Contemporary Considerations for Cancer Care in the COVID-19 Era

Edward S. Kim, MD, FACP

The downstream effects of the coronavirus disease 2019 (COVID-19) on patients with cancer have become apparent over the past few months, said Edward S. Kim, MD, FACP, who added that the onus is on the field to provide clinical guidance on best practices in the absence of definitive data. 

In a virtual presentation during the 2020 ASCO Direct Highlights^TM webcast, a program developed by Physicians’ Education Resource^®(PER^®), LLC., Kim, chair of the Department of Solid Tumor Oncology at Levine Cancer Institute, Atrium Health, said that the pandemic has reduced cancer screening and diagnostic testing as well as clinical trials and research. Additionally, there have been less visits and referrals, which have in turn, led to disruptions in cancer care and a rise in telemedicine.

Despite these changes, the goals in any individual practice, specifically patient and staff safety as well as adhering to best practices, should remain the same, said Kim.

In order to facilitate that, Levine Cancer Institute launched the EAPathways web platform, allowing in-house providers to share the latest COVID-19-related news and information.

“We have a COVID-19 site with expanded chapters within it,” said Kim. “Some of the pages we were updating every couple of hours based on how guidance was changing.”

Additionally, on April 20, 2020, investigators at Levine Cancer Institute published their institutional experience in managing patients with cancer during the pandemic.

Within clinical practice, Kim said that providers will have to weigh the current standard of care with something that is perhaps less effective but safer for the patient. In lung cancer, that could include switching from intravenous etoposide to oral etoposide. In addition to considering alternative delivery methods, providers could consider shortened treatment durations, increased treatment intervals, and decreased treatment frequency, particularly for patients on immunotherapy, for which the optimal duration of therapy is not well defined.

With regard to clinical research, non-essential studies should continue to be suspended until further notice to ensure the safety of patients and staffs alike. To that end, all clinical trials at Levine Cancer Institute were triaged and suspended accordingly. Only trials that provided promise for patients without equivalent standard therapy remained opened, said Kim.

“Hematologic studies with CAR T-cell therapy are a little more complicated because patients have to go to the hospital sometimes, but our research staff has been great in supporting those and working hard to offer those treatments to patients,” said Kim.

Wherever possible, telemedicine is used to provide access to providers, reduced exposure to COVID-19, and more frequent check-ins with patients, said Kim.

“Patient perceptions have changed,” said Kim. “They are fine accepting data and results over the phone or on video. They are fine with delaying treatment. We’re continuing to learn about the virus. Ultimately, we don’t know what the impact down the road will be,” concluded Kim.

Providing additional perspective during the presentation was Saad Z. Usmani, MD, FACP, chief of Plasma Cell Disorders and director of Clinical Research in Hematologic Malignancies at Levine Cancer Institute.

“The sobering fact is that despite all of the necessary preparations and the lead time we had, we have struggled with the observed case-fatality ratio in the United States.”

As testing ramped up around the United States, a report from the Centers for Disease Control and Prevention (CDC) showed that patients between the ages of 18 to 64 were as, if not more likely, to test positive for COVID-19 than older patients, explained Usmani.

However, another report from the CDC showed that older patients above the age of 65 had a significantly higher likelihood of being admitted to the hospital for COVID-19–related complications. Usmani explained that older patients are more likely to have comorbidities, thereby raising their risk of developing severe complications from the virus. Not surprisingly, a paper published in Lancet Oncology showed that patients with cancer have the highest risk of invasive ventilation or intensive care unit admission or death compared with patients without cancer (HR, 3.56; 95% CI, 1.65-7.69).¹

To mitigate this risk, professional organizations created disease-specific guidelines regarding common treatment interventions (Tables 1, 2, 3).²

Table 1. Lymphoid Malignancies Considerations (ASH Guidelines)

Table 2. Myeloid Malignancies Considerations

Table 3. International Myeloma Society Considerations

To monitor the outbreak itself, Atrium Health employed drive-through testing, after which patients were virtually housed on the “observation floor” or the “acute care” floor. Patients under observation have limited symptoms and receive an every-other-day phone assessment from a nurse, and 24/7 physician call coverage. Patients under acute care have moderate symptoms and receive home monitoring, 24/7 nurse coverage, community paramedicine and/or daily nurse visits, and virtual providers rounds daily.

“We’re continuing to do this because the pandemic is not over yet,” concluded Usmani.

References

1. Liang W, Guan W, Chen R, et al. Cancer patients. In SARS–CoV–2 infection: a nationwide analysis in China. Lancet Oncol. 2020(3):335-337. doi:10.1016/S1470-2045(20)30096-6

2. Usmani S. Impact of COVID19 on management of hematologic malignancies. Presented at: 2020 ASCO Direct Highlights webcast; June 13, 2020; Virtual.