Recommendations from a European Society for Medical Oncology (ESMO) expert panel say doctors should not stop or delay any type of cancer treatment that might affect a person’s overall survival.
The recommendations also say that all people diagnosed with cancer are not automatically at high risk for coronavirus infection or for serious complications if they do get COVID-19.
The recommendations were published online on July 31, 2020, in the Annals of Oncology. Read “Managing cancer patients during the COVID-19 pandemic: An ESMO Interdisciplinary Expert Consensus.”
What is COVID-19?
Coronaviruses are a large group of viruses that can cause respiratory illness in humans and animals. The coronavirus affecting the world right now is called SARS-CoV-2, and the illness it causes is called coronavirus disease 2019, which is abbreviated as COVID-19.
Many people infected with COVID-19 have mild symptoms and some have no symptoms at all. Still, anyone infected with COVID-19 can carry and spread the infection, no matter how severe or mild their symptoms are.
COVID-19 is very contagious — about 3 times as contagious as the flu, according to the U.S. Centers for Disease Control and Prevention (CDC). It mainly spreads through close contact with infected people through droplets of respiratory fluids produced by coughs or sneezes. These respiratory droplets can travel through the air and can be inhaled or otherwise get into the noses, mouths, or eyes of people nearby. This is why keeping 6 feet away from other people, wearing a face mask, and frequent handwashing have been recommended to slow the spread of the virus.
Risks of COVID-19 for people with cancer
When COVID-19 started to spread across the globe in early 2020, people diagnosed with cancer were considered to be particularly at risk for having serious complications, even though not much was known about the virus. Still, as more research has been done, it seems that not all people diagnosed with cancer are at high risk for COVID-19. To make sure that people with cancer get the best care during the COVID-19 pandemic, the ESMO experts created their recommendations.
Recommendations on managing cancer care during COVID-19
“The general advice is that whenever an anti-cancer treatment can impact overall survival of the patient it should not be discontinued or delayed,” first author Giuseppe Curigliano, M.D., Ph.D., of the European Institute of Oncology, said in a statement.
The recommendation was written because there is no evidence linking immune checkpoint inhibitors, hormonal therapy, or targeted therapies to a higher risk of COVID-19 complications.
“Of course, case-by-case discussions run by multidisciplinary teams remain pivotal to balance the risk of being infected against tumor control,” Curigliano added.
Curigliano said the recommendations also warn against labeling all cancer patients as vulnerable to COVID-19, no matter their age, gender, tumor type, or stage.
During the early days of the COVID-19 pandemic, people diagnosed with cancer were reported to be at higher risk of contracting the virus and developing more severe disease. Still, evidence collected up to the end of July 2020 suggests that many people with solid tumors are not more vulnerable to COVID-19 severe outcomes than a person in the general population who hasn’t been diagnosed with cancer.
“Based on current evidence, only patients who are elderly, with multiple comorbidities, and receiving chemotherapy are vulnerable to the infection,” Curigliano said. “In this population, before starting any treatment, we recommend to test patients for COVID-19 with a real-time RT-PCR (reverse transcription polymerase chain reaction), the current gold standard for diagnosis, in order to exclude that the patient is infected by the coronavirus.”
The complete recommendations are made up of a number of statements, including:
- Regarding telehealth visits, face-to-face appointments discussing important cancer-related information, including diagnosis and treatment plans, may be more effective than video or telephone appointments. The risks of travel for the patient and COVID-19 exposure need to be considered. If practical, a clinic should take safety measures so patients can bring one person with them for support during the face-to-face consultation.
- Cancer care prioritization should be adapted to the state of the pandemic. When healthcare resources are not exhausted, the general rule is that operations planned for cancer patients that cannot be postponed for 3 months should be scheduled as soon as possible, taking the necessary precautions. In situations where resources are exhausted, only emergency services can be provided and alternative cancer treatments that are still available have to be administered, with a plan put in place in concert with health authorities.
- If people diagnosed with cancer need to be admitted to the hospital, they should be tested for COVID-19, no matter what symptoms they do or don’t have.
- People diagnosed with cancer going to an outpatient clinic should be assessed for COVID-19, including questions about symptoms and travel and a temperature check.
- Personal protective equipment should be provided to all healthcare workers and used meticulously.
- To reduce the risk of people being treated for cancer having low white blood cell counts, doctors should consider using granulocyte-colony stimulating factor medicines more broadly. Neulasta (chemical name: pegfilgrastim) is one example of a granulocyte-colony stimulating factor.
- People diagnosed with cancer who are infected with COVID-19 should be treated with anti-coagulant medicines to reduce their risk of blood clots.
- Real-time reverse transcription polymerase chain reaction (RT-PCR) is the current gold standard to diagnose COVID-19.
- Antibody tests can’t replace real-time RT-PCR testing for COVID-19.
- A person’s ability to infect others with COVID-19 is determined by the presence of the virus in different body fluids, secretions, and waste.
- If a person diagnosed with cancer is prescribed treatment with an immune checkpoint inhibitor medicine and doesn’t have COVID-19, the medicine should not be delayed or cancelled. If a person diagnosed with cancer tests positive for COVID-19, the medicine should be postponed until the person recovers from COVID-19.
- High-dose steroids may increase the risk of severe COVID-19 side effects in a person diagnosed with cancer. If a person is taking high-dose steroids for cancer and is infected with COVID-19, a different immune-suppressing medicine should be used, if possible.
- Tyrosine kinase inhibitors, such as Tukysa (chemical name: tucatinib), can affect how the immune system responds if a person is infected with COVID-19. Doctors and patients need to weigh the risks and benefits of continuing with a medicine like Tukysa if a person is infected with COVID-19.
- For people diagnosed with early-stage breast cancer being treated with chemotherapy, doctors and patients should discuss the risks and benefits of continuing with chemotherapy. Long delays in chemotherapy should be avoided, and patients should be treated with supportive medicines to reduce their risk of infection.
- Being older, having cancer that is growing, smoking/vaping, being in poor physical shape, and having other health conditions, such as high blood pressure or diabetes, are risk factors for having more serious COVID-19 complications.
- During the COVID-19 pandemic, changes to a clinical trial protocol may be considered, provided everything is documented in a participant’s records and the sponsor is notified. There should be no changes to safety reporting.
What this means for you
While there are still many unknowns about COVID-19, these expert recommendations are mostly reassuring. It’s helpful to know that the people diagnosed with cancer who are at the highest risk of serious COVID-19 complications are:
- have multiple other health conditions, such as diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD)
- being treated with chemotherapy
If you are in this group, you can take very strict measures to reduce your risk of being infected with COVID-19, including:
- staying home
- avoiding public spaces and social gatherings
- wearing a mask
- working from home
- washing your hands
- avoiding touching your face
- using alcohol-based hand sanitizer
- cleaning and disinfecting surfaces you touch frequently, including things you might not think about, such as light switches, door knobs, faucet handles, and phones
It also makes sense to make a plan with your doctor to monitor you for COVID-19 symptoms, as well as a plan for steps you will take if you do become infected.
For more information on COVID-19 and breast cancer, read the Breastcancer.org Special Report: COVID-19’s Impact on Breast Cancer Care.
To talk with others who are managing a breast cancer diagnosis during the COVID-19 pandemic, join the Breastcancer.org Discussion Board forum All things COVID-19 or coronavirus.
Written by: Jamie DePolo, senior editor
Reviewed by: Brian Wojciechowski, M.D., medical adviser
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