Cancer Connect Editorial Team updated 11/2022
The COVID-19 pandemic swept through the world impacting every aspect of life creating fear and anxiety while leaving a toll of health and economic devastation. As the virus continues to cycle through society we are learning to live with the "new normal”. Cancer patients, their families, and caregivers are disproportionally impacted by the COVID pandemic but advances in vaccination, new treatments for COVID, and a better understanding of how the coronavirus impacts cancer gives us optimism that the future will be better and the impact of the virus will continue to diminish.1
As we begin this winter SARS-CoV-2, the virus that causes COVID-19, is constantly changing and accumulating mutations in its genetic code over time. New variants of SARS-CoV-2 are expected to continue to emerge that can evade the immune system's current defenses. These variants have taken over in the U.S, and for the first-time fatalities from COVID are greater among the vaccinated than the unvaccinated. Elderly and immunocompromised individuals should take precautions. If infection is suspected seek early treatment.
Paxlovid, Actemra and Remdesivir remain the best treatments but many of the different monoclonal antibodies have lost their effectiveness against the new variants of the coronavirus. Bebtelovimab, bamlanivimab, casirivimab, sotrovimab have all lost their effectiveness for treating the newer variants. Monoclonal antibodies are easily outmaneuvered by new COVID strains - the spike protein has been the target of all the monoclonal antibody treatments and its evolution diminishes their effectiveness. Researchers are now trying to create antibodies that target parts of the virus that are less like to change and remain the same on several different viruses within the larger coronavirus family.
Understanding COVID-19 Risk and Cancer
Patients with cancer and a weakened immune system who are treated with immunotherapies tend to fare far worse from COVID-19 than those who haven't received such therapies in the three months before their COVID diagnosis according to findings in a new study published in the November 2022 JAMA Oncology.
Researchers analyzed data from 12,046 patients with COVID-19 who had a current or past diagnosis of cancer. The analysis examined whether a suppressed immune system or treatment with immunotherapy was associated with worse outcomes from COVID-19. The researchers found that patients who were both immunocompromised and treated with immunotherapies did much worse than those who didn't receive these therapies. Cytokine storm and death from COVID were three to four times higher. For patients who were immunocompromised and received some types of systemic treatments cytokine storm and death from COVID were two to three times higher than in non-treated patients.
- Immunosuppressed patients with cancer, treated with systemic therapies have increased their risk of severe COVID-19 and cytokine storm.
- Patients treated with immunotherapies – but whose immune systems are healthy appear to fare no worse from COVID than untreated patients.
- Immunocompromised patients with cancer should be especially careful about avoiding COVID and, if necessary, should be aggressive about getting treatment.
National Comprehensive Cancer Network Vaccine Update
The following groups should consider the "booster" based on the latest FDA/CDC decisions:
- Patients with solid tumors (either new or recurring) receiving treatment within 1 year of their initial vaccine dose, regardless of their type of cancer therapy
- Patients with active hematologic malignancies regardless of whether they are currently receiving cancer therapy Anyone who received a stem cell transplant (SCT) or engineered cellular therapy, especially within the past 2 years.
- Any recipients of allogeneic SCT on immunosuppressive therapy or with a history of graft-vs-host disease, regardless of the time of transplant.
- Anyone with an additional immunosuppressive condition or being treated with immunosuppressive agents unrelated to their cancer therapy.
- People living in the same household with immunocompromised individuals should also get a third dose once it is available.
Individuals with Blood Cancers and COVID-19 Are Particularly Vulnerable
Leukemia, lymphoma, multiple myeloma and myeloproliferative neoplasms are all blood cancers that range from rapidly progressive to slow growing or indolent – many are associated with a compromised immune system which increases the risk of infection.
Doctors have learned a great deal about managing blood cancers during the pandemic in individuals with and without COVID-19 and patients and their physician must work together to determine optimal management. Effective strategies have been developed to ensure the best treatment and patients should NOT DELAY OR ALTER TREATMENT without discussing options with their doctor.
