Clinical Insights: June 2020
CE lesson worth 1 contact hour that is intended to advanced practice nurses, registered nurses, and other healthcare professionals who care for patients with cancer.
Release Date: June 22, 2020Expiration Date: June 22, 2021
This activity is provided free of charge.
STATEMENT OF NEED
This CE article is designed to serve as an update on cancer detection and prevention and to facilitate clinical awareness of current and new research regarding state-of-the-art care for those with or at risk for cancer.
Advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients may participate in this CE activity.
Upon completion, participants should be able to:
- Describe new preventive options and treatments for patients with cancer
- Identify options for individualizing the treatment for patients with cancer
- Assess new evidence to facilitate survivorship and supportive care for patients with cancer
ACCREDITATION/CREDIT DESIGNATION STATEMENT
Physicians’ Education Resource®, LLC is approved by the California Board of Registered Nursing, Provider #16669 for 1 Contact Hour.
DISCLOSURES/RESOLUTION OF COI
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METHOD OF PARTICIPATION
- Read the articles in this section in its entirety.
- Go to www.gotoper.com/go/ONN20June
- Complete and submit the CE posttest and activity evaluation.
- Print your CE Certificate.
This CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CE activity is for continuing medical nursing purposes only and is not meant to substitute for the independent medical judgment of a nurse or other healthcare provider relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual authors and do not reflect those of PER®.
Tocilizumab Successfully Treats COVID-19 in Patients With Myeloma
By Jason M. Broderick
Special attention to reducing the risk of cardiovascular disease should be a priority for long-term care of patients with breast cancer, according to Jean-Bernard Durand MD, FACC, FACP, FHFSA, FAHA.1
The oncology supportive care agent tocilizumab (Actemra) successfully treated COVID-19 in a patient with multiple myeloma, according to a case study from Wuhan, China, published in Blood Cancers.1,2
The investigators specifically concluded that their research suggests that tocilizumab might effectively treat cytokine storm caused by COVID-19, and that this benefit could potentially be extrapolated to patients with other blood cancers. Cytokine storm is a type of severe immune overreaction that can cause life-threatening respiratory complications.
"Our patients with hematologic malignancies are immunosuppressed, which may put them at higher risk for novel coronavirus infection. What are the characteristics of COVID-19 in patients with blood cancers? What is the optimal treatment approach? Everything is unknown, and that was the motivation for this study," the study’s lead author Changcheng Zheng, MD, of the University of Science and Technology of China, said in a press release.
In the patient with multiple myeloma, tocilizumab successfully resolved COVID-19 symptoms after standard treatments failed, and he was able to be released from the hospital. Zheng emphasized that the patient did not have the standard COVID-19 symptoms of cough and fever, suggesting that patients with hematologic malignancies may not typically have these clinical symptoms of the coronavirus.
Going forward, Zheng is hopeful that the success of tocilizumab in this patient can be a model across hematologic malignancies, but cautions that much more research is still needed.
"Tocilizumab was effective in the treatment of COVID-19 in this patient with multiple myeloma, but further prospective and randomized clinical trials are needed to verify the findings," said Zheng.
The case study involved a 60-year-old male with multiple myeloma diagnosed in 2015. He was receiving maintenance therapy for myeloma at the time of his hospitalization on February 1, 2020, for chest tightness and shortness of breath. He tested positive at the time for COVID-19 that was considered severe, despite not having the standard symptoms of cough or fever.
Antiviral and corticosteroid therapies were initially used but did not completely resolve his symptoms. A chest CT scan done on his second day of hospitalization revealed that there were ground glass opacities in his lungs, a characteristic of pneumonia. Additionally he had high levels of the proinflammatory cytokine IL-6.
The patient received 8 mg/kg of tocilizumab (IV, administered 1 time) on day 9 in the hospital, which was day 24 of his having COVID-19. The patient’s IL-6 levels went down after the single intravenous dose of tocilizumab, continuing to decrease over the next 10 days (121.59 to 20.81 pg/mL). The levels then started to increase rapidly, peaking at 317.38 pg/mL, but eventually settled to 117.10 pg/mL.
