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MARCH 20, 2020 Even in the midst of the COVID-19 pandemic, cancer care must continue, but changes to the way care is provided may be necessary."We are heading toward a time when there will be significant disruptions in the care of cancer patients," said Len Lichtenfeld, MD, deputy chief medical officer for the American Cancer Society (ACS), in a statement. "For some it may be as simple as a delay in elective surgery. For others, it may be delaying preventive care or adjuvant chemotherapy to prevent cancer from coming back or rescheduling appointments."Lichtenfeld emphasized that cancer care teams will do their best to provide care to those most in need. However, even under those circumstances, life will not be as usual. "It will take patience from everyone as we go through this pandemic," he said."The way we treat cancer in the coming months will change enormously," writes a British oncologist in an article published in The Guardian."As oncologists, we will have to find a tenuous balance between insufficient treatment of people with cancer, leading to more deaths from the disease in the medium and long term and the increase in deaths from COVID-19 in a population of vulnerable patients. Together with our patients, we will have to make difficult decisions regarding treatments, with only low-quality evidence to guide us, "writes Lucy Gossage, MD, consulting oncologist at the University Hospital of Nottingham, UK.Evidence to date (from China's Lancet Oncology reports) suggests that people with cancer are at significantly higher risk of serious disease resulting in intensive care admissions or death when infected with COVID-19, particularly if they recently received chemotherapy or surgery."Many of the cancer treatments we use today, especially those given after surgery to reduce the risk of cancer recurrence, have relatively small benefits," he writes."In the current climate, the balance of offering these treatments may change; a small reduction in the risk of cancer recurrence in the next 5 years may be offset by the potential for a short-term increase in the risk of death from COVID- 19. In the long term, more people's cancer will come back if we can't offer these treatments, "he adds.

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Postpone routine detection

One thing that may be in the background for now is the routine cancer screening, which can be postponed for now to conserve health system resources and reduce contact with health centers, ACS says."Patients seeking routine cancer screenings should delay them until further notice," said Lichtenfeld. "While early detection is important, the need to prevent the spread of the coronavirus and reduce strain on the medical system is more important at this time."But as soon as restrictions are lifted to reduce the spread of COVID-19 and routine visits to health facilities are safe, regular screenings should be rescheduled.

ASCO Orientation

The American Society for Clinical Oncology (ASCO) has released a new guide on caring for cancer patients during the COVID-19 outbreak.First, ASCO encourages providers, centers, and anyone caring for cancer patients to follow existing guidelines from the Center for Disease Control and Prevention (CDC) when possible.ASCO highlights the CDC's general recommendation for healthcare facilities that suggests that "elective surgeries" in inpatient facilities be rescheduled if possible, which has also been recommended by the American College of Surgeons.However, in many cases, cancer surgery is not elective but essential, he notes. Therefore, this is very much an individual determination that doctors and patients will need to make, considering the potential harm of delaying the cancer related surgery that is needed.Systemic treatments, including chemotherapy and immunotherapy, leave cancer patients vulnerable to infection, but ASCO says there is no direct evidence to support changes in regimens during the pandemic. Therefore, it is not recommended to routinely discontinue anticancer or immunosuppressive therapy, as the balance of potential harm that may result from delaying or stopping treatment versus the potential benefits of possibly preventing or delaying COVID-19 infection remains very unclear.Clinical decisions should be individualized, ASCO emphasized, and suggested that the following points of practice be considered:

For patients who are already in deep remission and who are receiving maintenance therapy, stopping treatment may be an option.

Some patients may switch from IV to oral therapies, which would decrease the frequency of clinic visits.

Decisions about modifying or discontinuing chemotherapy should take into account both the indication and the goals of care, as well as the patient's location in the treatment regimen and tolerance to therapy. As an example, the risk-benefit assessment for continuing chemotherapy in patients with untreated extensive small cell lung cancer is quite different from proceeding with pemetrexed maintenance for metastatic non-small cell lung cancer.

If local coronavirus transmission is a problem at a particular cancer center, reasonable options may include taking a 2-week break from treatment or scheduling treatment at a different center.

Assess whether the infusion at home is medically and logistically feasible.

In some settings, delaying or modifying adjuvant treatment presents a higher risk of compromised disease control and long-term survival than others, but in cases where the absolute benefit of adjuvant chemotherapy may be quite small and there are other options. available, the risk of COVID -19 can be considered an additional factor when evaluating care.

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Delaying stem cell transplants

For patients who are candidates for allogeneic stem cell transplantation, a delay may be reasonable if the patient is currently well controlled with conventional treatment, ASCO says. It also directs physicians to follow the recommendations provided by the American Society for Transplantation and Cell Therapy and by the European Society for Blood and Marrow Transplantation regarding this matter.Finally, there is also the question of prophylactic antiviral therapy: should it be considered for cancer patients undergoing active therapy?The answer to that question is currently unknown, ASCO says, but "this is an active area of research and the evidence may be available at any time."

Medscape Medical News

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