Key Principals in Individuals With COVID-19 Infection
Some patients with blood cancers and COVID-19 are at higher risk for severe infection and death.1,3,4 In general older patients, those with a poor prognosis and those requiring more intensive treatment are at greater risk of dying during treatment.
Importantly, the emerging data suggest that therapy can be safely administered to patients with COVID-19 infection, and that disease control portends improved outcome of COVID-19 infection.
Individuals impacted by a cancer diagnosis should consider two different strategies to reduce their risk during the pandemic. The first is to ensure they take appropriate precautions to avoid unnecessary exposure to the virus. The second is to consider whether changes to their treatment strategy could be implemented to reduce their risk of infection.
How to Limit COVID-19 Exposure
Limiting exposure to COVID-19 in order to avoid getting infected is key and consists of practicing good social hygiene, ensuring precautions are taken by the healthcare delivery environment to protect patients, to prioritize patients for COVID-19 testing and vaccine distribution.2
Should I take the vaccine even though I had COVID?
The US CDC recommends vaccination regardless of whether you already had COVID because we don't know how long an individual is protected again after recovering from COVID-19. Even if you have already recovered from COVID-19, it is possible—although rare—that you could be infected with the virus that causes COVID-19 again. Individuals treated for COVID-19 with monoclonal antibodies or convalescent plasma should also wait 90 days before getting a COVID-19 vaccine.
FDA Authorizes Evusheld to Protect Immunocompromised Individuals
The United States Food and Drug Administration gave emergency use authorization (EUA) to Evusheld (AZD7442) for use in preventing COVID in individuals with weakened immune systems who do not mount an effective immune response to vaccination. Evusheld is a long-acting monoclonal antibody developed by AstraZeneca that can stay active for months which should offer longer-lasting protection compared to the other currently monoclonal antibody treatments that are given to high-risk people already sick with Covid.
Vaccination is the primary strategy to prevent severe COVID-19 disease and is highly effective however not all individuals, especially those with compromised immune systems can be effectively vaccinated. Evusheld is a combination of 2 monoclonal antibodies, tixagevimab and cilgavimab, derived from B-cells donated by convalescent patients who were infected with the SARS-CoV-2 virus. The antibodies are designed to bind to distinct sites on the SARS-CoV-2 spike protein rendering it less dangerous.
The multicenter PROVENT clinical trial included 5197 unvaccinated participants aged 18 years and older who were at increased risk for inadequate response to active immunization or had increased risk of SARS-CoV-2 infection. Findings showed that AZD7442 achieved a 77% risk reduction of developing symptomatic COVID-19 compared with placebo. There were no cases of severe COVID-19 or COVID-19-related deaths in the AZD7442 treatment arm compared with 3 cases of severe COVID-19 in the placebo arm, including 2 deaths.9,10
Third COVID-19 Vaccine Improves Immune Response
New research suggests that lymphoma patients can have improvements in antibody and T-Cell responses after a third vaccine dose, except in patients who had recently received Rituxan. Doctors evaluated blood samples from 457 adult lymphoma patients prior to their first vaccination of either the Oxford-AstraZeneca or BioNTech Pfizer vaccines, four weeks after the first dose, two to four weeks and 6 months after the second dose, and four to eight weeks after the third dose. The scientists measured the ability of antibodies in the blood samples to prevent the viral spike protein from binding to ACE2 proteins, which are the virus’s key point of entry into the human body. They also measured the response of T cells. The results showed that over half of patients undergoing active cancer treatment had no detectable antibody levels after the second vaccination, T cell responses could be detected in about two thirds of all patients. After a third dose, 92 percent of patients who were not undergoing anti-CD20 treatment for their cancer showed improved antibody responses, compared to 17% who were receiving that treatment.11
Treatment of Stage I - IIIA Non-Small Cell Lung Cancer
Update on the management of early stage NSCLC: three trials confirm benefit of immunotherapy yet many patients still not receiving treatment.
