Cancer Patients & COVID-19 - What You Need to Know and How to Reduce Your Risks
by Dr. C. H. Weaver M.D. 4/16/2020
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 which will continue into the foreseeable future. As the virus cycles through society we are facing a new “normal” while we await the scientific biomedical community to develop effective anti-viral drugs, vaccines, and medications to treat the “cytokine storm” which is responsible for the bulk of the mortality associated with the infection.
Cancer patients, their families, and caregivers are disproportionally impacted by the COVID pandemic. Cancer patients are twice as likely to become infected than the general population and significantly more likely to die from COVID-19 once infected. (1)
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.
What is 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. Chinese government released updated data on March reporting an overall mortality rate of 0.4% which is less than initially reported. (1) Deaths in the U.S. exceed 60,000 but are mostly in NY and in "at risk" individuals.
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
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.)
- Avoid cafeteria-style eating and public transportation - wash hands after using any public facility.
Is There a Vaccine?
Not yet but researchers are working to develop one. Cancer patients do however need to get a “Flu shot” In the U.S we are still in the midst of flu season and patients with cancer are at higher risk, especially if they are receiving immunotherapy, steroids and immunosuppressive which reduce immunity. Many individuals with blood cancers have diminished immunity even if they are not currently on therapy.
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 with a test available through the Centers for Disease Control and now commercial laboratories. As of April 30 over 3 million people had been tested for the virus in the U.S.
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 vunerable. 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 mainly consists 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.
- Is a common anti-malarial drug the answer?
- COVID-19 Treatment Update-Remdesivir and Hydroxychloroquine
What are Clinics and Cancer Centers Doing?
In order to protect cancer patient’s cancer centers and clinics are already adopting measures designed to improve patient safety by decreasing the risk of exposure to the virus. They are;
- Delaying or deferring non-essential clinic visits.
- Using phone consultation or telemedicine appointments when possible.
- 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
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 several 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.
Does the benefit of adjuvant therapy justify the risk?
The answer for most patients will be yes but some patients with early stage breast, colon or other cancers elect to receive post-operative adjuvant therapy to reduce the risk of cancer recurrence that is of marginal benefit. For example, if chemotherapy increases your chance of cure from 80% to 85% is that benefit enough given the risks of COVID-19? Are there tests that can help better define the benefit of chemotherapy so it can be avoided in individuals that don't benefit? Measurement of cell free ctDNA can help determine who should receive chemotherapy for colon cancer, and the OncotypeDX test helps determine which patients with early stage breast cancer might avoid chemotherapy.
What is the benefit of radiation therapy and can it be administered over a shorter duration of time?
In certain situations, including some patients with early stage breast cancer radiation may be delivered over a shorter period of time and therefore reduce the number of visits and exposures to others during treatment. Accelerated partial breast irradiation (APBI) is radiation delivered at a more concentrated and higher dose over a shorter period of time, (typically over a one week period). APBI can be delivered using intensity modulated radiation (IMRT) which delivers fractionated radiation, meaning that the total dose of radiation is delivered in many small daily, or twice daily, doses or internally using brachytherapy.
Can oral chemotherapy medications be used instead of infusions to decrease clinic/infusion center visits?
Switching to an equivalent oral therapy can help avoid prolonged clinic visits and oral chemotherapy is available for many cancer types. Certain patients with MPN’s require frequent clinic visits to undergo phlebotomy as part of their treatment – phlebotomy can also be replaced by using an oral chemotherapy to control their cancer.
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.
What is the best 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.
What if I was Considering Elective Surgery?
Amer College of Surgeons Updated March 13, 2020
COVID-19: Recommendations for Management of Elective Guided by the trajectory of cases in Italy and other countries, it is very likely that the U.S. health care infrastructure and resources, particularly as it relates to care of the most critically ill patients, are likely to be strained over the coming weeks. Social distancing, crowd avoidance, and other techniques do help to flatten the curve of the dissemination of Coronavirus Disease 2019 (COVID-19), but beyond that, it is appropriate to be forward thinking regarding those patients who will, nevertheless, become infected.The American College of Surgeons (ACS) has additional comments on this issue. Following a careful review of the current situation, we recommend the following:
- Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs.
- Immediately minimize use of essential items needed to care for patients, including but not limited to, ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators. There are many asymptomatic patients who are, nevertheless, shedding virus and are unwittingly exposing other inpatients, outpatients, and health care providers to the risk of contracting COVID-19.
We are aware that surgeons who practice in hospitals in geographic COVID-19 hot zones are already getting an advisory from the Centers for Disease Control and Prevention (CDC) on how to prepare. If you practice in an area that's not a hot zone, we still recommend that you refer to the CDC website for guidance. (2,3)
- Reschedule elective surgeries as necessary.
- Shift elective urgent inpatient diagnostic and surgical procedures to outpatient settings, when feasible.
- Limit visitors to COVID-19 patients.
- Plan for a surge of critically ill patients and identify additional space to care for these patients. Include options for:
- Using alternate and separate spaces in the ER, ICUs, and other patient care areas to manage known or suspected COVID-19 patients.
- Separating known or suspected COVID-19 patients from other patients ("cohorting").
- Identifying dedicated staff to care for COVID-19 patients.
Time is of the essence. Please be vigilant and take a leadership role in your practice setting so that these recommendations begin to take hold immediately.
Products from China?
The production of many medical products, medications and household items of course occurs in China. Currently there is no reason to suspect that packages from China can contain active COVID-19 and medications and other products appear safe The CDC has said there is no evidence supporting the transmission of the disease through imported goods. Currently, it’s only known that the spread of the disease outside of China happens between person to person although there is an active investigation of an individual with COVID-19 in Sacramento and no known contact with an infected individual.
- 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