Caring for Patients With Cancer Presents Unique Challenges During COVID-19 Pandemic

Although preventive measures may be largely the same for patients with cancer during the novel coronavirus (COVID-19) pandemic, an article in the Journal of the National Comprehensive Cancer Network outlined how the pandemic could result in difficult treatment decisions.

“The potential threat of COVID-19 to our immunocompromised patients as a result of their disease or the treatment we provide is thought to be significant, tipping the usual risk-benefit balance in extreme ways,” the authors said.

The first step in any health system is maintaining strict infection and environmental control, according to the authors, who are members of the Seattle Cancer Care Alliance. They noted that although early identification and masking of individuals with respiratory symptoms is routine, their health system had initiated triage and masking at all entry points.

In addition to triaging and managing patients with symptoms, enforcing a strict “stay at home when sick” policy for employees has been a key step in limiting exposures. Other control measures have included restricting travel and enabling work-from-home wherever possible.

Deciding whether to delay treatment may be the most difficult decision for clinicians handling patients with cancer. The authors recommend that adjuvant therapy with curative intent should most likely proceed for patients with solid tumors.

Patients with metastatic disease present more complicated issues, however. Treatment delays could lead to worsening performance status and loss of the treatment window, but the immunocompromising effects of many anti-cancer medications could also increase their risk of being infected. When deciding how to proceed, considerations should include how a delay of treatment could lead to admission for symptom palliation, which puts even more stress on inpatient resources.

Surgical approaches should also be reconsidered during the COVID-19 pandemic. Although cancer surgeries are not considered elective, the authors said surgical interventions should be carefully considered and prioritized, in addition to considering how those surgical interventions affect intravenous or oral treatments.

“For example, several months of endocrine therapy and delay in surgery may be appropriate for some patients with early-stage hormone receptor-positive breast cancer,” the authors said.

Treatments for certain conditions, of course, cannot be delayed. Stem cell transplantation and cellular immunotherapies can provide curative treatments and should, therefore, be strongly considered depending on the patient’s situation.

Finally, the authors discussed clinical trial enrollment decisions, coming to the conclusion that enrollment regardless of disease should be limited to the trials that are most likely to benefit patients.

“Cancer centers should make it their mission to do all possible to continue to keep their doors open to provide care, unless there comes a time when staff and patient safety are no longer tenable,” the authors concluded.

REFERENCE

Ueda M, Martins R, Hendrie P, McDonnell T, et al. Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal. Journal of the National Comprehensive Cancer Network; March 16, 2020. https://jnccn.org/fileasset/jnccn1804-Ueda_20118_preprint.pdf. Accessed March 19, 2020.