COVID-19, Cancer, and the Need for Clarity

By Aakash Desai, MD, MPH; Gilberto Lopes Jr., MD, MBA; Nicole M. Kuderer, MD; Brian I. Rini, MD; Gary H. Lyman, MD, MPH, FRCP; Petros Grivas, MD, PhD; Michael A. Thompson, MD, PhD; and Jeremy L. Warner, MD, MS


In late 2019, the world witnessed the outbreak of COVID-19, which was first identified in Wuhan, China. On January 20, 2020, the first case of COVID-19 in the U.S. was confirmed in Snohomish County, Washington.1 Despite the fact that most people exposed to the SARS-CoV-2 virus will recover without serious complications, vulnerable populations – such as patients with active cancer, transplant recipients, and cancer survivors – appear to be at an increased risk for hospitalization and death from the disease.

Yu et al. reported that the infection rate of SARS-CoV-2 in patients with cancer who were treated at a tertiary cancer institution in Wuhan was 0.79% (12 of 1,524 patients), which was greater than the 0.37% infection rate for the general population in Wuhan, suggesting that patients with cancer might harbor a higher risk of SARS-CoV-2 infection compared with the rest of the community (odds ratio [OR] = 2.31; 95% CI 1.89-3.02).2 (It is also possible that oncology patients are more likely to be diagnosed because they are seen more frequently for health care.)  Another study from China indicated that patients with cancer have a higher risk of severe events – a composite endpoint defined as death or admission to the intensive care unit requiring invasive ventilation – compared with patients without cancer: 7 of 18 patients (39%) versus 124 of 1,572 patients (8%), respectively (p=0.0003).3 Furthermore, patients who underwent chemotherapy or surgery in the month prior to admission had a numerically higher risk of clinically severe events than those who did not (3 of 4 patients [75%] vs. 6 of 14 patients [43%]); however, those numbers are too small.

Early data from Italy corroborate the idea that COVID-19 can cause serious complications in patients with cancer. Among Italian patients with COVID-19 and comorbidities who died, 20% had a concomitant diagnosis of cancer.4 Meanwhile, the overall pooled prevalence of cancer in patients with COVID-19 from China was found to be 2.0% (95% CI 2.0-3.0%; I2=83.2%).5

Despite the presence of 2,170 publications on COVID-19 in a literature search at the time of this writing, there is no data on COVID-19 and the optimal treatment of patients with cancer. Researchers from China have proposed three major strategies for patients with cancer in the COVID-19 crisis:

  • postponing adjuvant chemotherapy or elective surgery for “stable patients”
  • providing personal protection equipment (PPE) for patients with cancer or cancer survivors
  • performing more intensive surveillance or treatment for patients with cancer infected with COVID-19

More recently, conceptual frameworks have been suggested for prioritizing the use of radiotherapy and systemic treatments during the COVID-19 pandemic.6

As the U.S. grapples with a shortage of PPE and limited COVID-19 testing capabilities, cancer centers and organizations, such as the American Society of Hematology (ASH) play a vital role in increasing awareness and adherence to important infection prevention measures, such as social distancing, personal hygiene and handwashing. Other actions have been suggested, including  screening all patients, caregivers, staff, and providers for COVID-19 symptoms; limiting exposure to sick contacts while on anti-cancer therapy; minimizing non-essential follow-up visits; restricting visitors; increasing engagement in telehealth and phone visits rather than in-person clinic visits; and prescribing oral drugs that can be taken at home, rather than injectable agents requiring administration in an infusion center, whenever possible.7 More details on such an early response by tertiary cancer centers in the epicenter of the COVID-19 outbreak in the U.S. were outlined in a recent publication.8

At the same time, the oncology community is working hard to minimize interruptions in cancer-related care. Delays in frontline autologous hematopoietic cell transplantation (AHCT), switching to less well-established chemotherapy or immunotherapy regimens and dosing schedules, reducing access to preventive cancer care, or disruption of clinical trials might affect patients’ likelihood of survival.

As we search for answers to the many new urgent clinical questions posed in the COVID-19 era, it is imperative we make data-driven decisions when caring for patients. Professional societies, such as ASH, the American Society of Transplantation and Cellular Therapy (ASTCT), the International Society of Thrombosis and Hemostasis (ISTH), and the European Hematology Association (EHA), will continue to play a significant role in ensuring delivery of optimal, high-quality, and evidence-based care.

