2019, Indian American actress and producer, Sheetal Sheth, disclosed her diagnosis of breast cancer. In the wake of the novel coronavirus outbreak, she shared concerns of her immunocompromised status during an appearance on MSNBC. “We’re scared because we’re having to decide what’s worse for us: coronavirus or a cancer diagnosis,” said the star of The World Unseen.
What’s The Fatality Rate for Cancer Patients?
The cancer-specific case fatality rate is based on a Report of the WHO-China Joint Mission on Coronavirus Disease 2019, released February 28th, 2020. The case fatality rate among cancer patients was 7.6%, which is higher than the overall rate of 3.8%. Of note, the highest fatality rates were among patients with comorbid cardiovascular disease (13.2%) and diabetes (9.2%). Individuals reporting no comorbid conditions had a fatality rate of 1.4%.
Caring for Patients with Cancer
In addition to following the CDC’s general care guidelines tailored to home care, clinical care and high-risk subpopulations, ASCO adds the following recommendations: inform patients with cancer about common COVID-19 symptoms; train cancer patients on proper handwashing technique, cough/sneeze hygiene; and emphasize physical distancing especially from sick contacts.
“I’m recommending the strictest of precautions for my patients,” said Edwin Choy, MD, PhD, associate professor, Harvard Medical School, and sarcoma specialist.” The biggest change in Dr. Choy’s practice has been in the way he conducts physical exams. “I’m trying to limit my interaction with patients, so I only do a physical exam for concerning signs or symptoms.”
Do Cancer Patients Need to Wear Masks?
Current evidence does not suggest mask use in individuals with cancer, neither surgical nor N95 masks. If, however, a cancer patient develops a fever or other symptoms suggestive of infection, he or she should be evaluated by their medical team. Again, CDC guidelines are recommended as standard protocol.
Should Surgery be Rescheduled or Delayed?
At this time, the CDC recommends that all elective surgeries be rescheduled in an effort to reduce the risk of COVID-19 transmission via physical distancing and in an effort to preserve dwindling personal protective equipment (PPE). The American College of Surgeons also issued guidance including triaging of elective surgical cases related to cancer care. Ultimately, however, care must be tailored to the individual patient by his or her physician and clinical team.
“Clinicians and cancer patients will need to make personalized determinations based on the potential harms of delaying needed cancer-related surgery or therapy for patients on active treatment,” according to Aditi Hazra, PhD, MPH, associate epidemiologist, Brigham and Women’s Hospital. Dr. Hazra added: “Initiatives to collect data, such as the CCC19 Registry, will inform our understanding of COVID-19 in patients with cancer.”
What About Potentially Immunosuppressive Therapy?
Right now, there is no data to suggest changing or withholding chemotherapy or immunotherapy in individuals with cancer. Again, individual treatment plans should be tailored to each patient, their type of cancer, stage, prognosis, etc. Special considerations were made by ASCO:
1. Chemotherapy could be stopped for patients in deep remission receiving maintenance therapy
2. Chemotherapy regimens could be switched from intravenous to oral, thereby reducing clinic visits and exposure risks
3. Consideration of chemotherapy home infusion as being medically and logistically feasible for the patient and the medical team
4. Prophylactic growth factors (as used in high-risk chemo regimens) and prophylactic antibiotics may not only improve overall health but also reduce susceptibility to COVID-19-related infection
Financial and Human Costs
Widespread shelter-in-place public health protocols has placed an economic strain on many patients and their families, compromising access to necessary medications. “Capecitabine (Xeloda) and other oral chemotherapy co-pays are beyond some patients now,” said Dr. Van Deusen.
The other precarious issue involves the well-publicized limited supply of ventilators. Based on current COVID-19 caseload and prediction of critically-ill patients, New York state governor, Andrew Cuomo, requested 30,000 ventilators. The federal government gave him 400. “Our patients with metastatic cancer need supportive care including ventilator support,” said Dr. Van Deusen. “But will it even be an option for them?” Some patients asked him if they could buy a used ventilator and bring it to the hospital.
Desperate times call for desperate measures. And this unheeded desperation is manifesting in patients and most certainly among my fellow medical professionals who are reusing masks and jerry-rigging PPE out of garbage bags and bandanas – compromising both their safety and that of their patients. Medical and public health professionals have been ringing the alarms for weeks, using social media, mainstream media and op eds to demand a drastic increase in basic and lifesaving medical supplies. They’ve also urged the federal government to activate the Defense Production Act (DPA) to mandate the manufacture of said supplies, particularly ventilators. As of two hours ago, President Trump ordered General Motors to build ventilators under the DPA. Lives will continue to be lost but hopefully the fatality rate will plateau and decline earlier than predicted. Dr. Chabner, who worked through the AIDS epidemic, displayed optimism: “Most people will get the care they need.”