The pandemic with the new coronavirus forces us to evaluate our activity regarding the period required for the treatment of a patient with cancer.
Thus, Prof. Karol Sikora describe what is happening in the UK, where a sort of agreement is that six weeks to get started on treatment is what it should be aiming for, maybe even less. But in different countries, depending on their capacity to deliver cancer care, there are different attitudes. In North America, some cancers are viewed as an emergency and the treatment should start within a week.
Cancer patients are not exempt from getting the new coronavirus, most of the data we have coming from China. These data suggest that cancer patients are not those selectively targeted by the virus, and don’t necessarily get a worse illness than other people that haven’t got cancer(1).
For oncologists and for other clinicians caring for patients with cancer, the COVID-19 pandemic represents a dynamic clinical challenge that is changing daily and which can be overwhelming at times, say experts.
Oncology clinicians are well versed in caring for immunosuppressed patients with cancer, of all ages.
Patients with cancer are at higher risk for COVID-19 and have a worse prognosis if they become infected than those without cancer, and that affirmation contradicts the statement of Prof. Sikora(2).
Patients with cancer who are in active treatment are immunosuppressed and are more susceptible to infection and to complications from infection.
Common sense rules apply for all patients with cancer, regardless of age, said Markham. The measures include thorough handwashing, staying home when sick, and avoiding sick contacts.
“At Mount Sinai, for patients with cancer, routine, non-urgent appointments are being rescheduled for May, Smith said. Those in active treatment are screened by telephone 24 to 48 hours before arrival, after which they undergo a full risk assessment in an isolation room. Those with a respiratory infection are given a mask. Patients are very anxious and worried about COVID-19”, said Smith, who has young children and an elderly parent at home. “We don’t have all the answers, and this can heighten anxiety”(3).
Information on what patients with cancer need to know about COVID-19 are available at Cancer.net. People with cancer, people who are in active cancer treatment, older patients and people with other serious chronic medical conditions, such as lung disease, diabetes or heart disease, may be at higher risk for the more severe form of COVID-19. The same rules apply for people with cancer, as for those without cancer(4).
A study from China
Lung cancer was the most frequent type (5 [28%] of 18 patients). Four (25%) of 16 patients (two of the 18 patients had unknown treatment status) with cancer infected with COVID-19 had received chemotherapy or surgery within the past month, and the other 12 (25%) patients were cancer survivors in routine follow-up after primary resection. Compared with patients without cancer, patients with cancer were older (mean age 63.1 years old [SD: 12.1] versus 48.7 years old [16.2]), more likely to have a history of smoking (4 [22%] of 18 patients versus 107 [7%] of 1572 patients), had more polypnea (8 [47%] of 17 patients versus 323 [23%] of 1377 patients; some data were missing on polypnea), and more severe baseline CT manifestation (17 [94%] of 18 patients versus 1113 [71%] of 1572 patients), but there were no significant differences regarding sex, other baseline symptoms, other comorbidities or baseline severity of X-ray.
Most importantly, patients with cancer were observed to have a 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 (7 [39%] of 18 patients versus 124 [8%] of 1572 patients; Fisher’s exact p=0.0003).
Significantly higher median age of patients with cancer and smoking in those patients compared with non-cancer patients (63 years old versus 49 years old) may have contributed to the poor prognosis(2).
Li Zhang (MD, PhD) and Hanping Wang (MD) from the Peking Union Medical College and the Chinese Academy of Medical Sciences, Beijing, emphasize that patients with cancer need online medical counseling and that critical cases need to be identified and treated.
“In endemic areas outside Wuhan, decisions on whether or not to postpone cancer treatment need to made on a patient-by-patient basis and according to the risk of the patient and the prevailing situation because delays could lead to tumor progression and ultimately to poorer outcomes. Patients who did not survive the hospitalization for COVID-19 in Wuhan were more likely to be older, had comorbidities and elevated D-dimer, according to the first study to examine risk factors associated with death among adults hospitalized with COVID-19. Older age, showing signs of sepsis on admission, underlying diseases like high blood pressure and diabetes, and the prolonged use of noninvasive ventilation were important factors in the death of these patients.” It was underlined that abnormal blood clotting was part of the clinical picture, too(5).
The most serious complications that can occur in the evolution of coronavirus infection are sepsis and multiple organ dysfunction (MODS).
“Sepsis is a life-threatening syndrome usually caused by bacterial infection. Sepsis is a response of the body’s immune system that results in organ dysfunction or failure”. Sepsis can evolve to the systemic inflammatory response syndrome (SIRS). The criteria for SIRS were recently replaced by the quick Sequential Organ Failure Assessment (qSOFA) in 2016. The qSOFA score includes a respiratory rate of 22 breaths/minute or more, systolic blood pressure of 100 mm Hg or less, and altered level of consciousness(6,7). Also, severe sepsis is defined as sepsis complicated by organ dysfunction.
“Multiple organ dysfunction syndrome (MODS) is characterized by progressive organ dysfunction in a severely ill patient, with failure to maintain homeostasis without intervention”. It is the end stage in infectious conditions (sepsis, septic shock) and non-infectious conditions (SIRS due, for example, to pancreatitis)(8).
In conclusion, the new coronavirus is a factor that could increase the risk of a bad evolution for patients with cancer, which are more likely to become infected with this virus. Some specialists recommend, when possible, to use telemedicine for these patients. Postpone of therapy will be discussed for each individual patient. The individual means of prevention are the same for cancer patients and they must be respected.