It’s a tough time for all of us and it’s fair to say that no one was prepared enough for exactly what’s going on now. It has given physicians a huge responsibility to remain updated, as the things are changing so rapidly. Obviously it’s a huge concern for our cancer patients and their relatives as well. Therefore, it is important that all of us be aware of how COVID-19 could impact the management concerns on cancer.
One thing that I want to focus on is that for most of our cancer patients and their relatives, COVID-19 remains a possible concern; however, cancer is a definite concern. Therefore, It important to think about cancer first, and then think about how COVID-19 will impact the person suffering from cancer.
Origin and transmission:
The COVID 19 infection is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). It first originated in Wuhan, China, in December 2019. It has affected more than 180 countries within four months. Most people experience mild-to-moderate respiratory illness and recover without requiring any special treatment. However, older people and those with underlying medical problems such cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illness.
The best way to prevent and slow down transmission is to be well informed about the COVID-19 virus, the disease it causes and how it spreads. It spreads primarily through droplets of saliva or discharge from the nose, i.e., when an infected person coughs or sneezes, or from contact with bodily fluids.
Incidence and mortality:
While most data do not establish a definitive increase in incidence of COVID-19 infection in cancer patients, there are few reports of increased incidence by two folds among cancer patients who are on active treatment. There is no reliable evidence regarding change in incidence or mortality based on specific histology, and type of therapy for cancer patients.
However, patients with a history of cancer usually have a higher incidence of severe events, requiring ICU care, and invasive ventilation. The death rates are also higher compared with other patients. Most data suggest the case fatality rate of COVID 19 confirmed cases with Cancer as co-morbidity is around 7.5%. The overall the mortality with COVID 19 infection is around 4%. Those without any comorbid condition the death rate is 1.5%. if we compare with other co -morbidities the death rate is 10-15% for patients with cardiovascular disease, 10% for Diabetes, 10% for chronic respiratory disease.
For all patients it is mandatory to provide health education:
a) Avoid crowded places
b) Wear PPE when you attend hospital for visits and treatments;
c) Correctly wash your hands according to World Health Organization (WHO) indications:
- frequent hand washing with soap and water for at least 20-30 seconds using the six-step technique or
- hand sanitizer with at least 60% alcohol base
d) Do not have contacts with friends and relatives with COVID-19 symptoms or living in endemic zones
e) Maintaining social distancing with all people
Its very simple to remember: protect yourself to protect others.
Apart from all these you need to keep your immune system strong
- Don’t use tobacco products
- Eat a well-balanced diet rich in fruits and vegetables
- Exercise regularly
- Get enough sleep
Discussion with oncologist:
Before planning of any diagnostic tests or treatment, it is important to discuss the benefits and risks of present cancer therapy in the setting of the COVID-19 pandemic like:
- Logistic issues
- Treatment setting
- Disease prognosis
- Patient comorbidities
- Patient preferences
- Probability and risks from COVID-19 infection
Warning sign and symptoms of COVID 19:
Special attention should be considered in case of recent new symptoms such as:
- Sore throat
- Difficulty breathing
- Loss of smell sensation
- Presence of new-onset diarrhoea
- Muscle pain
In such situations, recommendations include to test for confirmation of COVID 19, if not already done.
RT-PCR SRAS-CoV-2 testing should be proposed to all patients undergoing surgery, radiotherapy, chemotherapy or immunotherapy, if feasible.
COVID 19 and Cancer:
- Diagnosis/ evaluation
- Radiation therapy
Diagnosis and Staging:
COVID-19 infection do not interferes with or influences the diagnosis and staging of cancer. However, it is reasonable to limit the diagnostic tests or the staging procedures, to only those that are most necessary to plan for initial treatment.
There is no direct evidence to support changing or withholding chemotherapy or immunotherapy in patients with cancer. Therefore, routinely withholding critical anti-cancer or immunosuppressive therapy is not recommended at present. It is always important to consider the indication for chemotherapy and the goals of care before modifying any treatment regimen. Chemotherapy protocol can be changed to less frequent dosing interval like 3 weekly schedule instead of weekly or two weekly schedule. In some patients we can switch IV chemotherapy to oral therapies, which would decrease the frequency of clinic visits. For patients in deep remission who are receiving maintenance therapy, stopping chemotherapy may be an option. For patients under oral treatments, prefer telephonic or web-technology for consultation. If needed, favour telephone or web-technology contacts also for toxicity evaluation, dose adaptation and supportive care recommendation
Immune Checkpoint Inhibitors:
It may be appropriate to adjust to less frequent dosing intervals when different schedules are considered reasonable options. However, as these agents may cause immune-related serious adverse events and immunosuppression may not be advisable as a treatment for those events, the potential harms and benefits of therapy should be considered for each patient. Of concern is treatment-related pneumonitis, which may increase the chance of serious complications should the patient develop COVID-19.
Planned surgery should be delayed if feasible. In some situations (e.g. early stage breast cancer) where neoadjuvant therapy is available but not routinely considered, it may be reasonable to consider neoadjuvant therapy instead of surgery or simply delaying surgery.
The risks of tumour progression with delay in definitive surgery should be weighed against the potential added burden on hospital resources, case complexity and patient risk of exposure to COVID-19.
Shorter schedule of radiation therapy should be considered wherever feasible. Radiation should not be delayed for patients with rapidly progressing, potentially curable tumours. But, patients receiving radiation for symptom control or at low risk of harm due to alteration of schedule for radiation treatment visits could potentially be safely delayed.
Central Venous Catheters/Ports:
There is evidence that flushing can occur at frequencies as long as every 12 weeks with no notable increase in adverse events or harms. If patients can flush their own devices, that should be considered, although the process of training may itself be a source of exposure and access to sterile supplies at home may be limited.
In general, any clinic visits that can be postponed without risk to the patient should be postponed. Most surveillance guidelines recommends visit to oncologist every 3-6 months.
So, it is reasonable to delay scheduled interventions to the longest possible duration. Telemedicine consultation can be more useful in such patients.
For the time being the screening tests like mammography pap smear etc should be postponed. This is important to conserve health system resources and reduce patient contact with health care facilities.
Prophylactic Therapy against COVID 19
Currently, there is no evidence or published guidance on the use of prophylactic therapy for COVID-19 in immune suppressed patients. Clinical trials are ongoing or have been reported in brief publications on the use of potential antiviral medications e.g. Chloroquine, Remdesivir, Lopinavir, etc. However, to date none of these trials have been specific to patients with cancer. This is an active area of research and evidence may be available at any time.
Final Advise for Cancer Patients:
- Stay informed and stick to trustworthy sources for information like local health authority and the government.
- Stay connected with family and healthcare provider
- Take up relaxation practices, recreational activities to reduce anxiety and panic episodes
- Reach out to healthcare provider at the earliest in case symptoms worsen.
I know this is tough time for all of us but I do believe we will come out of this. Be safe.
Free consultation available for all cancer patients/related queries by prior registration on 7766055563.