COVID-19 Vaccines and Cancer - Evushield "Authorized"
Preventing COVID-19 in Cancer. Answers to frequently asked questions about vaccination and Evushield.
How Precision Medicine in Oncology Has Dramatically Changed the Way Cancer is Diagnosed and Treated
What Patients Need to Know About Biomarker Testing
Additional research suggests that among patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL), a third dose of the BNT162b2 mRNA vaccine against COVID-19 may induce an antibody response in nearly one-quarter of patients. The effectiveness of a third BNT162b2 mRNA vaccine dose among patients with CLL/SLL who did not respond to an initial 2-dose regimen was evaluated in 172 patients. Overall, an antibody response rate was observed in 24% of patients. Patients who were treatment-naïve or who were not receiving active were more likely to have a response than were those actively receiving therapy.13
Can COVID-19 be Treated?
The first specific antiviral drugs to prevent or treat human coronaviruses (HCoVs) infections responsible for the COVID-19 pandemic are now approved by the US. Food and Drug Administration (FDA) and vaccines are in clinical use. While prevention is important, treatment of the virus and its consequences will still be necessary to limit mortality from the pandemic and from future outbreaks. Vaccines take time to be distributed, have limited effectiveness and not everyone will elect to be vaccinated.
Currently available medications that can be used to treat patients diagnosed with novel coronavirus include Paxlovie (paxlovid), Veklury (remdesivir), Actemra, Olumiant (barcitinib), Vitamin D, and steroids. Over 70 other treatments are being developed with a major focus on monoclonal antibodies. Early results from small trails suggest each might improve the success rate of treatment, shorten hospital stay and improve patient outcomes, especially for individuals with lung complications.7,8,9 learn more...
What are Clinics and Cancer Centers Doing?
In order to protect cancer patient’s cancer centers and clinics have adopting measures designed to improve patient safety by decreasing the risk of exposure to the virus.
- Delaying or deferring non-essential clinic visits.
- Using phone consultation or telemedicine appointments when possible.
- Have laboratory work drawn locally with by primary care physician.
- If clinic or hospital visits are necessary. Wear a mask or facial covering. Practice physical distancing. Clinics are screening for exposures either at clinic entrance or by phone one day prior to visit by checking for fever, cough, and other symptoms. Minimizing visitors (1 visitor + patient). Increasing the interval between visits when possible.
Evaluate your Treatment Plan to Reduce Unnecessary Risks
Make sure you understand the goal of therapy and that your treatment plan matches that goal. Is it to cure the cancer, prolong life’s duration, or to maintain quality of life? It’s more important than ever to be informed and understand how the treatment you select impacts outcomes compared to other treatment options or no treatment at all. There are some examples below that highlight areas where treatment changes or avoidance can reduce immunosuppression and or decrease the number and frequency of hospital visits. Each cancer center is developing recommendations and you should carefully evaluate your treatment options with your physician.
Is maintenance therapy really beneficial?
Many cancers, especially blood malignancies are currently treated with maintenance chemotherapy which is immunosuppressive. Maintenance is used because it delays the time to cancer recurrence, but it rarely prolongs survival. In the COVID-19 era does it make sense to stay on prolonged therapy that suppresses the immune system if there is no survival benefit?
How useful is imaging - are follow up CT/MRI scans really necessary?
Evaluation of a cancers response to treatment is performed at intervals during and following treatment. These tests can provide physicians and patients information about how an individual cancer is responding to treatment. They can reduce anxiety but may also contribute to “scan anxiety” as patients await the results. Another way to think about a scan is to ask the question; how will the scan results change management? The answer is often that it won’t change management but will give the physician and patient some indication about the progress of therapy. During the COVID-19 era it may be prudent for patients to reduce the frequency of scans especially when the result won’t immediately change their treatment. Blood biomarker tests are also increasingly available that can detect recurrence and patients should inquire whether a simple blood test can be performed instead of several scans.
