Axel S. Merseburger and Nils Gilbert
Department of Urology, Campus Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
With the rapid progression and global impact of COVID-19, we want to update you with the latest information and research on the current situation, focusing on how this is affecting the fields of oncology and haematology. With patients undergoing chemotherapy and radiotherapy on the list of those most at risk, it is important that caregivers are kept informed on how to manage cancer care during the COVID-19 pandemic.
The predominant goal should be to keep our cancer patients and staff safe while continuing to provide empathetic, high-quality care under circumstances we have never had to face before.
People with cancer appear to be at increased risk of COVID-19, and their outcomes are worse than individuals without cancer. Currently, one comprehensive report comparing COVID-19 course of illness in patients with cancer to those without cancer could be identified.1 This prospective evaluation of 1,571 patients with COVID-19 found that patients with a history of cancer had a higher incidence of severe events – defined as the percentage of patients admitted to an intensive care unit requiring invasive ventilation, or death – compared with other patients. However, a total number of 18 patients with a history of cancer was low to draw meaningful conclusions. In agreement to the correspondence by Xia et al., these 18 patients represent a heterogeneous group and are not an ideal representation of the entire population of patients with cancer.2 So far there is no specific guidance concerning COVID-19 testing in patients with cancer.
In case of scarce or missing data, we should rely on expert opinion and common sense. Pulmonary affection in community acquired respiratory viruses CARV infections is often observed in cancer patients who are often immobilised and have an altered immune system compared to the general population.3,4 This likely also accounts for infection with SARS-CoV-2, therefore special precautions are advised and should be communicated to the patients and primary care doctors.1,5,6
Clinicians and patients will need to make individual determination based on the potential harms of delaying needed cancer-related surgery. Currently there is no straight 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, however, some considerations are currently under discussion. In some cancers the value of perioperative (neoadjuvant or adjuvant) chemotherapy results in a marginal survival benefit (e.g. bladder cancer) and therefore needs to be decided upon the individual situation. Furthermore, instillation therapy to avoid recurrence of non-muscle invasive bladder cancer must also be weighted under the current circumstances.
Another example of avoiding in-house visits and potential exposure to infected patients is to consider extending the time between cycles of therapy. Androgen deprivation therapy has the potential to lower the testosterone for more than the 3-month formulation. Bisphosphonate therapy can be given every 3 months instead of monthly. Knowing the relatively long half-life and long-lasting activity, the application of checkpoint-inhibitors could also potentially be delayed.
The balance of potential harms that may result from delaying or interrupting treatment versus the potential benefits of possibly preventing or delaying COVID-19 infection is very uncertain. Clinical decisions should be individualised, considering factors such as the risk of cancer recurrence if therapy is delayed, modified or interrupted, the number of cycles of therapy already completed and the patient’s tolerance of treatment.
Advice for patients
1. Social distancing
2. Restricted inpatient visitation
3. Avoid elective treatment and consultation and second opinion
4. Trust doctors in their recommendations
Advice for doctors and other care-givers
1. Social distancing
2. Telephone or web consultation of patients
3. Cancel all elective clinical visits and surgery in case of severe COVID-19 caseload – be prepared
4. Check guidelines from societies
5. Provide patient information via handouts, signs, web-based communication and a dedicated phone line for questions and triage
6. Stay at home when ill
7. Wash hands
8. Considering moving procedures from inpatient to outpatient
We hope to raise some discussion among this contemporary and important topic. Several recent peer-reviewed articles sharing best practices are available for free online-ahead-of-print
- Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21:335–7.
- Xia Y, Jin R, Zhao J, et al. Risk of COVID-19 for cancer patients. Lancet Oncol. 2020: DOI: https://doi.org/10.1016/S1470-2045(20)30150-9
- von Lilienfeld-Toal M, Berger A, Christopeit M, et al. Community acquired respiratory virus infections in cancer patients-Guideline on diagnosis and management by the Infectious Diseases Working Party of the German Society for haematology and Medical Oncology. Eur J Cancer. 2016;67:200–12.
- Hirsch HH, Martino R, Ward KN, et al. Fourth European Conference on Infections in Leukaemia (ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainfluenza virus, metapneumovirus, rhinovirus, and coronavirus. Clin Infect Dis. 2013;56:258–66.
- Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020: DOI: https://doi.org/10.1056/NEJMoa2002032
- Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020: DOI: https://doi.org/10.1016/S0140-6736(20)30566-3
Support: No funding was received in the publication of this insight article.
Published: 24 March 2020