The COVID-19 pandemic is placing an immense strain on global healthcare services and, with the pressure to reduce patient visits to hospital and non-urgent medical procedures, the outlook for patients with cancer is increasingly bleak.

As of 15 April 2020, there were 2,017,810 cases of COVID-19 with 128,044 deaths worldwide (Worldometers.info). Patients with cancer, who are immunocompromised as a result of malignancy and anticancer treatments, may be particularly vulnerable to the virus, and may have a poorer prognosis. In China,an analysis of 1,590 patients with confirmed COVID-19 infection identified that approximatelly 1% of patients had a history of cancer, with lung cancer being the most frequent tumor type. The analysis showed that cancer patients had a higher risk of severe events (a composite endpoint defined as the percentage of patients being admitted to the intensive care unit requiring invasive ventilation, or death) compared with patients without cancer [39% versus 8%; p=0.0003] (Liang, 2020). Furthermore, according to an Italian analysis, about 20% of patients who died in Italy due to COVID-19 infection had active cancer (Onder, 2020).

Physicians who care for cancer patients are facing numerous challenges such as balancing the adverse effects of delaying cancer diagnosis or treatment against the risk of potential exposure to COVID-19, alleviating the risk of significant care disruptions associated with social distancing measures, and managing limited healthcare resources. These challenges and potential treatment decision-making guidance for cancer patients are discussed in an article by Kutikof et al. Authors highlight that many solid tumors, including lung and pancreatic cancer, and some hematologic cancers, such as acute leukemia, require immediate diagnosis and treatment, while this may be less critical in some early-stage cancers.

Maintaining social distancing to reduce the spread of the virus is particularly difficult while providing multidisciplinary cancer care. The requirement for numerous hospital visits for assessment and treatment, often with family members for support, and patient participation in ongoing clinical trials is not conducive to distancing measures. In addition to these measures, the significant squeeze on healthcare resources is translating into the postponement of non-urgent procedures. However, the implementation of non-traditional healthcare options, such as telemedicine, can provide remote support for many cancer patients and reduce patient hospital visits during this pandemic.

Currently, recommendations and useful resources are being compiled by several oncology societies, including the Amercian Society for Clinical Oncology (ASCO), the European Society for Medical Oncology (ESMO), the American Society for Radiation Oncology (ASTRO), the American Society of Hematology (ASH), the European Society for Blood and Marrow Transplantation (EBMT), and the Society of Surgical Oncology (SSO) to support the multidisciplinary teams that care for patients with cancer. For many oncologists, ethical considerations surrounding which patients are likely to benefit most from successful, symptom relieving or lifesaving treatments are becoming a reality (Ueda, 2020). In the UK, the National Health Service (NHS) England recommends that the multidisciplinary team decide on each individual patient’s cancer treatment based on priority groups for surgery, radiotherapy and systemic therapy. For example, for systemic therapy, NHS England has set out six priority levels; patients who are in line for curative treatment and have at least 50% of chance of a cure are in the highest priority level, while patients who are awaiting non-curative therapy that is unlikely to offer palliation, tumor control or more than one year’s extension of life are assigned the lowest level. Similarly, for radiotherapy, there are five levels of priority, with the highest level including patients with rapidly proliferating tumors with little scope for delay (Burki, 2020).

The deterioration of cancer care during this COVID-19 pandemic is unavoidable; difficult decisions regarding treatment are necessary and many patients will not receive the monitoring or treatment that they require. An additional future concern is the potential delay in the diagnosis of new cancers that could be treated effectively if diagnosed early. On a positive note, the epidemic seems to be slowing down in China and cancer management is normalizing after approximately two months of disruption (Burki, 2020).

References

Burki TK. Lancet Oncol. 2020; April 2 [Epub ahead of print].

Burki TK. Lancet Oncol. 2020; April 2 [Epub ahead of print].

Kutikof A, et al. Ann Int Med.2020; March 27 [Epub ahead of print].

Liang W, et al. Lancet Oncol. 2020: 21(3):335-337.

Onder G, et al. JAMA. 2020; March 23 [Epub ahead of print].

Ueda M, et al. J Natl Compr Canc Netw. 2020; March 20 [Epub ahead of print].

Worldometers.info