Cancer and COVID-19: How do you care for patients when hospitals are danger zones?

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Sara Musetti

Disclaimer: This article is based on summaries of academic studies and medical society guidelines. It is not intended as medical advice; if you find yourself needing to seek care during this pandemic, please contact your doctor for a discussion based on your hospital’s resources and your specific needs. 

The world has been turned upside down by the emergence of SARS-CoV-2, the novel coronavirus that causes COVID-19. No one’s life has been untouched by the effects of the virus or the global shutdown necessary to slow its spread. Many people’s lives have ground to a near standstill, while hospitals have been overrun with activity. 

It’s hard to remember, sometimes, that cancer doesn’t stop for COVID-19. 

Oncologists have been given the daunting task of balancing treating their patients for cancer and safeguarding their health from COVID-19 infections. While all hospital patients are at increased risk, the danger increases for cancer patients. The mortality rate for COVID-19 is about 1.4% for patients without other risk factors, called comorbidities. However, in cancer patients, that rate rose to 7.6% in Wuhan, China, a trend that seems to be holding true in the United States. This means that people with cancer and their doctors are faced with a serious choice: do they risk undergoing cancer treatments, putting them at increased risk for COVID-19, or do they minimize their exposure to COVID-19 while risking their cancer progressing? It’s a difficult predicament, and patient care has taken a hit in recent months. A recent survey of American patients indicated that 51% of cancer patients contacted experienced some delay in care during the COVID-19 crisis, including postponed treatments and reduced access to screening procedures. However, only 8% of patients actively undergoing therapy experienced delays, indicating that while doctors are trying to reduce hospital visits to slow the spread of COVID-19, they are not interrupting ongoing care, for the most part.

There are several ongoing clinical studies trying to understand the specific factors that put cancer patients at higher risk, such as the COVID-19 and Cancer Consortium (CCC19). The goals of CCC19 are to: 1) identify risk factors from observational studies with data from hospitals around the world, including examining which treatment options seem safer for patients, and 2) to produce plans to help hospitals mitigate risk. Age and sex appear to play a large role in COVID morbidities, as older patients and male patients have higher morbidity rates, on average, but CCC19 also identified that living in certain regions of the US, treatments such as azithromycin plus hydroxychloroquine, history of smoking and disease stage all increase risk of COVID-19 morbidity in cancer patients. Based on this study and others like it, doctors are working to identify guidelines for care that correctly identify patients’ risk of life-threatening COVID infections and delineate the best course of care for them. 

Some guidelines have come out that are specific for certain cancers; for example, an international team of doctors put together guidelines for radiation therapy for breast cancer, based on the fact that breast cancer treatments are responsible for 30% of overall radiation therapy in Europe. The recommendations were: 

1. Do not give radiation to patients 65 and over or with certain comorbidities if their tumors are low-grade, estrogen receptor-positive, HER2-positive, have clear edges (margins), and have not spread to lymph nodes, because they can undergo endocrine therapy with less risk. 
2. Give 5 doses, either over the course of a single week or over the course of 5 weeks, of radiation therapy to patients who do not meet the criteria above but whose cancer has not spread to the lymph nodes. 
3. Boost radiation therapy, which has no proven survival benefit, should not be given except to patients under 40 years and/or at high risk of relapse. 
4. Radiation therapy targeted at lymph nodes can be skipped in post-menopausal women undergoing whole breast radiation therapy if those patients have undergone surgery and their tumors are ER-positive, HER2-positive, low grade, and have few metastases. 

Similar guidelines have been compiled for prostate cancer to limit patient treatment whenever possible, including meeting with patients virtually whenever possible. The emphasis in these studies is to keep patients out of the clinic whenever possible with the lowest impact on their health. 

Larger organizations, such as the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO), have been compiling these focused studies and issuing larger guidelines for hospitals and patients. The New England Journal of Medicine even has simulations on their website to help doctors train for COVID-19 care. ESMO has links to new publications, guidelines for doctors, links for patients, webinars, and cancer subtype-specific recommendations. ASCO is currently holding their national meeting and will be discussing COVID-19 at length, and lists learning resources and donation funds on their website to support appropriate patient care during this time. Both organizations are great resources for patients and their families looking for good information during this overwhelming time. 

However, with all this information available and yet still so many unknowns, hospitals are responsible for figuring out their own method for handling the crisis. It’s important to treat each patient on a case-by-case basis, and the COVID-19 outbreak is at different stages in each region. I spoke to Dr. Mark Lewis, the Director of GI Oncology at Intermountain Healthcare, about his experiences as an oncologist during COVID-19. Intermountain Healthcare had a few advantages when it came to weathering COVID-19, including experience with telehealthcare due to serving vast, largely rural states of Utah and Idaho. It is also a member of the COVID-19 and Cancer Consortium mentioned above. Dr. Lewis notes that they expanded their telehealthcare network when the pandemic hit in order to reduce the amount of spread that occurred within the hospital itself. While surgeries were not paused during the peak of the crisis, Dr. Lewis did take the time to explain how they assessed patient risk within his department:

“There are two risks at play here: the risk of the SARS-CoV-2 virus and the risk of postponing/de-intensifying therapy. I wrote about fearing a bimodal peak of deaths here: https://www.nejm.org/doi/full/10.1056/NEJMp2006588 I have personally stratified my patients into 3 categories: i) those who are on surveillance/in survivorship and can be more safely monitored via telehealth for the moment, ii) those with highly immunosuppressive chemotherapy whereby they might be an untenable risk during nadirs and who thus putatively benefit from lower doses or more time elapsed between doses, and iii) those whose cancers are so aggressive that it would be more risky to down-titrate or delay their chemotherapy.”

Now that the peak in COVID-19 cases has passed and the situation is somewhat stable, Intermountain Healthcare, like many hospitals throughout the country, is reaching out to patients and actively transitioning back to in-person care where necessary (with necessary COVID-19 screening), including preventative screenings like mammograms. They continue to gather data for CCC19 so that decisions regarding cancer care can be made more safely, giving more patients access to care. Public health experts warn that a second peak in the fall is likely, so gathering information and putting plans in place now can help mitigate risk if a second shutdown becomes necessary. 

In this changing world, it’s important to remember that while there are more questions than ever, scientists and doctors are working around the clock to figure out the best course of action for patients. They are working hard to gather and share data to help determine the best outcomes for patients and using every tool at their disposal to keep patients safe and healthy. There are resources available for both doctors and patients that are updating almost daily. Remember that you can still seek care safely, so please do not hesitate to contact doctors if you have a question about your health. Care may take different forms during this time, but doctors are working hard to keep you safe!

Edited by Diana Moreira and Manisit Das