The country’s largest association of cancer doctors, The American Society of Clinical Oncology (ASCO), invited its members to submit questions about issues and challenges emerging while caring for cancer patients during the coronavirus pandemic. While hard data on cancer-specific coronavirus issues are limited, ASCO put together these answers based on evidence gathered through a search of the existing medical literature and input provided by its members.
Early Data: Cancer Patients Who Get Coronavirus Do Worse
Do we have data from Italy or China about the risk of COVID-19 infection in cancer patients with vulnerable immune systems, or Neutropenia? (Neutropenia is the medical term for abnormally low white blood cell counts. It’s often the result of chemo or radiation). Is the risk increased for our patients with solid malignancies that go through periods of 5-10 days of neutropenia between cycles of chemo?
- At this time, only one published, detailed report comparing COVID-19 course of illness in patients with cancer to those without cancer could be identified (Liang et al, Lancet Oncol). This paper reporting on 1571 patients with COVID-19, 18 of which had a prior history of cancer, found that patients with a history of cancer had a higher incidence of severe events compared with other patients. This was defined as the percentage of patients admitted to an intensive care unit requiring invasive ventilation, or death.
- The report did not establish a definitive increase in incidence of COVID-19 infection. In correspondence related to the report, Xia et al (Lancet Oncol) state that these 18 patients represent a heterogeneous group and are not an ideal representation of the entire population of patients with cancer. Additional information about patients at increased risk of severe COVID-19, and tips for managing this risk, are available through the CDC.
Are there guidelines about what a doctors should do if a patient tests positive for COVID-19?
- The CDC has published guidance for infection control and prevention in healthcare settings in the context of COVID-19.
- The CDC also published guidance for risk assessment and public health management of health care workers who may have been exposed or who are infected with COVID-19.
- ASCO encourages clinicians and oncology practices to follow this guidance where possible.
- If a patient is seen at an outpatient clinic, should the clinic be quarantined?
For patients with blood cancers
Should oncologists consider less intensive care where possible, for instance 1) delaying allogenic stem cell transplant, 2) using R-CHOP instead of R-EPOCH for double hit lymphomas?
- At this time, no specific recommendations can be made (except for stem cell transplantation, see below) for delay in therapy or choosing alternate therapy in the context of COVID-19 infection. Patients scheduled for immunosuppressive therapy and at risk for exposure per local public health guidance should be screened, where possible, for COVID-19 prior to the initiation of therapy in order to guide decision-making.
- In some cases of patients at high-risk for COVID-19, delaying a planned allogeneic SCT may be reasonable, particularly if the patient’s malignancy is controlled with conventional treatment. Until further data are available, clinicians are encouraged to follow the recommendations provided by the American Society of Transplantation and Cellular Therapy (ASTCT), and the European Society for Blood and Marrow Transplantation (EBMT) with respect to stem cell transplantation.
- It may be prudent to test potential donors for COVID-19 even in an absence of evidence of transmission by blood transfusion.
- As a general precaution, visitation post-transplant may need to be limited and visitors may need to be screened for symptoms and potential exposure.
Is there any value in providing preventative antiviral therapy to a wider population of immune suppressed patients than we routinely do? If so, who and what?
- At this time, there is no evidence or published guidance on the use of prophylactic antiviral therapy for COVID-19 in immune suppressed patients.
- This is an active area of research and evidence may be available at any time.
- Prophylactic antiviral therapy directed at other viral infections should be continued according to standard clinical guidelines and institutional practices.
What is the role of Tamiflu or similar agents in patients with or suspected of COVID-19?
- Tamiflu is not known to be effective in treatment of COVID-19.
What guidance is available about holding chemo for patients currently on treatment so that their immune systems can reconstitute as they get infected from likely community spread of COVID-19?
- At this time, there is no evidence to support changing or holding chemotherapy or immunotherapy in patients with cancer or in BMT/SCT patients. Withholding critical anti-cancer or immunosuppressive therapy is not currently recommended. Furthermore, BMT/SCT patients may have prolonged immunosuppression despite stopping post-transplant chemotherapy. With respect to stem cell transplantation, also see the response to Question 1.
