Topic: COVID-19 and Cancer

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Contents

At a glance Guidelines                                                            
COVID-19 symptoms Questions to ask your doctor             
What are risks for infection? COVID-19 in the media
Immune system and treatment What does this mean for me?
Changes in care Resources and references


TOPIC AT A GLANCE

This topic is about:

The issues faced by people with cancer or at high-risk of cancer during the COVID-19 (coronavirus) pandemic.

Why is this important?

The coronavirus pandemic brings new challenges to people coping with cancer or people who are at increased risk for cancer have unique concerns.

What is COVID-19?

Coronavirus Disease 2019, or “COVID-19” for short, is a disease caused by a type of virus known as a coronavirus. There are different types of coronaviruses. This particular strain—officially known as Severe Acute Respiratory Syndrome Coronavirus 2 (or SARS-CoV2)—is new to people and therefore has not been well-studied. This is why some reports use the term “novel coronavirus” to describe SARS-CoV2.

COVID-19 and cancer

Health care experts rely on research and facts to help guide medical care. However, because COVID-19 is very new, there are still many unanswered questions. Research on COVID-19 is ongoing, but experts will need more time to learn the best ways to prevent and treat the virus. Although much of the media coverage has been accurate, some misinformation has also been making the rounds.

In the face of such uncertainty, our goal is to provide you with information that is reasoned and evidence-based so that you can make the best possible healthcare decisions. We address issues specific to hereditary cancer and link you to credible resources. We will provide updates as these guidelines, insights or knowledge about COVID-19 change.

What are the symptoms of COVID19?

Symptoms of COVID19 vary by person. Some people infected with coronavirus do not have any symptoms. The most common symptoms of this virus are:

  • dry cough
  • temperature of 100.5 or higher
  • shortness of breath

Other symptoms include:

  • fatigue
  • a productive cough (coughing up sputum)
  • diarrhea
  • nausea
  • body aches
  • chills
  • reduced sense of smell or taste

The Centers for Disease Control (CDC) provides a description of COVID-19 symptoms and actions you should take to protect yourself and your family from contracting the virus.

How long after exposure do symptoms appear? When is it contagious?

The exact time between exposure to the virus and the appearance of symptoms may vary, but it is thought to be between 2 and 14 days. The virus can be passed between people before or while they are experiencing symptoms. Some people may be infected with this coronavirus and never have symptoms. Even without symptoms, people infected with the virus are still able to pass it to others.

What are the risks of infection?

Although people of any age can become infected and develop severe COVID-19 illness, the risk of having a severe infection varies with age. The risk is greatest among older adults, particularly for those over 60. The rate of infection among people without symptoms is unknown at this time.

The risk of infection, severe illness and death are greater for people who have other underlying health issues and those who have a weakened immune system.

Conditions that affect the risk for serious COVID19 complications include:

  • cardiovascular disease
  • diabetes
  • high blood pressure
  • chronic respiratory disease
  • moderate or severe asthma
  • having a suppressed immune system (being immunosuppressed)

Experts are uncertain if just having a cancer diagnosis can increase the risk of becoming infected or of complications related to COVID-19. However, the World Health Organization and representatives of 25 countries, including the United States, published "Report of the WHO-China Joint Mission on Coronavirus Disease" on February 28, 2020. They found that among 56,000 SARS-CoV2 patients, the risk for death was higher in people diagnosed with cancer compared the study group overall. More research is needed to confirm these findings.

An editorial posted in the Journal of the American Medical Association stated, “Cancer and cancer-related treatments frequently cause immunosuppression, and patients with cancer have excess mortality risk from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The magnitude of this risk is not yet known but early reports suggest a substantial increased risk of death associated with COVID-19 infection among patients with cancer, perhaps highest among those older than 60 years and those with pulmonary compromise.”

There is no evidence or reason to believe that having an inherited mutation in a cancer gene suppresses the immune system or leads to increased risk of serious infection.

If you are unclear about your risk for COVID-19, contact your doctor for advice. This type of consultation is best done remotely (telemedicine by phone, email or online).

Immune system and cancer treatment

Experts know that people with a weakened or altered immune system have an increased risk of severe illness or death from COVID-19. Different cancer treatments may affect how the immune system responds to infection.

  • Chemotherapy (e.g., paclitaxel, carboplatin, adriamycin) causes immune suppression. Typically, patients treated with chemotherapy can expect that they will be at least partially immunosuppressed for four to six months after their last chemotherapy treatment.
  • Immune checkpoint inhibitors (e.g., ipilimumab, pembrolizumab, nivolumab) are a relatively new type of immunotherapy. They are associated with a number of immune-related side effects, such as arthritis and pneumonitis (inflammation in the lungs) and may affect the body’s response to COVID-19.
  • Surgery can cause stress, and by extension may have a (usually mild) effect on the immune system. Most patients who had routine risk-reducing surgery are no longer be considered immune suppressed once they have reached the 4-8 week post-recovery period.
  • Radiation therapy is thought to affect the immune system to help it kill cancer cells. It is unclear whether radiation therapy would lead to immunosuppression.

