The world is facing a new pandemic caused by a novel beta coronavirus (COVID 19),
which causes severe respiratory coronavirus syndrome (SARS-CoV-2). Unfortunately,
there are currently no US Food and Drug Administration (FDA) approved medications
for the treatment of COVID-19 patients. High mortality rates in frail patients is
a notable feature of the virus registered since the onset of COVID-19 pandemic. Above
all, elderly patients or those with underlying chronic illnesses and compromised immune
system are most at risk (1). Thus, the consideration is that the possible coexistence,
in the same individual, of a cancer diagnosis and a COVID-19 infection could generate
a synergistic negative prognostic effect.
About the prevalence, the only available data are reported in a retrospective study
on 1,590 COVID-19 patients from 575 Chinese hospitals, wherein 1% of them had a history
of malignancy (2). Among cancer patients, 25% of them had recently received chemotherapy
or surgical treatment, while the others were in follow-up. Multivariate analysis showed
that a history of cancer was associated with a higher risk of serious/negative events
(OR = 5.399, P = 0.003), with a median time in their development of 13 vs. 43 days
in non-cancer patients (P < 0.0001; hazard ratio = 3.56, 95% confidence interval =
1.65–7.69). Therefore, the diagnosis of cancer was shown to be an important comorbidity
associated with a higher rate of intensive care admissions.
Several questions still remain unanswered in this scenario: (1) Do routine screening
programs need to continue as usual? (2) What should be the correct management for
a positive COVID-19 patient before or after a cycle of chemotherapy, immunotherapy,
and/or targeted therapy? (3) What policies are being adopted in every single country
to manage oncology departments? (4) How should fragile patients with the advanced
disease be treated when they are in areas heavily affected by the virus? (5) What
are the ethical and practical implications?
In other words, how can oncologists deal with these patients? Can we find these answers
by analyzing the data available in the literature? Unfortunately, it is not possible.
At present, the follow-up period from the moment of the COVID-19 pandemic onset is
too short to reach definitive conclusions.
According to recent American Cancer Society guidelines for cancer patients during
the COVID-19 pandemic, screening programs should be delayed (3).
It should appear to be a reasonable choice during this COVID-19 crisis period to carry
out a risk/benefit balance in every patient evaluation, especially when the potential
benefit of an oncological intervention in terms of cancer recurrence/overall survival
is so small that it doesn't counterbalance the potential risk of death from COVID-19.
Certainly, triage by telephone with the possible identification of symptomatic patients
and at the entrance of hospital structures with the monitoring of body temperature
and saturation could reduce the probability for health personnel and for the patients
themselves to be exposed to the risk of contagion.
Cancer thoracic/abdominal surgery sometimes requires recovery in intensive care units.
How should these needs be managed need in emergency situations? On the other hand,
the risk is that a localized disease may become metastatic over time.
Patients in treatment for neoadjuvant/adjuvant treatments should continue their treatments,
and, if it is possible should also receive longer intervals between a cycle, longer
treatments, and the avoiding of weekly infusions, considering every specific drug
schedule. For advanced cancer patients, it should be decided on a case-by-case basis,
taking into consideration the relationship between health risks and benefits, whether
to delay or suspend ongoing treatments for a period, miming the already known “drug
holiday.” So, the considerable risk is that patients will survive COVID-19, but then
endanger their lives due to the absence of sufficient cancer care.
Last but not least, the alterations in the mood of these patients cannot be underestimated,
just like this aspect cannot be underestimated among clinicians and paramedics working
in oncology departments.
The follow up of patients without evidence of recurrence should be postponed or carried
out through “remote visits,” through telephone, email, or other telemedicine tools,
reserving the possibility to access the cancer center only in selected cases.
It should not be suggested that accompanying persons/family members/caregivers of
cancer patients should stay in waiting rooms, or should access rooms where anti-cancer
therapy and outpatient clinics are administered. It is advisable to avoid visits to
patients during their hospitalization, only suggesting the presence of a single family
member/companion, after specific authorization, only for a limited time.
As mentioned above, particular attention should be reserved for older cancer patients,
due to their comorbidities.
And what is to be decided regarding oncological research? Cancer Research UK proposes
to stop recruiting patients in several clinical trials with two aims: to reduce patient
overflow and to dedicate time and financial resources to patients affected by COVID-19
looking for clinical research treatment (4).
More recently, based on a consensus of experts, ASCO (5) recommended several suggestions
including the use of proper hand washing, hygiene, and minimizing exposure to sick
contacts with the use of masks for patients, indicating a comprehensive evaluation
in those with fever or respiratory symptoms. Moreover, ASCO did not make a recommendation
with respect to COVID-19 testing in patients with cancer. Regarding cancer patients
affected by COVID-19, treatment should not be reinitiated until symptoms of COVID-19
have resolved. Regarding all cancer patients, maintenance chemotherapy may be stopped,
if possible intravenous chemotherapy should be orally administrated less frequently
at clinics, and decisions on chemotherapy treatments should consider the aim of care
evaluating the risk/benefit assessment. Regarding adjuvant treatments, delays or modifying
main treatments may compromise disease control and long-term survival.
In an international position paper, several experts have published some suggestions
on the treatment of cancer patients in the COVID-19 era (6). In particular, as ASCO
experts, these authors recommended a clear communication and education about hand
hygiene, infection control measures, high-risk exposure, and the signs and symptoms
of COVID-19. They recommended a strong consideration of the new risk/benefit balance
for active intervention, postponing elective surgery, or chemotherapy with low risk
of progression analyzing each patient's case.
Another topic of interest should be the future after the Covid-19 crisis ends. Even
if the grip of the pandemic loosens, the SARS-CoV-2 could infect other people, especially
more brittle patients, such as cancer ones. The return to a normal style of life must
be gradual. But for these patients, can it ever be? We will probably have to wait
for a vaccine against this virus, as for the flu, with the aim to better protect the
health of these patients.
It's a challenging and stressful time for cancer patients under the situation of the
worldwide COVID-19 pandemic. In a period of social distancing, cancer patients excluded
from outpatient and hospital flows should be brought closer to oncologists through
the multimedia means of communication and it should deepen the new chapter of telemedicine.
A focus should be placed on the delivery of health-related services and information
via media/electronic information. It should allow for oncologists to contact all patients
that cannot go to the hospital for monitoring on their health status and suggest care
when possible. So far, telemedicine would be considered as a strong ligand between
patients and oncologists which could guarantee the continuum of care and follow them
without losing clinical and human contact. Can we maintain the survival standard by
limiting access and therapies? Could we affect the overall quality of life? Or on
the contrary, by continuing to administer the same treatment, could we facilitate
the spread of the epidemic among these patients by limiting their survival? We believe
it is an ethical and moral duty not to abandon these patients in their physical and
psychological weakness at this particular historical moment. It remains the task of
all investigators to collect data that can be observed, in particular in regards to
the possible correlation between immunosuppression and the course of the disease,
considering the recent initial evidence of immunosuppressive treatment activities
in COVID-19 patients affected by lung complications.
Last but not least, individual protection measures for all healthcare professionals
are clearly essential in order to protect their health as well as that of their patients
and family members.
Probably, this international crisis will lead us to reconsider the Ars Medica, which
aims to identify the right patient balance between cancer under-treatment and its
increase in cancer-related mortality and active cancer treatments potentially linked
to a greater risk of death from COVID-19 complications.
Author Contributions
OB and NS concepted the study. AD, BB, AG, and AR developed the study.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.