“The transient rebounding of the IL-6 level to the peak does not mean COVID-19 relapse: instead, this might be attributed to the recovery of the normal T cells,” Zheng et al explained in the article.
His chest tightness resolved 3 days after initiating tocilizumab and on his 19th day in the hospital, a CT scan showed an obvious decrease in the range of ground-glass opacities. On March 13, 2020, the hospital considered the patient to be cured and he was discharged. He also showed no symptoms of multiple myeloma and had normal laboratory results.
The FDA recently approved the initiation of a double-blind, randomized phase III clinical trial of tocilizumab for use in combination with standard of care for the treatment of hospitalized adult patients with severe COVID-19 pneumonia, according to Genentech (Roche), the manufacturer of the interleukin-6 receptor antagonist.3
Genentech is collaborating with the Biomedical Advanced Research and Development Authority (BARDA), a part of the US Health and Human Services Office of the Assistant Secretary for Preparedness and Response (ASPR), to evaluate tocilizumab combined with standard of care versus placebo plus standard of care.
Enrollment is expected to start soon, with a target accrual of 330 patients across the United States and other countries. Investigators will follow patients for 60 days after randomization and early proof of efficacy will be assessed at an interim analysis. Key study endpoints will be clinical status, mortality, mechanical ventilation, and intensive care unit variables.
As the CAR T-cell therapy revolution has spread across the treatment paradigm for patients with hematologic malignancies, tocilizumab has become critical to ensuring that patients are able to receive this type of therapy. Specifically, tocilizumab is approved by the FDA for the treatment of cytokine release syndrome (CRS) that is severe or life-threatening. CRS is the most severe toxicity associated with CAR T-cell therapy. Tocilizumab is used in adults and children aged 2 years and older who have CRS caused by CAR T-cell therapy.
Tocilizumab has been a critical component to ensuring the success of several pivotal clinical trial of CAR T-cell therapy. For example, the FDA is currently reviewing a biologics license application for the anti-CD19 CAR T-cell therapy lisocabtagene maraleucel for the treatment of adult patients with relapsed/refractory large B-cell lymphoma after at least 2 prior therapies, based on data from the multicenter phase I TRANSCEND NHL 001 study.4 In this pivotal trial, the incidence of any grade CRS was 42%, which occurred at a median onset of 5 days. Nineteen percent of patients received tocilizumab to manage CRS. Nearly all cases of CRS were entirely reversible.
Another oncology drug, ruxolitinib (Jakafi), is being explored in the planned phase III RUXCOVID trial as a treatment for cytokine storm in patients with COVID-19. The RUXCOVID trial will specifically evaluate the JAK1/2 inhibitor in combination with standard of care treatment versus standard of care alone in patients with severe COVID-19 pneumonia caused by SARS-CoV-2 infection.
Novartis and Incyte, the covdevelopers of ruxolitinib, decided to launch the trial based on preclinical and preliminary clinical findings indicating ruxolitinib could lower the number of patients with these complications who need intensive care and mechanical ventilation. In a press release, the companies reported that they plan to initiate a compassionate use program for patients with COVID-19 to have access to ruxolitinib.5
1. Case Study: Treating COVID-19 in a Patient with Multiple Myeloma. Published online April 3, 2020. https://prn.to/2JzIakv. Accessed April 3, 2020.
2. Zhang X, Song K, Tong F, et al. First case of COVID-19 in a patient with multiple myeloma successfully treated with tocilizumab. Blood Adv. 2020;4(7):1307-1310. https://doi.org/10.1182/bloodadvances.2020001907
3. Genentech Announces FDA Approval of Clinical Trial for Actemra to Treat Hospitalized Patients With Severe COVID-19 Pneumonia. Posted March 23, 2020. https://www.gene.com/media/press-releases/14843/2020-03-23/genentech-announces-fda-approval-of-clin. Accessed March 23, 2020.
4. U.S. Food and Drug Administration (FDA) Accepts for Priority Review Bristol-Myers Squibb’s Biologics License Application (BLA) for Lisocabtagene Maraleucel (liso-cel) for Adult Patients with Relapsed or Refractory Large B-Cell Lymphoma. Published February 13, 2020. https://bit.ly/39uYC0l. Accessed February 13, 2020.