Experts believe the following treatments do not cause immune suppression:

  • PARP inhibitors (e.g., niraparib, olaparib, rucaparib, talozoparib, veliparib) are not known to cause immunosuppression.
  • Hormone therapy drugs (also called endocrine therapy) are not associated with immunosuppression.
    • For breast cancer, this includes treatments with selective estrogen receptor modulators (SERMs) such as tamoxifen and raloxifene, selective estrogen receptor downregulators / degraders (SERDs), such as fulvestrant, or aromatase inhibitors such as anastrozole, letrozole and exemestane.
    • For prostate cancer, these include androgen receptor blockers such as flutamide, enzalutamide, apalutamide, bicalutamide and nilutamide.
  • Certain targeted therapies, including trastuzumab (Herceptin), bevacuzimab (Avastin), and CDK4/6 inhibitors, such as Ibrance, Kisqali and Verzenio)

Changes in screening, prevention and treatment

The health care community is working to minimize the risks of exposure to coronavirus for patients and providers during the pandemic. The CDC is asking healthcare providers to:

  • Delay all elective walk-in provider visits.
  • Reschedule elective and non-urgent hospital admissions
  • Delay inpatient and outpatient elective surgical and procedural cases
  • Postpone routine dental and eye care visits

This has led to changes in medical care for people with cancer and for those at high risk for cancer including:

  • Postponing surgeries for people diagnosed with some cancers, especially if systemic treatments (e.g., chemotherapy, hormonal therapy or targeted therapy) may be safely given before surgery.
  • Changing the frequency, dose or type of treatment to minimize hospital time or risk of side effects.
  • Delaying chemotherapy for new patients if other viable alternative treatments
  • Postponing screening tests in people with no cancer symptoms.
  • Postponing risk-reducing surgeries.
  • Replacing in-person visits with telehealth (video or phone) appointments.
  • Moving appointments, blood draws, and procedures from busy hospitals to less-crowded facilities.
  • Restricting hospital visits to patients only.
  • Checking the temperature of patients before admitting them into the hospital or clinic
  • Reducing the number of appointments and number of people allowed in the reception area in a hospital or clinic.

This article is relevant for:

People in treatment for cancer, or people scheduled for surgery

This article is also relevant for:

Breast cancer survivors

Healthy people with average cancer risk

Metastatic cancer

People with a genetic mutation linked to cancer risk

Previvors

Newly diagnosed

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Questions to Ask
  • Are there options for consultations or appointments by telephone or video?
  • What are the risks and benefits of delaying in-person appointments, screening or treatment?
  • Are there treatments that limit the number of in-person visits I will need?
  • Can any of my treatments be safely delayed; and if so, for how long?
  • What signs or symptoms should I monitor?
  • If I require an in-person visit, are there times of the day that are less crowded or locations other than hospitals that are not treating COVID-19 patients where I can be seen?
  • Given my treatment or health, am I immunocompromised? If so, what recommendations do you have for me? What precautions should I take?
Clinical Trials
  • NCT04321811 Behavior, Environment And Treatments for Covid-19 (BEAT19). This study asks participants to track symptoms associated with COVID-19 in order to better understand the timeline of symptoms of this disease. It is enrolling adult men and women (age 18 and older) in the United States who feel sick but either have or have not tested positive for COVID-19, as well as people who are not feeling sick but want to participate. This study is seeking to enroll 100,000 participants.
  • NCT04331509 COVID-19 Symptom Tracker. This study provides a free “COVID-19 Symptom Tracker” app to record and monitor the symptoms of the coronavirus infection and track in real time how the disease progresses. It also monitors how measures aimed at controlling the pandemic, including self-isolation and distancing, are affecting the mental health and well-being of participants. The app is available to anyone 18 years and older who is able to download it or use the web-based equivalent tool to self-report their symptoms.
  • NCT04334954 SARS-COV2 Pandemic Serosurvey and Blood Sampling. The goal of this study is to find how many people have detectable antibodies to COVID-19 from a sampling of adults who have no known exposure or clinical illness. This study is enrolling adults ages 18 and older without a confirmed COVID-19 infection or current symptoms consistent with COVID-19.
  • NCT03808922 STOP PIV - Phase III DAS181 Lower Tract PIV Infection in Immunocompromised Subjects. This study seeks to test whether the drug DAS181 helps immunocompromised patients with respiratory infections from either parainfluenza infection (a common virus that can cause respiratory infections, including colds and pneumonia) or severe COVID-19 infection. The main outcomes tested are the percent of participants who Return to Room Air (RTRA) or with COVID-19 Clinical Status Scale (sub-study). At the time of randomization to drug or placebo, participants must be at least age 18, were able to carry out self-care activities of daily living prior to SARS CoV2 (COVID-19) infection, have a confirmed lower respiratory tract infection, have laboratory confirmation of SARS CoV2 in the respiratory tract and are able to give consent for the study.
  • NCT04328012 COVID MED Trial - Comparison Of Therapeutics for Hospitalized Patients Infected With SARS-CoV-2 (COVIDMED). This study is a randomized, double-blind, placebo-controlled, multi-center, Phase 2-like, investigator-directed trial, of hospitalized adult patients with laboratory confirmed SARS-CoV-2 infection to look at the usefulness of three potential treatments for SARS-CoV2. Participants will be randomly assigned to one of four groups: standard care and lopinavir/ritonavir, standard care and hydroxychloroquine, standard care and losartan or standard care and placebo. Participants must be 18 years or older, who are hospitalized with confirmed SARS-CoV-2, who can give consent and can be randomized to drug treatment within 72 hours of hospital admission.
  • NCT04292899 Study to Evaluate the Safety and Antiviral Activity of Remdesivir (GS-5734™) in Participants With Severe Coronavirus Disease (COVID-19) and NCT04292730 Study to Evaluate the Safety and Antiviral Activity of Remdesivir (GS-5734™) in Participants With Moderate Coronavirus Disease (COVID-19) Compared to Standard of Care Treatment. The primary goal of these modified phase 3 studies are to look at whether either of two treatment methods of the antiviral drug remdesivir (RDV) are useful in improving clinical status of patients with severe or moderate COVID-19.
  • NCT04280705 Adaptive COVID-19 Treatment Trial (ACTT). This study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) is an adaptive, randomized, double-blind, placebo-controlled trial to evaluate the safety and efficacy of novel therapeutic agents in hospitalized adults diagnosed with COVID-19. The study is a multicenter trial that will be conducted in up to approximately 75 global sites. It will compare different investigational therapeutic agents to a control arm. Eligible participants are 18 years old with confirmed COVID-19.

