COVID-19 is not an equal-opportunity illness. Older people and patients with chronic conditions are, on average, far more vulnerable to suffering serious illness and death from the disease than younger people without ongoing health problems. Although the data are not as clear, cancer patients are also among those vulnerable to the SARS-CoV-2 virus that causes COVID-19 and more likely to suffer its serious consequences.
Oncologists around the country, supported and informed by guidance from healthcare leaders and professional associations, are reviewing the available research and carefully weighing treatment decisions. Many patients, with their physicians, are wrestling with question of whether the risks associated with putting off their cancer treatment are greater than the risk of COVID-19.
Randall Oyer, M.D., a medical oncologist at Lancaster General Health, a health system in Lancaster, Pennsylvania, says that in addition to understanding that cancer patients are a vulnerable group, healthcare leaders need to recognize that cancer patients are at heightened risk of contracting COVID-19 in the hospital.
Oyer says research from early COVID-19 hot spots such as China, Italy and the Seattle area suggests that patients with lung, liver and some types of gastrointestinal tumors, as well as hematologic malignancies, are at greater risk of suffering COVID-19 than patients with other kinds of cancer. Sparse as these data may be, they should still guide decision-making by oncologists and healthcare leaders, Oyer says. Many professional associations are providing guidance to oncologists during the outbreak, including the Association of Community Cancer Centers (Oyer is the president), the American Society of Clinical Oncology, the American Society of Hematology, the American Society for Radiation Oncology and the American College of Surgeons.
‘Agility and collaboration’
Patients with cancers of the lung, the liver and possibly the gastrointestinal system are at increased risk of COVID-19 because the SARS-CoV-2 virus attaches to the angiotensin-converting enzyme 2 (ACE2) that is highly expressed in these organs and system, explains Oyer. ACE2 “paves the way” to cancer cells in these areas and acts as a “welcome mat” for SARS-CoV-2, he says.
It’s a different story with hematologic cancers, which include the leukemias, the lymphomas and multiple myeloma. The cancers themselves reduce immunity and make people vulnerable to infection because they interfere with the production of healthy levels of lymphocytes. In addition, the treatment of hematologic cancers targets the immune system and the bone marrow to get rid of the malignant cells, but it also affects noncancerous cells, further suppressing the patient’s immunologic defenses. Oyer describes the process as one in which “the bouncer’s (been) removed from the door” and can’t defend against the virus.
Masumi Ueda, M.D., M.A., assistant medical director for inpatient blood and bone marrow transplant at the Seattle Cancer Care Alliance, a hospital in its namesake city, says patients with compromised immune systems should adhere to the core recommendations for preventing COVID-19: Wash your hands, and maintain social distancing. “Aside from that, there’s not much more than we can do in the absence of a vaccine,” she says.
Ueda was the lead author of an article in the April 2020 issue of the Journal of the National Comprehensive Cancer Network describing the changes that the Seattle cancer hospital made in response to the COVID-19 outbreak. The title is telling: “Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal.” Ueda and her colleagues mingled advice with brief accounts of the steps they took to respond to COVID-19:
- The first step is robust infection and environmental control. Patients with respiratory symptoms need to be triaged. In Seattle, wrote Ueda and her colleagues, they had early access to testing and could perform nasopharyngeal swabs on symptomatic patients that met COVID-19 testing criteria.
- Healthcare leaders need to strictly reinforce “stay at home when ill” policies and establish other policies for testing staff, tracking exposures and defining when people can return to work.
- Forming an “incident command” structure is necessary to centralize information. Leaders need to hold virtual town halls.
- Outpatient well visits were rescheduled or handled through telemedicine visits, and telemedicine capabilities and training were ramped up. Hours of operation were added to make sure that emergency departments and hospital resources were used only by those needing high-level care.
- Adjuvant therapy with curative intent for patients with solid tumors should likely proceed.
- Decisions about delaying treatment should factor in whether delays may lead to inpatient admissions for symptom palliation that would burden hospitals.
- Stem cell transplants and cellular immunotherapies provide curative treatment and can’t be delayed in many cases.
- By speaking to patients on the phone, surgeons optimized decision-making about delays in surgery.
- Oncology disease groups were given the job of determining which treatments might reduce the risks of immunosuppression. They also weighed whether treatments might be moved from an inpatient to outpatient setting or delayed.