by Dr. C. H. Weaver M.D. updated 11/2022
The COVID-19 pandemic has 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 cycles through society we are facing a new “normal.”
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.5
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.
Cancer patients, their families, and caregivers are disproportionally impacted by the COVID pandemic. Although cancer patients are more likely to become infected than the general population and significantly more likely to die from COVID-19 once infected, the greater risk may be altering or foregoing cancer treatment.1 Cancer patients should discuss their concerns about the pandemic and treatment with their doctor and work together to develop a treatment plan that optimizes cancer care and reduces the risks from COVID-19.
In general, 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. All cancer patients should undergo vaccination.
Risk of Death from COVID-19 ‘Remains High’ in Vaccinated Cancer Patients
The risk of COVID-19-related death after breakthrough SARS-CoV-2 infection “remains high” for patients with cancer, according to researchers who compared outcomes in cancer patients and health care workers (HCWs) who were vaccinated against COVID-19.4
Data from 2391 cancer patients with a median age of 65 years, 52% of which were women were evaluated. Cancer types included hematologic malignancies (22%), breast cancer (19%), lung cancer (12%), and prostate cancer (5%). About half of patients (51%) had metastatic disease, and 3% had received anti-CD20 therapy within 3 months of vaccination.
Ninety-five patients (4%) had a prior SARS-CoV-2 infection and received a single COVID-19 vaccine dose (in compliance with guidelines at the time). Among patients without a prior infection, 63% received 2 vaccine doses, 28% received 1 dose, and 6% received 3 doses. Among the 2285 HCWs, 11.3% had received 1 vaccine dose, and 88.7% had received 2 or 3 doses.
Results: Breakthrough Infections and Death
The rate of breakthrough SARS-CoV-2 infection was 1.6% in the cancer patients and 1.5% in the HCWs. Among the cancer patients, the incidence of breakthrough infection was 4% in those who received 1 vaccine dose and 0.7% in those who received 2 doses. None of the patients who received 3 doses had a breakthrough infection. Additional risk factors for developing COVID-19 after vaccination included receiving only 1 vaccine dose and receiving anti-CD20 therapy in the last 3 months. Six of the 39 cancer patients with a breakthrough infection died of COVID-19 compared with none of the HCWs.
The study suggests that 2 or more doses of a COVID-19 vaccine reduce the risk of COVID-19 for cancer patients. However, the risk of death is high, and SARS-CoV-2 infection before vaccination is associated with an increased risk of death.
Booster and 3rd Dose
The following groups should be considered eligible for a third dose of the mRNA COVID-19 vaccine right away 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.
What is the 2019 novel coronavirus?
The 2019 novel coronavirus (COVID-19 is a new virus that causes respiratory illness in people and can spread from person-to-person. This virus was first identified during an investigation into an outbreak in Wuhan, China and has quickly spread throughout China and to most other countries including the United States. Hundreds of thousands of people in the US now have documented infections, and doctors and society are working to understand the disease, develop new treatments, and recommend behavioral changes to reduce the risks of transmission and infection. Individuals with weakened immune systems such as cancer patients or those on immunosuppressive medications might be at higher risk for infection and complications associated with the virus that causes COVID illness.
How does the virus spread?
It is believed that the disease is spread mainly by person-to-person contact, individuals can be infected even if they come in close contact with someone who has the virus. The virus is transmitted via respiratory droplets that are produced when an infected person coughs or sneezes. These droplets can land in the mouths or noses of people who are nearby or can possibly be inhaled into the lungs. The main manner of spread however occurs after touching a surface or object that has COVID-19 on it and then touching one’s own mouth, nose, or eyes. According to a recent study published in the New England Journal of Medicine, SARS-CoV-2, the virus that causes COVID-19, can live in the air and on surfaces between several hours and several days. The study found that the virus is viable for up to 72 hours on plastics, 48 hours on stainless steel, 24 hours on cardboard, and 4 hours on copper. It is also detectable in the air for three hours.Although the virus can last on plastic for 72 hours, what's more important is the amount of the virus that remains. It's typically less than 0.1% of the starting virus material. Infection is theoretically possible but unlikely at the levels remaining after a few days.2
What are the symptoms of coronavirus infection in cancer patients?
The symptoms of COVID-19 are the same in cancer patients as the general population. Patients being treated with steroids can suppress the development of fever.
Common symptoms include:
- Coughing - typically dry non-productive cough
- Myalgia (muscle aches)
- Head Ache
- Shortness of breath
- Some patients report GI symptoms (nausea, diarrhea)
Symptoms typically appear within 2-14 days after exposure, although new data suggests that some people infected with the disease are contagious even before they develop symptoms.
Take Preventive Measures - Everyday Precautions
For now patients should undergo the same preventive measures they would for other common illnesses like the common cold and influenza “the flu.” Most important is to wash your hands frequently, make sure you cover your cough and your sneezes, stay away from other individuals with respiratory symptoms, and avoid travel to places where there are documented cases of COVID. Avoid crowds and situations where you’re likely to be less than six feet from others. (Airborne spread of the virus occurs when an infected individual coughs or sneezes, releasing droplets that can travel three feet. Maintaining a six-foot distance provides a safety margin.)
- 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).
- Avoid all non-essential travel. This includes vacations as well as everyday trips to the store.