5. Novartis announces plan to initiate clinical study of Jakavi® in severe COVID-19 patients and establish international compassionate use program. Published April 3, 2020. https://bit.ly/3aHA2dF. Accessed April 3, 2020.
Shifting Lung Cancer Treatment Strategies in Response to COVID-19
By Kristi Rosa
Through the use of telemedicine and modified treatment plans, experts in the cancer community are working hard to prevent patient exposure to COVID-19. These efforts are particularly important for patients with lung cancer, as this population is at increased risk of developing more severe complications from the virus, according to Joshua M. Bauml, MD.
“It seems that patients with lung cancer are at higher risk for more severe complications, likely due to multiple issues. For one, there is cancer in the lung that can limit the amount of normal lung tissue,” said Bauml. “Some patients have also undergone surgery or radiation that further limits the amount of healthy lung tissue. In addition, many patients with lung cancer have underlying lung disease, such as emphysema, asthma, or chronic bronchitis, that puts them at higher risk [for complications].”1,2
Bauml, an assistant professor of medicine at the Hospital of the University of Pennsylvania, discussed challenges in providing care to patients with lung cancer in light of the COVID-19 pandemic and ongoing efforts to reduce exposure to the virus.
What do we know so far about COVID-19 and how it is affecting patients with lung cancer specifically?
Bauml: We have very limited data available now; it is a very fluid situation. Based on data that have come out of both China and Italy, it does seem that patients with cancer in general, and lung cancer specifically, are at higher risk for complications from COVID-19 infection. That being said, it is important to remember that all these data remain very preliminary; there is so much more we don’t know versus what we do know at this point.1,3,4
How are you differentiating symptoms of lung cancer from those of COVID-19?
It is very tricky! We are screening patients at Penn by asking if they have a cough, but many of my patients have a chronic cough. I tend to ask them whether [they have experienced] any changes to their symptoms. When they have a CT scan, [we see] a relatively classic appearance for COVID-19.5 Unfortunately, these findings are pretty similar to [those observed with] inflammation in the lungs, or pneumonitis, that can be seen with immunotherapy or TKIs. From there, we can often rely on when the changes happened to help address that clinical question.
Has this pandemic affected how you approach the treatment of your patients? For example, are you using immunotherapies less often? Are you shifting approaches to delay surgeries?
It has been a huge change. We are doing more and more visits as telemedicine, and we are also spacing out treatments when clinically feasible. For example, if a patient is on maintenance immunotherapy that I usually [administer] every 3 weeks, sometimes [I am] spacing that out to every 4 weeks [instead]. Also, bronchoscopy is one of the highest-risk procedures in the era of COVID-19, so I am referring fewer patients for it.6-8
What has your institution done to reduce the risk of exposure to the virus for staff and patients?
We have minimized patient exposure by making as many visits by telehealth as we can, using telephone and video conferencing. Each of the providers in our group come to clinic once per week for onsite support, but most of our patient interaction occurs with telehealth. If someone needs to see [someone face-to-face], one of the onsite providers can see them at any time. Providers are all wearing masks when in public areas. In addition, we have multiple screening questions [in place] to minimize the chance that anyone with COVID-19 [will] come into our clinic.6-8
What is your personal experience with telemedicine? Are you facing any particular challenges?
Doing telehealth is very difficult when discussing tough topics like lung cancer. Being able to be present for my patients is so critical to provide them with necessary support. I try to stay in contact as much as possible using the tools we have available. I have also been referring many of my patients to the LUNGevity HELPLine if they have further questions: 844-360-5864. It’s a great resource for my patients and their families, and [that HELPLine is] fully staffed.9
Are any interesting COVID-19—related research efforts being made that you would like to highlight?
