Protecting cancer patients during COVID-19 pandemic

The rapid spread of acute respiratory illness caused by COVID-19 has severely affected all aspects of life. They are preventing the spread of the disease, including keeping contact distance, disinfecting hands and upper respiratory tract, limiting going out when not necessary are critical factors.

Caring for cancer patients at this stage is a big challenge; it is necessary to weigh the risk of death from cancer and respiratory complications caused by SARS-CoV-2, especially cancer risk. The risk of death is higher with COVID-19 infection in immunocompromised individuals.

Many cancer patients struggle to continue their cancer treatment because some hospitals have postponed surgery or chemotherapy and radiation therapy.

What is the rate, clinical symptoms and prognosis of COVID-19 infection in cancer patients?

Cancer patients are people susceptible to COVID-19, so it is necessary to limit contact with people around them, including family members.

Up to this point, it has been reported that about 1-2% of cancer cases are infected with SARS-CoV-2. These cases include current and previous cancers, especially if they've just been treated or are still being treated. However, the data are limited, and more extensive studies are needed.

In many studies, the rate of cancer cases in patients infected with COVID-19 varies widely. For example, some studies in Wuhan, China, show that this rate is only about 1-2%. Meanwhile, research in Italy shows that 20% of COVID-19 deaths are cancer patients undergoing treatment.

A record of SARS-CoV-2 symptoms in 28 cancer patients in 3 Wuhan hospitals, China, is as follows:

• 67% of men, mean age 65, 25% have lung cancer.
• Clinical symptoms include: fever (82%), dry cough (81%), shortness of breath (50%), lymphopenia (82%) and anaemia (75%)
• More than 50% of patients progressed seriously, 21% had to be transferred to ICU. Critically ill patients are those receiving chemotherapy, radiation, targeted therapy or immunotherapy within 14 days

SPECIAL GUIDELINES

• The risk of exposure to SARS-CoV-2 must be balanced with the risk of delaying cancer treatment.
• There is no uniform regulation for the treatment of cancer patients during the COVID-19 season, but it must be on a case-by-case basis.
• If the cancer is slow-growing, treatment can be delayed for more than three months, regardless of age, including surgery and radiation therapy, for example, non-melanoma skin cancer. Breast ER, PR positive and HER-2 negative in postmenopausal women can be replaced by hormonal therapy or cancers of the hematopoietic system, such as chronic lymphocytic leukaemia.
• If the cancer is moderately advanced, treatment can be delayed for about three months, especially in patients over 50 years of age.
• Selected cases can be treated with chemotherapy, such as distant metastatic breast cancer, colorectal cancer, lung cancer and other solid tumours. However, sometimes the decision is quite complex depending on each patient's case. In cases where the disease progresses too quickly, delaying treatment up to 3 months can have serious consequences, while some slow-growing patients such as metastatic clear cell kidney cancer can be monitored still gives good results.
• If the cancer is likely to progress rapidly, should not delay treatment in patients younger than 70 years of age. Older cases need to weigh the benefits and risks. In addition, it is necessary to minimize contact with people with flu symptoms while taking cancer drugs, minimize unnecessary visits, and limit inpatient and outpatient visits, strengthen the support of remote examination and consultation, can give a prescription for oral medication at home.
• In some cases will prioritize neo-adjuvant (endocrine) treatment to delay surgical hospitalization during the epidemic period.

ASCO guidelines recommend

For stable patients requiring maintenance therapy, chemotherapy discontinuation should be considered. The same is true for patients for whom adjuvant chemotherapy is of little benefit and can be replaced with drugs that have little effect on the immune system, such as hormones in breast cancer and prostate cancer.

Oral chemotherapy or an infusion pump can be performed but requires close coordination between the medical staff and the patient.

If an affected cancer facility has a severe COVID-19 infection, doctors may consider changing their treatment plan to reduce visits or arrange for patients to be treated in another hospital.

Immunotherapy:

To date, there are no data to show whether immune checkpoint inhibitor treatment has any effect on COVID-19 infection. However, Immunotherapy can cause pneumonia, which will increase the severity of complications from COVID-19 infection. If there is an exposure factor for these patients, it is best to discontinue treatment until the safe period has passed.

Careful testing for COVID-19 is required in blood donors even if there are no symptoms of illness, should also minimize examination after blood transfusion

Supportive care

Although the use of myeloproliferative factors is usually indicated in high-risk cases of febrile neutropenia during epidemics, ASCO recommends that the drug be used in patients at risk of febrile neutropenia, low for preventive purposes.

There is no preventive role for antiviral drugs, even in immunosuppressive patients.

Syringe irrigation still needs to be done every 4-6 weeks; some recommendations allow a delay of up to 12 weeks; even the patient can be trained to do it at home but requires an aseptic technique, problems that limit implementation.

All non-essential, non-urgent or emergency surgery or procedures must be rescheduled.

Follow up after treatment

According to CDC recommendations, if routine follow-up visits are performed in asymptomatic, low-risk patients with limited follow-up intervals, we should delay follow-up to the most extended limit.

Psychological care

The epidemic causes anxiety that leads to stress, tension, depression, insomnia, rejection, anger and fear. Cancer patients are more severely affected with inherent feelings of anxiety, fear, vulnerability, etc., so when medical care is limited, they feel more isolated and isolated.

Observe maximum social distancing when providing medical care for people with cancer

All consultation, treatment, and follow-up activities involve a high risk of close contact with medical facilities, medical teams and other patients. It increases the likelihood of COVID transmission between contacts.

All patients should be screened by telehealth 1-2 days before hospital arrival. Remote consultation and examination is a new medical service model (by phone or video call) in social distancing, which contributes to solving the patient's worries and primary treatment. However, it can lead to misunderstandings or loss of communication with the patient, causing unnecessary delays in treatment.

So when healthcare workers and patients use this type of health care, one must accept the potential benefits and risks. In addition, there are cases where the disease must be examined directly by a doctor but cannot replace the remote examination and medication.

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