27 May 2020 | Features
All follow-up can be converted to telehealth consultations to ensure patient safety
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Many studies have reported that cancer patients are at an increased risk of COVID-19 infection fatality. This increase in risk is due to many factors including underlying cancerous growth, treatment-related immunosuppression, and often comorbidities. A report of the WHO-China Joint Mission on Coronavirus Disease published on February 28, 2020 indicates that in China the case fatality rate (CFR) for patients with cancer and laboratory confirmed infection was 7.6%, which was double the overall CFR.
A study by Liang et al. published in Lancet Oncology in February reported that COVID patients with cancer in China were observed to have an almost 5 times higher risk of severe events (a composite endpoint defined as the percentage of patients being admitted to the intensive care unit requiring invasive ventilation, or death) compared with patients without cancer. Moreover, patients who underwent chemotherapy or surgery in the past month had almost double the risk of clinically severe events than those that did not receive chemotherapy or surgery.
Another study from China by Dai et al. published in Cancer Discovery in April reported that COVID patients with cancer were significantly more likely to require ICU admission (OR 2.84), have higher rates of severe/critical symptoms (OR 2.79).
A paper by Onder et al. published in JAMA in March reported that of the COVID patients who died in a particular hospital in Italy, 20.3% had active cancer. Mehta et al. published the CFR in a hospital in another epicentre, New York, in Cancer Discovery in May. They reported a CFR of 37% for hematologic malignancies and 25% for solid malignancies. Another paper reporting figures from New York, by Miyashita et al., published in Annals of Oncology in April reported that COVID patients with cancer were significantly more likely to require intubation, with rate of intubation in cancer patients being double that of non-cancer patients.
How to manage treatment?
Doctors face a huge dilemma at this point. On one hand, a patient might be at high risk of contracting COVID-19 infection and dying from it; on the other hand, the patient might be at high risk of the cancer progressing or causing death if it is not treated appropriately. Oncologists have to evaluate whether treatment should be initiated as scheduled or delayed. And if delayed, how long is it safe to delay treatment? Various cancer focused organizations like American Society of Clinical Oncology, American College of Surgeons, European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network and even medical societies in India like Indian Association of Surgical Oncology have established guidelines on cancer treatment during the COVID-19 pandemic.
They advocate that individual patient decisions have to be made by multidisciplinary teams who triage and prioritize treatment based on various parameters such as severity of disease, consequences of delaying treatment, COVID-19 transmission rate etc. They advocate deferring treatment where scientific evidence suggests it does not impact the patient’s outcome. This is because both the cancer and the treatment can cause immunosuppression that increases the risk of contracting the COVID-19 infection.
However, since cancer surgery and treatment are not elective procedures, the risk-benefit ratio for a patient has to clearly establish that postponing the treatment does not damage the patient’s prognosis in the short and long-term. Even if treatment is initiated, doctors have multiple options to de-escalate treatment today, in order to reduce hospital visits and reduce exposure to COVID-19. Taking the example of breast cancer, if diagnosed in early stages, as per ESMO guidelines patients who are hormone receptor positive can entirely avoid chemotherapy if they are low-risk as per a prognostic test.
They can opt for the ‘CanAssist Breast’ test that is well validated and affordable. Taking another example from breast cancer, radiotherapy schedules can be shortened to 1 week versus the traditional 3 weeks for early stage patients, based on new data available. Even if chemotherapy is prescribed for a patient, it is possible to change the dosing schedule or convert to oral chemotherapy. All follow-up can be converted to telehealth consultations to ensure patient safety. I encourage patients to seek medical advice promptly, early diagnosis of cancer offers the best chance at beating it. Your oncologist can work with you to reduce your exposure to COVID-19 while still getting treatment for your cancer.
Dr Avinash C.B, HOD and Sr Consultant Medical Oncologist, ClearMedi Radiant Hospital, Mysuru.