It’s never easy to be living with a cancer diagnosis, but for the millions of Americans being treated for cancer right now, these are particularly trying times.
Cancer can compromise the immune system — sometimes the cancer itself does this, and sometimes it's the therapies used to treat it. And what we know so far from data reported during the COVID-19 pandemic is that, not surprisingly, people with cancer are at higher-than-average risk of infection with the virus and severe consequences if infected.
For instance, an article published February 2020 in the journal the Lancet Oncology reported that in China, patients with a cancer diagnosis, patients being treated with chemotherapy, and patients with lung cancer were more likely to end up on a ventilator or die with a COVID-19 infection compared with healthy people.
It was undoubtedly data like this that prompted the publication of a March 2020 article in the journal Annals of Internal Medicine, which stressed the importance of delaying cancer therapy — when possible — during the pandemic.
It’s a good article, and it's the right recommendation.
Delaying therapy may have two benefits: It will keep vulnerable patients out of hospitals and treatment facilities, where they’re more likely to become infected, and it may relieve patients of the potentially immune-dampening effects of therapy at a time when everyone needs an optimally functioning immune system.
The million-dollar question, for patients and doctors, is what delaying treatment might mean, ultimately, for patients' survival.
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Does Delaying Cancer Treatment Make a Difference?
In normal times we generally encourage people not to delay. I used to tell my patients that unless you have a good reason for delay, start treatment as soon as possible.
But urging patients not to delay was often just a way of being consistent. If a treatment program that produced good results for postoperative chemotherapy for breast cancer when started four weeks after surgery has been tested and proved to work, for instance, it’s best to do it that way so all patients are treated alike, and so that we can predict the benefit a patient might get out of it. This then takes the issue of scheduling out as a variable.
Truthfully, four weeks was not necessarily selected because we know it’s the best time to start treatment; eight weeks might have worked as well or better. These kinds of variables are usually not put under stringent tests.
Have we allowed delays of treatment in the past? Sure. Sometimes a patient may have wanted to wait until after a daughter’s wedding, or a special trip they had planned. Depending on the type of cancer, and the stage, we tried to accommodate them.
The truth is, we don’t have good data on what delays mean, because it’s not something we’ve had to consider on a grand scale.
Right now, though, we have to weigh the risk of patients getting and succumbing to COVID-19 against the risk of delaying a work-up and treatment. In most cases, delaying treatment is the less risky path. It's confusing when oncologists tell patients this, and probably scary. But the truth is, many cancers take years to develop, and in most cases, a few months' delay is probably not that risky, especially compared with the risk of getting COVID-19.
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Deciding When Immediate Treatment Is — and Is Not — Necessary
There’s no one-size-fits-all template when deciding who needs immediate treatment and who can delay. Each case really should be addressed individually.
One of the most critical factors that will go into the decision is the age of the patient. Age is a critical factor in defining risk of dying from COVID-19. In most data reported, the case fatality rates are highest in patients over 70 and especially high in those over 80. Many in this age group also have a co-morbid (more than one) health condition, which puts them at increased risk.
If two patients have the same stage of the same cancer, but one is 75 with emphysema and the other is 55, their different risks if they get COVID-19 will affect the decision about treatment. The bottom line is that, when age is a factor, it’s in everyone’s best interest to keep high-risk older patients out of hospitals and clinics for a while. Most likely, older patients are going to be advised to wait.
Some cancers are an easier call than others. Prostate cancer, which tends to occur in older men, falls into this category. Low and even intermediate risk patients with prostate cancer are often offered the option of watch and wait even in normal times, so they can wait three more months for sure.
Even high-risk patients with prostate cancer can be offered hormone deprivation therapy to tide them over.
But some cancers grow rapidly, like acute leukemias and aggressive lymphomas, and many times they are the ones we can cure with aggressive treatment. In those cases, delay may well be detrimental, and arrangements need to be made to provide care in a way that minimizes, as much as possible, the risk of contracting COVID-19.
At Yale, where I am a professor, our oncologists have reorganized our outpatient facilities so that those who must go ahead can do so as safely as possible. We moved an outpatient cancer clinic to a facility 15 miles away from the main hospital, which is treating COVID-19 patients. From what I hear, other centers that have the option to repurpose clinics are doing the same thing.
And while most centers have stopped initiating new clinical trials and have stopped accruing new patients to ongoing studies, patients already participating in studies will continue to get treatment.
Of course, the usual precautions (use of protective gear like masks and, for doctors, face shields) still need to be taken for those undergoing chemo in this environment, because we know some apparently well individuals are unknowingly harboring the COVID-19 virus.
Being keeping people being treated for cancer away from the center of the action, by distancing them from the main hospital, can only help protect them right now.
It goes — almost — without saying that all these are decisions that oncologists need to share with their patients.
After COVID-19: What Might Oncologists Learn From It?
We are in an unusual time for cancer patients. Two major things have happened to them — their cancer, and a pandemic washing over their community. The latter is moving very fast. The former, in many cases, more slowly.
For most patients, it’s best to delay treatment if your doctor thinks it’s possible, and let the pandemic wave crash by. This will reduce the risk for most patients of getting COVID-19 and also make a safer, less-crowded space for cancer patients who don’t have the option of delaying treatment.
The 21st Century Cures Act passed by Congress in 2016 urged the U.S. Food and Drug Administration (FDA) and the entire medical field to make better use of real-world data to make decisions in drug development. We’re seeing that put into practice now with the use of hydroxychloroquine in patients infected with COVID-19. Perhaps, if we are clever enough, we can glean some useful data and insight on the impact of delaying cancer treatment when this pandemic ends.
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