Many oncologists are pooling their efforts to build a large registry of outcomes for patients with lung cancer who [become infected with] COVID-19. This registry will serve as a critical data source in the future.10
1. Passaro A, Peters S, Mok TSK, et al. Testing for COVID-19 in lung cancer patients. Ann Oncol. Published online April 9, 2020. doi: 10.1016/j.annonc.2020.04.002
2. CDC COVID-19 Response Team. Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019 — United States, February 12-March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382-386. doi: 10.15585/mmwr.mm6913e2
3. Sidaway P. COVID-19 and cancer: what we know so far. Published online April 7, 2020. Nat Rev Clin Oncol. doi: 10.1038/s41571-020-0366-2
4. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/ S1470-2045(20)30096-6
5. Calabrò L, Peters S, Soria JC, et al. Challenges in lung cancer therapy during the COVID-19 pandemic. Lancet Respir Med. Published online April 9, 2020. doi: 10.1016/S2213-2600(20)30170-3
6. ESMO management and treatment adapted recommendations in the COVID-19 era: lung cancer. European Society for Medical Oncology. Accessed April 13, 2020. https://www.esmo.org/guidelines/lung-and-chest-tumours/lung-cancer-in-the-covid-19-era
7. Pertinent questions regarding the care of patients with lung cancer in the COVID-19 environment. International Association for the Study of Lung Cancer (IASLC). March 31, 2020. Accessed April 13, 2020. https://www.lungcancernews.org/wp-content/uploads/2020/04/Covid19_8.5x11-PatientCare_0320-3.pdf
8. NCCN. Clinical Practice Guidelines in Oncology. Short-term recommendations for non—small cell lung cancer management during the COVID-19 pandemic, version 1.2020. Accessed April 14, 2020. https://www.nccn.org/covid-19/pdf/COVID_NSCLC.pdf 9. Lung cancer HELPLine. LUNGevity. Accessed April 14, 2020. https://lungevity.org/for-patients-caregivers/support-services/lung-cancer-helpline
10. TERAVOLT: Thoracic cancERs international coVid 19 cOLlaboraTion. International Association for the Study of Lung Cancer / IASLC Lung Cancer News. Accessed April 14, 2020. https://www.lungcancernews.org/teravolt-thoracic-cancers-international-covid-19-collaboration/
COVID-19 Breast Cancer Recommendations Stratify Patients by Risk
By Brielle Benyon
Leading cancer organizations have partnered to create joint recommendations for the treatment of patients with breast cancer during the coronavirus 2019 (COVID-19) pandemic.1
The recommendations from the organization—the American Society of Breast Surgeons, the National Accreditation Program for Breast Cancers, the National Comprehensive Cancer Network, the Commission on Cancer of the American College of Surgeons, and the American College of Radiology—focus on prioritization, treatment, and triage, categorize patients with the disease into 3 priority levels.
• Priority A: These patients have immediately life-threatening, clinically unstable, or completely intolerable pain and for whom even a short delay would significantly alter the patient’s prognosis. Under the assumption that treatment would be efficacious, priority A patients are, “given top priority, even if resources become scarce, requiring urgent treatment for preservation of life or control of progressing disease or symptomatic relief,” the recommendation says.
Priority B: This group, which most patients with breast cancer will belong, does not require immediate treatment, but should begin their treatment before the COVID-19 pandemic ends. Most of these patients will not have outcomes affected if their treatment has a short delay of 6 to 12 weeks, but longer delays may impact their prognosis. Priority B patients are sub-categorized into B1 (higher priority), B2 (midlevel priority), and B3 (lower priority).
• Priority C: Patients in this group, their treatment can be safely deferred until after the pandemic. “Patients in Priority C category are patients for whom certain treatment or services can be indefinitely deferred until the pandemic is over without adversely impacting outcomes,” the recommendations state.
Health care provider must also weigh the risk of disease progression and worse outcomes against the risk of patient and staff exposure to SARS CoV-2, which is the virus that caused COVID-19, according to the recommendations.
“Physicians should use these recommendations to prioritize care for their patients [with breast cancer] and adapt treatment recommendations to the local context at their hospital.”
The recommendations stress the importance of telemedicine, stating that the majority of patient-provider encounters should be conducted remotely. Most Priority A patients should be assessed in person, as they may be clinically unstable postoperative patients or have oncologic emergencies, such as febrile neutropenia, intractable pain.
