Understanding Cancer Magazine
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COVID-19 and the cancer patient: vulnerabilities and concerns
BY MARCIO ALVAREZ-SILVA
With the explosion of COVID-19 in the world, many public health priorities quickly turned to patient care due to the urgency and severity of the disease. According to the World Health Organization, older people and or of any age with pre-existing conditions (such as heart disease, diabetes, respiratory conditions) are more susceptible to developing serious medical complications related to COVID-19. Cancer patients are a very high-risk group for COVID-19. They are already more vulnerable to infection because of their disease, and as they are often immunosuppressed, they are at high risk of developing serious coronavirus complications [1].
The Lancet magazine published an interesting editorial: Redefining vulnerability in the era of COVID-19 [2]. This editorial discusses the degree of exposure to the coronavirus and the vulnerability to the disease: “Groups of vulnerable people are those who are disproportionately exposed to risk, but who is included in these groups can change dynamically.” The changes in social groups are due to strategies of social distancing. Social groups previously not considered vulnerable at the beginning of a pandemic can become vulnerable depending on the political response adopted by each country to combat the pandemic [2]. The immediate recruitment of various health professionals and members of community actions to combat the pandemic, logically placed them at the forefront of combating the pandemic and, consequently, also included them as a group of high vulnerability to COVID-19. So many of these professionals became ill from exposure to the virus. Approximately 20% of the pandemic workforce needed to be removed and isolated on suspicion of COVID-19 in the United Kingdom [3].
Each country has its own health policies. Suddenly the health system in the most diverse countries had to learn and develop strategies to deal with the pandemic. This had an impact on the way in which hospital assistance had to be relocated in order to meet the high demand for patients that was established in hospitals around the world. This has not prevented the collapse of the health system. The very large number of patients in need of isolation and special care in the face of the severe respiratory condition of COVID-19, overloads the established capacity of health systems in several countries.
In order to try to reduce the impact on the collapse of the health system, the recruitment of professionals from the most different areas of health and volunteers to join the patient care teams with COVID-19 has been an important strategy. The integration of health professionals to join forces to fight the pandemic brought very worrying situations for cancer patients: 1) significantly reduced the number of professionals for treatment and clinical cancer support, such as doctors, nurses, pharmacists, assistants, nutritionists and psychologists , and 2) the large number of these professionals also became ill as a result of fighting the pandemic.
We must also consider that a large portion of health professionals had their health deteriorated by the strong physical and psychological stress to which they have been subjected in their jobs. Certainly, in the midst of the COVID-19 pandemic, vulnerable groups are not only elderly, people with diseases and comorbidities, or homeless people, but also people with mental or physical difficulties in dealing with the pandemic [2]. The workload of health professionals to deal with the pandemic has a strong impact on the workforce and care for cancer patients. "The pandemic meant a transformation of all aspects of cancer treatment, regardless of treatment, inpatient or outpatient care, and radical or palliative intent," said James Spicer (Guy's and St Thomas' NHS Foundation Trust Hospital, London, UK) [ 3]. As many health professionals were recruited to combat COVID-19 (and many became ill), this resulted in a decrease in members of the treatment teams both on an outpatient basis and for the admission of cancer patients, including the reduction of many procedures, such as surgery, radiation and chemotherapy. The high risk of exposure of cancer patients in the hospital environment and the decrease in the clinical staff for care are reasons of great concern, since we do not have, in most countries, a policy for carrying out simpler procedures at home.
Health professionals recruited to combat COVID-19 are subjected to strong physical and psychological stress.
As far as possible, efforts are made by the Cancer Treatment Centers so that their work teams are not displaced to hospitals that are actively involved in the treatment of the pandemic. The departments of Oncology and Radiotherapy should ideally remain free of COVID-19. The presence of patients in Cancer Treatment Centers should be minimized. Any measures that allow patients to be treated at home should be encouraged. This includes telemedicine and telephone calls for non-face-to-face consultations. When possible, the replacement of intravenous drugs with oral drugs (for example, chemotherapy and hormonal therapies). Home administration of intravenous and subcutaneous medications should be encouraged when possible. Adjusting the dosing schedules for chemotherapy or radiotherapy treatments can be considered to reduce the frequency of hospitalizations (for example, every 3 weeks, instead of weekly administration, chemotherapy or radiotherapy protocols). In addition, some patients with slowly evolving metastatic disease could receive temporary breaks in treatment at the discretion of the oncologist, with the disease being evaluated every 2-3 months, to avoid hospital admissions [4]. Many modifications for administering chemotherapy and radiotherapy must be adopted to increase patient safety and prevent infection by the coronavirus.
The objective is to minimize the circulation of patients and to reduce the risk of coronavirus infection as much as possible. For this reason, the role of non-governmental organizations can be decisive in guiding the oncology population, in how to seek the best strategies and answer all their questions through centers for patient guidance via remote, telephone or internet.
The admission of cancer patients with COVID-19 to Cancer Treatment Centers should be avoided. However, if such patients are admitted to the hospital, they should be isolated from other cancer patients and referred to specialized departments to combat COVID-19 as soon as possible [4].
Care for older patients (over 70 years old) is a concern, since they represent a group at higher risk among cancer patients. As far as possible, alternatives to standard therapy that have few side effects on the immune system (for example, endocrine therapy versus chemotherapy) should be favored [5]. Measures of social confinement, supportive care and adjustment of treatment schedules (for example, increasing the intervals between treatments, dose reduction and alternative radiotherapy fractionation) should also be widely used in younger patients, when appropriate [5].
Lung cancer patients still represent the highest level of risk for COVID-19 among cancer patients. The already bleak scenario for cancer patients seems to be even more serious for lung cancer patients due to the high risk of COVID-19's interference with therapeutic management due to pulmonary complications resulting from the infection. In relation to clinical manifestations, the worsening of lung symptoms during the progression of lung cancer may be similar to COVID-19, adding more difficulties to the complete assessment of the disease course in patients with lung cancer and making the diagnosis of COVID-19 more difficult. . As a result, this can represent a challenge for doctors to distinguish the evolution of lung cancer from a potential superinfection by COVID-19, which is extremely important, as they are specific conditions, and require very different therapeutic approaches [6].
Overall, treating cancer patients can be challenging during the current COVID-19 pandemic. Although Cancer Treatment Centers must consistently use similar guidelines for patient management, some decisions will have to be made individually, according to the characteristics of the disease and the patient's history. Decision-making should not lead to the loss of therapeutic opportunities for cancer patients, since the relapse or progression of the disease puts these patients at great risk [7].
References:
1. The Lancet, O., COVID-19: global consequences for oncology. The Lancet Oncology, 2020. 21(4): p. 467.
2. The, L., Redefining vulnerability in the era of COVID-19. The Lancet, 2020. 395(10230): p. 1089.
3. Mayor, S., COVID-19: impact on cancer workforce and delivery of care. The Lancet Oncology.
4. You, B., et al., The official French guidelines to protect patients with cancer against SARS-CoV-2 infection. The Lancet Oncology.
5. Mourey, L., et al., Taking care of older patients with cancer in the context of COVID-19 pandemic. The Lancet Oncology.
6. Calabrò, L., et al., Challenges in lung cancer therapy during the COVID-19 pandemic. The Lancet Respiratory Medicine.
7. Malard, F. and M. Mohty, Management of patients with multiple myeloma during the COVID-19 pandemic. The Lancet Haematology.
This article was published in Understanding Cancer magazine, May 13, 2020.