Currently, no evidence exists regarding adjustment of cytoreductive therapy for hematologic malignancies, such as discontinuing JAK inhibition for myeloproliferative neoplasms or delay of AHCT for lymphoma or myeloma.9 Allogeneic transport is complicated by stem cell transport issues in this time of travel restrictions and potential lack of stem cell donors.10

As health-care workers and physicians on the frontline, we also can play an important role in sharing our experience with COVID-19 in patients with cancer, which will help inform future decisions.

Crowdsourcing for disaster management was first described during the 2010 Haiti earthquake and then later during 2012 and 2013 Colorado wildfires.11 The utility of social media has been evident in crisis monitoring, emergency planning and crisis management, and social cohesion and research during disasters.12 A similar crowdsourcing effort is currently underway under the auspices of the COVID-19 and Cancer Consortium (CCC19) and its survey tool, the CCC19 Registry.13 This international consortium presently comprises more than 70 cancer centers and other organizations that have come together to rapidly collect and disseminate data to better understand the scope and severity of COVID-19 in patients with cancer.

FIGURE. Map of U.S. institutions participating in the COVID-19 and Cancer Consortium, as of April 7, 2020. Image source: NCI (public domain)

The survey tool is designed so that health-care professionals can report on patients they are treating for cancer who also have, or are presumed to have, COVID-19. We aim to collect data on patient demographics, clinicopathologic factors, COVID-19 diagnosis and treatment, course of illness and outcomes, cancer diagnosis and treatment details, and information about the health-care professional. This study was determined exempt by the Vanderbilt Institutional Review Board (#200467) and can be accessed at ccc19.org.

The time to act is now.  Please join us to rapidly improve our understanding of COVID-19 and its impact on patients with cancer.


Dr. Desai is a resident in Internal Medicine at University of Connecticut who will be joining a Hematology Oncology fellowship at Mayo Clinic, Rochester in 2020; Dr. Lopes is Associate Director for Global Oncology at the Sylvester Comprehensive Cancer Center and Associate Professor of Clinical Medicine at the University of Miami Miller School of Medicine; Dr. Kuderer is an oncologist in Seattle; Dr. Rini is an oncologist and Chief of Clinical Trials at Vanderbilt-Ingram Cancer Center; Dr. Lyman is Co-Director of the Hutchinson Institute for Cancer Outcomes Research and Professor of Medicine and Medical Oncology at the University of Washington; Dr. Grivas is a medical oncologist at Seattle Cancer Care Alliance, Associate Professor and Clinical Director of the Genitourinary Cancers Program at the University of Washington School of Medicine; Dr. Thompson is Medical Director for the Early Phase Cancer Research Program and Co-Director of Oncology Precision Medicine Program at Advocate Aurora Health; and Dr. Warner is Associate Professor of Medicine and Biomedical Informatics at Vanderbilt University.

References

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  2. Yu J, Ouyang W, Chua MLK, Xie C. SARS-CoV-2 transmission in patients with cancer at a tertiary care hospital in Wuhan, China. JAMA Oncol. 2020 March 25. [Epub ahead of print]
  3. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21:335-337.
  4. Italian Oncologist Offers Cautionary Advice on COVID-19 for US Centers. Accessed March 23, 2020, from https://www.medscape.com/viewarticle/927213#vp_1.
  5. Desai A, Sachdeva S, Parekh T, Desai R. COVID-19 and cancer: lessons from a pooled meta-analysis. JCO Global Oncology. 2020 April 6. [Epub ahead of print]
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  8. Ueda M, Martins R, Hendrie PC, et al. Managing cancer care during the COVID-19 pandemic: agility and collaboration toward a common goal. J Natl Compr Canc Netw. 2020 March 20. [Epub ahead of print]
  9. American Society of Hematology. COVID-19 and Myeloproliferative Neoplasms: Frequently Asked Questions. Accessed April 6, 2020, from https://www.hematology.org/covid-19/covid-19-and-myeloproliferative-neoplasms.
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  13. The Cancer Letter. COVID-19 and Cancer Consortium. Accessed March 23, 2020, from https://cancerletter.com/articles/20200320_3/.