Preparing Your Home in the COVID-10 era
Individuals caring for someone who is at a higher risk for serious illness from COVID-19 should consider the following.
- Contact the patient's health care provider to ask about possibly obtaining extra, necessary medications. If this is not possible, see if you can have the medications mailed to you instead of picking them up in person.
- Be sure to have over-the-counter medical supplies on hand that can be used to treat fever and other symptoms.
- Have enough household items and groceries available so that you limit the time you need to be outside or at the store.
- Be sure to clean and disinfect your home to remove germs. A good practice is to routinely scrub often-touched surfaces, such as tables, doorknobs, and light switches. When cleaning these items, use detergent or soap and water prior to disinfecting.
Take Everyday Precautions
The best way to keep others from getting sick is to ensure that you yourself are not exposed to the virus. To do so, please keep the following tips in mind:
- Wash your hands thoroughly and often. This needs to be done for at least 20 seconds using soap and water. If you do not have access to soap and water, be sure to use hand sanitizer that contains 60% alcohol.
- Avoid touching your face, nose, and eyes, especially if you have come in contact with "high-touch" surfaces in public areas, such as elevator buttons, door handles, and handrails.
- Work to avoid crowds, and practice social distancing (a minimum of six feet).
- Cancel all non-essential travel. This includes vacations as well as everyday trips to the store.
As a caregiver, it is important to have your own support, too. So, it is essential to take some time for yourself (and having support around you can help).
Try to delegate responsibilities. If you are feeling overwhelmed or need to take a step back, it is very helpful to talk with someone about your feelings and needs. Make sure you also practice good personal wellbeing, healthy eating, and hygiene. Try to find an outlet to address the additional stress and anxiety you may be experiencing; it's difficult to give someone else the support and time they may need if you aren't also taking care of yourself.
The Ask The Expert Series is made possible by support from The Personalized Medicine Foundation, Incyte Oncology, Abbvie, and CancerConnect. The "Ask The Expert" series is not a substitute for your doctor but should serve as a guide to facilitate access to additional information and facilitate a shared decision making process with your treating physician.
- Wood WA, et al,"Outcomes of Patients with Hematologic Malignancies and COVID-19 Infection: A Report from the ASH Research Collaborative Data Hub" ASH 2020.
- De Ramón C, Hernandez-Rivas JA, García JAR, et al. Impact of Sars-CoV2 infection on 491 hematological patients: the Ecovidehe Multicenter Study. Presented at: 62nd American Society of Hematology (ASH) Annual Meeting and Exposition; December 5-9, 2020. Abstract 312.
- Chari A, Samur MK, Martinez-Lopez J, et al. Clinical features associated with COVID-19 outcome in MM: First results from International Myeloma Society Dataset. Blood. Published online November 6, 2020. doi:10.1182/blood.2020008150
- Ganatra S, Dani SS, Redd R, et al. Outcomes of COVID-19 in patients with a history of cancer and comorbid cardiovascular disease. J Natl Compr Canc Netw. Epub 2020 Nov 3.
- DOI: 10.1158/2643-3230.BCD-20-0151 Published November 2020.
- AZD7442 PROVENT phase III prophylaxis trial met primary endpoint in preventing COVID-19. News release. AstraZeneca. Accessed August 20, 2021. https://www.astrazeneca.com/media-centre/press-releases/2021/azd7442-prophylaxis-trial-met-primary-endpoint.html.
- Pfizer’s novel COVID-19 oral antiviral treatment candidate reduced risk of hospitalization or death by 89% in interim analysis of phase 2/3 EPIC-HR study. News release. Pfizer Inc. Accessed November 5, 2021.
- Herishanu Y, Rahav G, Levi S, et al. Efficacy of a third BNT162b2 mRNA COVID-19 vaccine dose in patients with CLL who failed standard 2-dose vaccination. Blood. 2022;139(5):678-685. doi:10.1182/blood.2021014085