With the number of cases of 2019 novel coronavirus disease (COVID-19) increasing daily, oncologists are tasked with meeting the ongoing needs of their patients while navigating the pandemic.
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An early report from China suggests that cancer patients face increased risk of infection by severe acute respiratory syndrome corona virus 2 (SARSCoV-2), and those who develop COVID-19 have poorer outcomes. While this study offers some insights into potential impacts and patient management, more information is needed.
“There are many different factors that can put you at higher risk” for COVID-19, says Halle Moore, MD, Director of Breast Medical Oncology and Co-Director of the Comprehensive Breast Cancer Program at Cleveland Clinic Cancer Center. “Although it makes sense that immunosuppressed patients are at higher risk for severe complications, in terms of this study, it is difficult to sort out which factors led to the worse outcomes.
“Age and a history of smoking are potential risk factors for both cancer and severe COVID-19 illness,” she adds. “We do not currently have strong evidence to suggest that a history of cancer, in the absence of recent treatment or active disease, will increase the risk for severe COVID-19 disease.”
Certain subsets of cancer patients may face a heightened risk of infection, including those with hematologic malignancies and those who have undergone bone marrow transplant, according to Dr. Moore. “In previous outbreaks of severe respiratory viruses, patients with advanced cancer, including advanced lung cancer, and those with hematologic malignancies appeared to fare worse than those with early-stage solid tumors.”
Finding the right approach
Managing cancer patients during the coronavirus pandemic poses a variety of challenges for oncologists, including access to care, timing of treatments, resource availability and risk reduction.
The symptoms of COVID-19 include fever, cough and respiratory issues. It can be difficult to determine whether these signs indicate a coronavirus infection or an oncology treatment-related issue.
“The current situation is certainly going to complicate treatment-related fevers, but we have a high index of suspicion for COVID-19, particularly if there are respiratory symptoms,” Dr. Moore says. “So while it is going to make it more challenging, it’s just one more potential diagnosis to be concerned about in our patients.
“If a patient is receiving immunosuppressive therapy, a fever should be considered a medical emergency, regardless of the current pandemic,” she says. “In these cases, we recommend that patients call their physician first and do not just go directly to the emergency room. Their symptoms can be assessed and we can determine the best place for evaluation and management. Precautions can also be taken to help avoid exposure to other patients.”
Cleveland Clinic is taking a comprehensive approach to ensure that cancer patients receive necessary care is in the safest way possible, according to Dr. Moore. This includes prohibiting most hospital visitors and screening those who are allowed to enter, as well as screening caregivers who enter patient-care areas, to reduce patients’ potential exposure to virus carriers. Adult patients, including cancer patients receiving infusion treatments, are not permitted to be accompanied by a visitor or guest unless special assistance is required or the patient’s physician has given authorization.
Cleveland Clinic also is providing options so that patients who don’t need a physical exam or in-person treatment can remain at home. For instance, patients who don’t have active cancer have the option to access routine follow-up care via telemedicine, or to delay those visits until a safer time. “Even some patients who have active disease and are undergoing treatments such as oral therapies can be offered telemedicine consultations,” Dr. Moore explains. “Although they may need to come in for testing, we can limit traffic.”
Cleveland Clinic is following governmental guidelines postponing nonessential surgeries and related procedures to preserve resources and reduce infection risks. “However, many of those restrictions aren’t applicable in our cancer patients for whom delaying surgery may result in disease progression,” she says.
Dr. Moore cautions that the anticipated surge of COVID-19 cases may force current policies to be reevaluated. “Some cancer surgeries may need to be delayed and we may have to be thoughtful about which patients can be treated in other ways first,” she says.
Many maintenance therapies — depending on the resulting degree of immunosuppression — can continue, according to Dr. Moore. Screening for new cancers usually can be safely delayed; however, scans to evaluate patients’ therapy response should be conducted to avoid continuing ineffective treatments.
Dealing with COVID-infected cancer patients and cancer survivors
The treatment approach for cancer patients diagnosed with COVID-19 will depend on the individual. “If they’re an immunosuppressed patient, or they have active cancer, they probably will need hospitalization,” Dr. Moore says, noting that in those cases, the usual criteria for hospitalization should be followed.
To preserve limited hospital resources, difficult discussions and decisions will be necessary. “From what we’ve seen, the prognosis appears quite dismal for patients with advanced cancer who require intubation for COVID-19,” Dr. Moore notes. “In those cases, it is important to have frank discussions with patients and their family members regarding the status of their disease.”
Cancer survivors without active disease who are no longer on immune-suppressing treatments should follow the same COVID-19 precautions as the general population, Dr. Moore says, including staying at home as much as possible, avoiding close contact with others who may be sick and washing hands frequently.
Navigating the unknown
The biggest concern cancer patients have, according to Dr. Moore, is the unknown. To help deal with the uncertainty of the situation, she recommends they plan ahead as much as possible, considering in advance such things as the steps they should take if they or a caregiver becomes ill, how they can obtain food if sheltering at home, and how to maintain an exercise routine while in isolation.
To mitigate exposure risk, Dr. Moore advises that patients with active cancer practice extreme social distancing. “This means not going out in public, as well as educating family members and people with whom they have contact, to ensure they are also taking more precautions.”
For fellow oncologists and healthcare providers, Dr. Moore emphasizes the need for planning. “We must think ahead to best care for our patients,” she stresses. “Having conversations now before the situation changes is key. Also, in the midst of all of the uncertainty, it is important to reassure patients that we remain available and are here to treat and manage their cancer.”