- Avoid cafeteria-style eating and public transportation - wash hands after using any public facility.
Is There a Vaccine?
Effective December 2020 vaccines became available. Cancer patients are at higher risk from COVID-19, especially if they are receiving immunotherapy, steroids and immunosuppressive medications which reduce immunity. Many individuals with blood cancers have diminished immunity even if they are not currently on therapy.
Understanding DNA Damage Response or DDR and Cancer Treatment
What is DNA Damage Response or DDR?
Paxlovid is indicated for the treatment of Covid-19 at home for those people who contract the virus prior to requiring hospitalization. This antiviral pill can be viewed as a breakthrough in the fight against Covid-19. The target population for the use of Paxlovid is for those individuals who are 12 years of age of older that are considered to be high risk for hospitalization and death from the virus, and have demonstrated a positive SARS-COV-2 test.
Evusheld for Immunocompromised Individuals
The United States Food and Drug Administration gave emergency use authorization (EUA) to Evusheld 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. Learn more....
Can Testing Determine If You Have Coronavirus?
The main symptoms of COVID-19 are similar to the common cold and include fever, cough, shortness of breath, and a runny nose. It’s difficult to differentiate COVID-19 from the common cold or flu and currently the only way to tell if someone has coronavirus is through testing. Tests are now widely available.
FDA Authorizes First COVID-19 Test Available without a Prescription That Also Detects Flu and RSV
The U.S. Food and Drug Administration authorized the Labcorp Seasonal Respiratory Virus RT-PCR DTC Test for use without a prescription by individuals with symptoms of respiratory viral infection consistent with COVID-19. This is the first COVID-19 test that allows an individual to self-collect a nasal swab sample at home and then send that sample to Labcorp for testing. The test can identify and differentiate multiple respiratory viruses at the same time, detecting influenza A and B, commonly known as the flu, respiratory syncytial virus, commonly known as RSV, along with SARS-CoV-2, the virus that causes COVID-19. Results are delivered through an online portal, with follow-up from a health care provider for positive or invalid test results. The kit can be purchased online or in a store without a prescription.
Are all patients with cancer at equal risk for infection?
Patients with a weakened immune system may be at greater risk of infection because their defenses against infection are lowered. Blood-related cancers such as leukemia, lymphoma, or multiple myeloma, those undergoing chemotherapy treatment, individuals with more advanced disease, and those with cancer involving the lungs are most vulnerable. Patients over the age of 70 are more likely to develop severe cases of COVID-19, as are those who also have cardiovascular disease, diabetes, or high blood pressure, or are active tobacco smokers.
What should I do if I have symptoms of COVID-19?
Call your treatment center or physician first to report your symptoms. This allows your doctor to determine what evaluation is necessary and where that evaluation should take place. Many cancer centers are directing symptomatic patients to locations to specific locations for testing and evaluation.
Do I risk being exposed to COVID-19 if I come in for treatment?
The steps that hospitals and cancer clinics have taken are designed to minimize the risk of coronavirus transmission to patients, visitors, and staff. Where possible, some centers are offering virtual appointments, in which patients and physicians meet by computer link.
Is there a treatment for COVID-19?
Treatment has mainly consisted of supportive measures to reduce symptoms and respiratory complications similar to the Flu. Researchers are rapidly evaluating medicines in order to determine if any available medications might be helpful in eradicating the disease and new medications designed to target COVID-19 are being developed and approved.
Final analysis of the protease inhibitor antiviral Covid-19 pill, Paxlovie shows near 90% efficacy in preventing hospitalizations and deaths in high-risk patients, and recent lab data suggests the drug retains its effectiveness against the fast-spreading omicron variant of the coronavirus. The pills are taken in combination with the older antiviral ritonavir every 12 hours for five days beginning shortly after onset of symptoms. Paxlovie will be the first oral antiviral treatments for Covid authorized in the United States.
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.
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.
What is the best way to protect against COVID-19 on surfaces?
Cleaning surfaces with disinfectant or soap is very effective because once the oily surface coat of the virus is disabled, there is no way the virus can infect a host cell. It is especially important to clean surfaces brought into the home such as packages and food containers.
The "Ask The Experts About COVID-19 and Cancer" Series
- What You Need to Know About COVID-19 and Cancer
- COVID-19 Vaccination and Cancer - What You Need to Know
- Cancer Treatment During COVID-19
- Blood Cancers and COVID-19 Myeloproliferative Neoplasms (PV, ET, MF) Lymphoma Myeloma CAR T Cell and Stem Cell Transplant Therapies
- Screening and Early Detection During COVID
- Keep Current With The CancerConnect Newsletter
- Connect With Others In The CancerConnect Community To Share Information And Support
- Yu J, Ouyang W, Chua MLK et al. medRxiv, 2020 doi.org/10.1101/2020.02.22.2002532010.1101/2020.02.22.20025320. Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Zhonghua Liu Xing Bing Xue Za Zhi 020;41:145–151
- Why The Death Rate From Coronavirus Is Plunging In China
- Heudel P, Favier B, Solodky M-L, et al. Survival and risk of COVID-19 after SARS-COV-2 vaccination in a series of 2391 cancer patients. Eur J Cancer. Published online February 9, 2022. doi:10.1016/j.ejca.2022.01.035