Media coverage of COVID-19

Be aware that all news is not equal. Information is changing quickly as new studies are conducted, new technologies are tested and new data is analyzed. Some media reports contain helpful, accurate, evidence-based and fact-filled news, while others promote fear, unsubstantiated rumors, hyped promises without support and inaccuracies.

A few tips for evaluating media
It is easy to be overwhelmed by the amount and rapidly changing information about COVID-19. Here are a few tips for deciding whether a particular media report is worth your time:

  • What is the source of the information? Is it reliable?
    • Scientists share their data through peer-reviewed journals, government or academic websites. These can be the most accurate source of data. If you see a reference to a research study in the media, check other references. Many expert sites will publish plain language versions of new research, including:
      • Medical centers and hospitals, such as Mayo Clinic or Johns Hopkins
      • Government websites such as the National Cancer Institute, the CDC and the National Library of Medicine
      • Professional societies such as ASCO and the Society of Gynecologic Oncology (SGO)
      • Established nonprofit organizations, especially those with a Scientific Advisory Board, such as the American Cancer Society, Susan G. Komen and FORCE, just to name a few
    • Media information that is based on guesses, personal opinions or anecdotes from a few people, without a cited source, are more likely to contain unreliable or inaccurate information.
  • Ask yourself whether the report is objective. Are statements neutral and reasonable or overblown and exaggerated?
    • Signs of objective and reasonable information include information in context of the field as a whole—caveats and limitations of information are pointed out and the language used is factual rather than primarily emotional.
    • Beware of dramatic or fear-based statements, particularly when they are not supported by the data presented. Sensational or attention-grabbing headlines commonly overstate an article’s content.
  • Look for verification. Does the media article include quotes or information from experts on the topic?
    • Accurate media reports will ideally quote several external experts who can provide context, confirm results or point out limitations of the information presented.
    • Inaccurate media reports may include no expert quotes or may quote people who are not experts in the topic discussed. Carefully look at the qualifications of these "experts."
  • Look for numbers. Does the media only vaguely report increases or decreases or are specific numbers, percentages or statistics provided?
    • References to increases, decreases and changes that can be quantified should have specific numbers, percentages or ranges given. The article or report should clearly state what is being measured and how it was measured. Ideally, it will also provide information about the reliability of these numbers and identify any ambiguity or incompleteness of the information.
    • Unreliable media reports will often refer to dramatic increases or decreases without making it clear what  actually being measured or how it is measured. Key reasons for uncertainty or study limitations may be left out.
  • Verify using the above tips before passing the information on to others.

What does this mean for me?

Almost everyone has been touched in some way by the COVID-19 pandemic. There are many factors that may influence how it affects your health and wellbeing, including your age, where you live, your general health, whether you have been diagnosed with cancer, which treatments you are taking, and your employment, financial and housing situation, among others. Here are some general suggestions:

  • Stay up to date on national, state and local recommendations or regulations by visiting the CDC and your state health department website daily. Follow their recommendations.
  • Speak with your doctor or health care team to understand what changes they recommend with regards to your health care.
  • Seek support and resources from reputable organizations.
  • Try to follow healthy lifestyle recommendations. Many organizations have tips for exercising at home and for maintaining a balanced diet.
  • Try not to binge on media coverage.
  • Remember that the goal of current guidelines is to keep us safe and well.

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