Many hospitals have adopted that approach.
“We are only doing emergent surgery because these activities could potentially compete for resources needed for acutely ill COVID-19 patients,” Debu Tripathy, MD, professor and chair, Department of Breast Medical Oncology at The University of Texas MD Anderson Cancer Center in Houston, said in an interview with Oncology Nursing News®.
Priority B patients should be seen by a member of the team, remotely or in person, to be evaluated on a case-by-case basis. These patients include those with the following conditions: recently diagnosed breast cancer; established patients with new concerns, such as breast infection; palpable findings; symptoms from therapy; patients on intravenous chemotherapy; patients completing neoadjuvant therapy preparing for surgery; postoperative patients, and those planning to undergo radiation therapy.
Finally, Priority C patients can either have their visit completely delayed or can be seen remotely. This includes follow-up for benign or malignant conditions, survivorship visits, and high-risk screening.
“Of course, there are shortcomings and no system is perfect, but our common sense approach has resulted in about a 50% to 70% drop in visits in the [past] 4 weeks or so. We also want to minimize traffic and chance of spread between patients and staff, so that is a big consideration as well. More than half our forces is working from home. We are ramping up remote visits— we have embedded Zoom capability into our [emergency medical record],” said Tripathy.
At MD Anderson, there is a push for COVID-19 testing, Tripathy said.
“As with many other centers, we would want to ramp up testing, turnaround time and move toward knowing who has already been exposed and may be immune due to presence of antibodies—this is work in progress and we have not been limited in testing for patients, but need to expand to testing asymptomatic patients and even staff. We do test all patients prior to surgery regardless of symptoms.”
The treatment recommendation authors noted that patient situations as well as the COVID pandemic will change.
“However, as the pandemic rapidly evolves, we are increasingly learning about viral transmission and its impact on the health system, thus, these recommendations will evolve over time with continued updates. This consortium will continue to adapt these recommendations to the current pandemic severity including future waves of the COVID-19 pandemic. It is our hope that these current 16 recommendations will help clinicians provide the highest quality care for their patients during this evolving pandemic.”
1. Dietz JR, Moran MS, Isakoff SJ, et. al. Recommendations for prioritization, treatment and triage of breast cancer patients during the COVID-19 pandemic. Breast Cancer Res Treat. In Press. Posted online April 8, 2020. https://www.facs.org/-/media/files/quality-programs/napbc/asbrs_napbc_coc_nccn_acr_bc_covid_consortium_recommendations.ashx
NCCN Publishes COVID-19 Recommendations for Oncology Providers
By JASON M. BRODERICK
Although there are signs that efforts to “flatten the curve” have met with some degree of success, the coronavirus disease 2019 (COVID-19) crisis continues to present major challenges to the oncology community.
As such, the National Comprehensive Cancer Network (NCCN) has published guidelines to help ensure that patients with cancer, care providers, and staff are kept as safe as possible during the crisis.1
“The unprecedented challenges we are all facing from the COVID-19 pandemic heighten NCCN’s commitment to sharing evidence-based consensus from leading medical experts as rapidly as possible, free-of-charge, to everyone around the world,” Robert W. Carlson, MD, chief executive officer of NCCN, said in a news release2. “We are doing everything we can to review and share reliable information that will help keep oncology patients, providers, and staff safe under the new reality of increased risk.”
