Topic: COVID-19 and cancer

Contents

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.

Financial resources

• CancerCare offers co-pay assistance, and financial assistance for treatment-related costs, such as transportation, home care and child care. They are also providing financial support for people with cancer who have been affected by COVID-19. 

• Cancer.net has a page of financial resources related to COVID-19 and cancer. 

• The Patient Access Network (PAN) Foundation has a COVID-19 Treatment and Prevention Fund to provide assistance to cancer patients facing hardship due to the COVID-19 pandemic.

• The Patient Advocate Foundation has a COVID Care page with resources related to financial support and COVID-19.  

• Susan G. Komen partners with Cancercare to offer the Komen Treatment Assistance Program which bridges the gap for underserved individuals who are actively undergoing breast cancer treatment. 

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References

Liang W, Guan W, Chen W, et al. "Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China." The Lancet. Published online February 14, 2020. 21:336-337.

World Health Organization (WHO): Report of the WHO-China Joint Mission on Coronavirus Disease. Feb 28 2020. 

Note: Many scientific journals that publish research studies only for paid subscribers have made articles about COVID-19 research freely available. This includes the New England Journal of Medicine, the Journal of the American Medical Association (JAMA) and many others. 
 

Disclosure

FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board before publication to assure scientific integrity.