Ueda’s area of expertise is in stem cell transplant. She says not much data exist about whether patients undergoing the procedure, which involves a period of severe immunosuppression, do in fact have a higher risk of experiencing serious COVID-19-related illness. But as a rule, she notes, patients undergoing immunosuppressive cancer treatments such as stem cell transplants are more vulnerable to infection and serious illness from viral diseases like COVID-19.
The number of patients with cancer and COVID-19 has been relatively low at Seattle Cancer Care Alliance. “I think we were lucky as an institution,” says Ueda, noting the center’s relatively early access to testing. Still, she’s cautious about what the future holds. Her hospital is preparing to revamp its cancer care operations once the worst of the pandemic has subsided. Among the changes in the offing might be greater use of telehealth.
To delay or not to delay
The COVID-19 outbreak has put nearly every medical service on hold and forced patients and physicians to do some cost-benefit thinking about diagnosis and treatment, now and later. But the decision to delay cancer treatment is especially fraught, and the seesaw of cost-benefit, huge. Delay could give an aggressive cancer an opportunity to progress, but treatment may lower immunity. J. Leonard Lichtenfeld, M.D., MACP, deputy chief medical officer at the American Cancer Society in its Atlanta headquarters, says the society’s around-the-clock call center has received questions from many patients whose cancer treatments have been stopped or put on hold. “Every cancer center is struggling with this,” he says.
Richard Van Etten, M.D., Ph.D., a stem cell transplant specialist at the University of California, Irvine, and director of its Chao Family Comprehensive Cancer Center, says the decision to delay care depends on the type of treatment. For autologous stem cell transplants, which involve using the patient’s stem cells, continuing treatment is plausible if the patient doesn’t have COVID-19. Maintenance therapy is also an option for these patients and would allow them to undergo the procedure later.
Allogeneic stem cell treatment, which involves using stem cells from a donor, presents a greater challenge, says Van Etten, because these patients can be profoundly immunosuppressed for up to a year after treatment. Many of these patients can’t wait long for a transplant, so moving forward with the procedure, and ensuring the patient is isolated afterward, may make sense, provided they don’t have COVID-19.
Oyer, a practicing oncologist for 40 years, describes himself as an optimist. He is challenging healthcare leaders and oncologists to use this experience with COVID-19 to transform cancer care. For example, patients undergoing treatment might be given the option of checkups using telehealth, which will increase convenience, he says. Oyer also notes how quickly medical journals have published articles about COVID-19. The evidence they have presented has helped professional organizations keep their guidelines timely and relevant.
Healthcare organizations should start planning now for when the worst of the outbreak is over, says Lichtenfeld. “There’s going to be an incredible rush to the door of patients seeking treatment,” he notes, and careful triage of patients is going to be important. He also recommends proactive communication with patients about when they will resume treatment. In addition, healthcare leaders must support staff members with employee assistance programs, he says.
“Everyone has a story,” Lichtenfeld says. “Everyone wants to be comforted, and staff will have emotional and community-based issues they have to deal with.”
Aine Cryts is a healthcare writer based in Boston.