The guidelines (below) were published by the NCCN Best Practices Committee in JNCCN: Journal of the National Comprehensive Cancer Network:
• Prescreen and screen for COVID-19 symptoms and exposure history via telephone calls or digital platforms
• Develop screening clinics to allow for patients with symptoms to be evaluated and tested in a dedicated unit with dedicated staff
• Convert in-person visits to telemedicine visits when possible
• Limit or disallow visitors
• Limit surgeries and procedures to only essential, urgent, or emergent cases
• Consider alternative dosing schedules to allow for fewer in-person visits to the cancer center and/or the infusion center
• Switch from infusional therapy to oral oncolytics if equivalent formulation is available
• Transition outpatient care to care at home whenever possible (eg, pump disconnection, administration of growth factors or hormone therapy)
• Increase intervals between scans or use biochemical markers in lieu of scans
• Provide resources for wellness and stress management for patients
The following are the guidelines for health care worker safety:
• Assure availability and use of appropriate personal protective equipment (PPE) per guidelines
• Create a centralized resource or website to communicate recommendations to health care workers around PPE and workflows
• Implement daily screening tools and/or temperature checks
• Telecommute when possible, with limited onsite staff participating in rotations on a daily basis
• Establish clear stay-at-home and return-to-work guidelines
• Provide resources for wellness and stress management for health care workers
“We can continue to provide our patients with effective and compassionate care, without sacrificing the health and safety of our teams, colleagues, and families, by carefully evaluating any emerging research and modifying our treatment approaches accordingly,” lead guidelines author Pelin Cinar, MD, MS, medical director of quality and safety, UCSF Helen Diller Family Comprehensive Cancer Center, stated in the news release.
“People with cancer and their loved ones already go through so much, and now they face new fears around catching COVID-19 or delaying necessary treatment. By sharing these recommendations, we want to reassure the oncology community that there are some aspects of care that we can and will control in order to improve outcomes for people with cancer,” added Cinar.
Top oncology centers across the country are also developing new techniques to enhance safety amid the COVID-19 crisis. For example, anesthesiologists at Memorial Sloan Kettering Cancer Center (MSK) have modified the standard single-unit protective boxes that are used during airway procedures, such as intubation, in patients who are infectious.3 The modified box is now a 2-piece unit, which, according to the inventors, gives health care providers improved access if issues occur during airway procedures.
The benefit of the 2-piece unit was explained in further detail in a news release, which explained that the 1-piece boxes contain most of the aerosolized virus from spreading into the room, and the MSK redesign adds a safety feature so the upper lid section can be removed by someone else, keeping the primary operator’s hands and airway equipment in place.
The MSK inventors have made the specifications for the 2-piece device publicly available.
“We believe our simple modification of going to a 2-piece design will be very helpful in patients with difficult airways,” Grant H. Chen, MD, an anesthesiologist at MSK, stated in the news release. “Under normal circumstances, around 2 percent of intubations are anticipated to be unexpectedly difficult. However, there have been reports that patients with COVID-19 are presenting with swollen airways, which may dramatically increase difficult intubations.”
The need for ventilatory support in patients has increased markedly due to hypoxic respiratory failure caused by COVID-19. Protective boxes are increasingly becoming part of standard practice at hospitals across the country to shield health care providers from contact with the aerosolized virus when conducting airway procedures in patients.
“Protecting patients and healthcare providers during this pandemic requires real-time, on-the-ground innovation and information sharing with our colleagues around the nation and world,” Takeshi Irie, MD, PhD, an anesthesiologist at MSK, said in the news release. “We want to get the word out about this critical design change, which may go a long way toward keeping our fellow healthcare providers safe during this public health crisis.”
1. Cinar P, Kubal T, Freifeld A, et al. Safety at the time of the COVID-19 pandemic: how to keep our oncology patients and healthcare workers safe [published online ahead of print, 2020 Apr 15]. J Natl Compr Canc Netw. 2020;1—6. doi :10.6004/jnccn.2020.7572
2. JNCCN: improving COVID-19 safety for cancer patients and healthcare providers. News release. National Comprehensive Cancer Network. April 9, 2020. Accessed April 9, 2020. https://prn.to/3bYYKXg
3. MSK redesigns the protective boxes used during airway procedures, change may help minimize the spread of COVID-19 to healthcare providers. Published April 8, 2020. Accessed April 9, 2020. https://bit.ly/2XoxihM
Rebecca Bank, BSN, RN, OCN, CHPNSansum Clinic Ridley Tree Cancer Center
Symptom management has changed a little bit [in] the way that we screen our patients. It’s a lot about asking the right questions and following up with their history. We know that coronavirus [disease 2019] started only this year, but maybe they had these kinds of symptoms for a while. It’s…[vital to] make really thorough assessments, especially if you are not able to see a patient in person. [It takes many questions] over phone or even telemedicine. Using video and using your resources to really provide that assessment and help patients be aware of those symptomatic changes [is important].