- The following practice points may be considered:
- For patients in deep remission who are receiving maintenance therapy, stopping chemotherapy may be an option.
- Some patients may be able to switch chemotherapy from IV to oral therapies, which would decrease the frequency of clinic visits.
- Decisions on modifying or withholding chemotherapy should include consideration of the indication for chemotherapy and the goals of care as well as where the patient is in the treatment course and their tolerance of treatment. For example, the risk: benefit assessment for proceeding with chemotherapy in patients with untreated extensive small cell lung cancer is different from that for patients on maintenance pemetrexed for metastatic NSCLC.
- Patients should be informed regarding the symptoms of COVID-19, and trained in proper handwashing, hygiene, and minimizing exposure to sick contacts and large crowds.
- If a local transmission affects a particular cancer center, giving a chemotherapy break for two weeks, arranging infusion at an unaffected satellite unit or arranging treatment with another facility that is not affected, may be reasonable options.
Should Chemo Be Delayed?
Is guidance available on use of adjuvant chemo in coming weeks, where risk of neutropenia may be a factor in patients with COVID-19? We consider small absolute benefits, for example, in ER+ breast cancer. Would the risk outweigh this small benefit in coming weeks? How do we counsel patients?
- At this time, there is no evidence or published guidance to support delaying or interrupting adjuvant chemotherapy. However, individuals receiving chemotherapy can be considered as a vulnerable population for serious coronavirus complications.
- There is limited or no evidence as to what the harms may be from delaying or interrupting adjuvant treatment versus the benefits of potential prevention of COVID-19 infection.
- Clinical decisions should be individualized considering factors such as the risk of cancer recurrence if adjuvant chemotherapy is delayed, modified or interrupted, the number of cycles of adjuvant chemotherapy already completed and the patient’s tolerance of treatment.
- The following practice points may be considered:
- In some settings delays or modifying adjuvant treatment may pose a higher risk of compromised disease control and long-term survival than in others.
- Prophylactic growth factors as would be used in high-risk chemotherapy regimens as well as prophylactic antibiotics may be of potential value in maintaining the overall health of the patient and make them less vulnerable to potential COVID-19 complications.
- In cases where the absolute benefit of adjuvant chemotherapy may be quite small, and where non- immunosuppressive options are available (e.g. hormonal therapy in ER+ early-stage breast cancer), potential exposure to COVID-19 may be considered as an additional factor in weighing the different options available to the patient.
Is it recommended that patients on treatment and neutropenic but who are not hospitalized wear a mask outdoor? Is an N95 necessary?
- At this time, no specific evidence or guidance on mask use in cancer patients has been published. Patients and clinicians are urged to follow the U.S. CDC’s general recommendations on mask wear. There is no guidance or evidence to suggest that N95 masks are required.
What is the best estimate for the incubation time after exposure?
- According to information from the CDC, the estimated incubation period for COVID-19 ranges from 2-14 days, based on existing literature from other coronaviruses such as MERS-CoV and SARS-CoV.
Is information available from Italy on how to protect our Day Oncology Units and chemotherapy patients from this unfolding crisis? Looking for practical advice on how intense the screening/lock-down needs to be in a hospital/unit BEFORE any know cases present. What could work?
- At this time, there are no published reports that describe the experience in Italy with respect to COVID-19 and cancer. However, the Italian Ministry of Health has published guidance (in Italian) specific to cancer centers on its website.
- For general advice regarding healthcare facility protocols, see question 1.
Is there definitive data showing cancer patients are at increased risk of complications from COVID-19, particularly with tyrosine kinase inhibitors and immune checkpoint inhibitors?
- At this time there is no specific evidence with respect to COVID-19 infection complications associated with any cancer systemic therapy regimens.
- The only available data is reported by Liang et al on a prospective cohort of 1571 patients with COVID-19, 18 of which had a prior history of cancer, found that patients with a history of cancer had a higher incidence of severe events – defined as the percentage of patients admitted to an intensive care unit requiring invasive ventilation, or death –compared with other patients.
- However, in correspondence related to the report Xia et al state that these 18 patients represent a heterogeneous group and are not an ideal representation of the entire population of patients with cancer.