One of the things I’ve noticed is that it is more challenging, but you [should implement] more follow-ups. If I call my patients more often, if I follow up with more of my telemedicine video conferences more often, sure, I might not be able to connect with the first phone call. But if I'm consistently there, if I answer their phone calls and follow up with their concerns, you bet that they will know that I care. I've had many patients connect with me that way and say, “Rebecca, I’m glad to know that you’ll pick up and be there if I have a question.”
To Treat or Not to Treat? Cancer During the COVID-19 Pandemic
By Brielle Benyon
Clinicians must weigh out the pros and cons when treating patients with cancer during the coronavirus disease 2019 (COVID-19) pandemic, according to an article by Fox Chase Cancer Center researchers that was recently published in the Annals of Internal Medicine.1
“Oncology specialists as well as other providers regularly involved in the diagnosis, active treatment, and longitudinal follow-up of cancer patients must consider how to 1) balance a delay in cancer diagnosis or treatment against the risk for a potential COVID-19 exposure, 2) mitigate the risks for significant care disruptions associated with social distancing behaviors, and 3) manage the appropriate allocation of limited health care resources in this unprecedented time of health care crisis,” the authors wrote.
Statistics have shown that people who are elderly or who have other health conditions are most negatively impacted by COVID-19, which could put patients with cancer at an increased risk.
Not only can it be risky to potentially expose a patient to the virus during cancer treatment, but such exposure can cause major issues after treatment as well. The researchers encourage clinicians to make decisions on a case-by-case basis, taking into consideration the type of cancer a patient has.
“Many solid tumors (such as lung or pancreatic cancer) and some hematologic cancers (such as acute leukemia) require immediate diagnosis and treatment. However, other common early-stage cancers (breast, prostate, cervical, nonmelanoma skin) may not,” they wrote.
While there shouldn’t be a “one-size-fits-all” approach, the authors said that experienced oncology providers should exercise their best judgement, and those decisions could change, “as efforts by the healthcare system to mitigate risks for exposure to COVID-19 improve.”
The researchers also outlined that patients undergoing cancer treatment disrupt social distancing protocols that were put in place to mitigate the spread of COVID-19.
“Every patient who engages with the traditional oncology care delivery system significantly disrupts this social distancing tactic, resulting in innumerable ripple effects,” the researchers wrote. “Clinic visits, surgical stays, infusion sessions, radiation planning and treatment appointments, hospital admissions, phlebotomy visits for laboratory tests, and radiographic imaging studies—all often attended with family members in tow—result in a massive number of personal contact points and many potential opportunities for viral transmission.”
Some patients, especially those receiving survivorship care, may be better off with “nontraditional care delivery strategies” and the use of modern technology, such as telehealth. The Centers for Medicare & Medicaid Services, along with other private insurers, have expanded telehealth benefits during the outbreak. The US Department of Health and Human Services will not impose penalties on providers who use telehealth in the event of nonadherence to Health Insurance Probability and Accountability Act (HIPAA).
Limited Healthcare Resources
Another major concern born out of the pandemic is the saturation of the healthcare system, especially when it comes to intensive care unit (ICU) beds, ventilators, pharmaceuticals, blood products, staff (and protective equipment for them), and basic medical supplies.
“Although most cancer care is not typically considered ‘elective,’ as resource constraints grow owing to supply chain issues, variations in geographic needs, and reallocation of medical infrastructure to care for infected patients, difficult tradeoffs will need to be made,” the authors wrote.
Patient education is key here. Additionally, standard post-acute treatment strategies including lab testing, imaging, and office visits may be postponed as well.
“In summary, as cancer care and COVID-19 collide, patients and providers will face extremely difficult choices. The combat plan during this battle must involve patience, communication, diligence, and resolve. Risks must be balanced carefully, public health strategies implemented thoroughly, and resources utilized wisely. Furthermore, the policies and procedures developed today will serve as the basis for addressing the next outbreak or similar crisis,” the authors wrote.