Sam Shares Strategies for Providing Optimal Care to Geriatric Patients With Cancer During the COVID-19 Crisis

Christine Sam, MD

The management of elderly patients with cancer during the COVID-19 pandemic presents unique challenges, according to Christine Sam, MD, and strategies to reduce risk of exposure and limit treatment-related immunosuppression and toxicities are key to ensuring the health and safety of this population as they continue to receive treatment during this time.

Efforts such as the COVID-19 and Cancer Consortium (CCC19)have revealed that elderly patients have certain risk factors beyond age that could impact mortality, added Sam. For example, patients with poor performance status and those whose cancer has progressed are at increased risk of mortality with COVID-19.

Several measures can be taken to mitigate the risk factors that would lead to worse outcomes in this patient population, according to Sam. These preventive efforts include social distancing, practicing proper hand hygiene, wearing a mask, and ensuring that patients are up-to-date on their vaccinations. On an institutional level, implementing more telehealth visits versus in-person visits are also effective in reducing unnecessary exposure to the virus.

Treatment modifications can also be made to mitigate risks in this patient population, said Sam. For example, dose reductions can be made with regard to chemotherapy in high-risk patients. Additionally, if a patient has low-risk, hormone-positive breast cancer, hormone-based therapies can be used to delay surgeries or other exposures that could increase the risk of COVID-19.

“[Treatment modifications can include] dose reductions, dose delays, and substitution strategies,” said Sam. “We [can practice] substitution in terms of endocrine therapy, by choosing regimens that are less immunosuppressive and growth factors that stimulate the white blood cell count, especially in an older population who are at more risk of experiencing bone marrow suppression with chemotherapy. We are also testing for COVID-19 prior to starting [therapy].”

In an interview with OncLive during the Institutional Perspectives in Cancer program, Sam, a hematologist and oncologist and an assistant member in the Department of Individualized Cancer Management/Senior Adult Oncology Program at Moffitt Cancer Center, highlighted strategies to prevent the spread of COVID-19 in geriatric patients with cancer and shared advice on how to overcome unique challenges faced in the care of this population.

OncLive: What do we know so far about the impact of COVID-19 on elderly patients with cancer?

Sam: Recent data were presented during the 2020 ASCO Virtual Scientific Program from the COVID-19 and Cancer Consortium, which looked at different risk factors for patients with cancer. Some of the factors mentioned were age greater than 75 years, patients with poor performance status, and those with progressing cancer.

Investigators noticed that compared with the baseline risk of mortality with COVID-19, [mortality] was greatly increased in older patients whose cancers were getting worse or [those who had] poor performance status; it was at least 2 to 3 times greater [in these patients]. If they had such severe risk that they had intubation from COVID-19, then their mortality rates were through the roof compared with the baseline.

The aforementioned patient populations definitely have a higher risk of developing severe infections with COVID-19. As such, if you have an elderly patient with cancer who fits all 3 [risk factors], then their risk of having a serious outcome if they become infected with the infection is pretty high.

It's important to assess patients in terms of their functional status and go based on that rather than just age; age plays a factor, but other medical comorbidities [must also be considered].

What are the different risks that these patients face during the COVID-19 pandemic?

Contracting COVID-19 poses a great risk to these patients, so physical distancing is very much encouraged, especially in the older population. [Patients should be] staying home and trying to avoid going outdoors; they should be wearing masks, performing hand hygiene, and avoid touching their face. We must ensure that elderly patients have the appropriate vaccinations because pneumonia is a very high risk in this population, and that could lead to more healthcare exposures.

Older patients generally have more doctor visits than younger patients, which means more healthcare exposures, so ways to mitigate that also include improving our telehealth options; that has a little bit of a double-edged sword because some of these patients are not comfortable with technology. Going forward, we need to help these patients feel more comfortable with this approach or find a more geriatric-friendly way of conducting telehealth visits. They might need some extra education or extra IT support; however, we've definitely noticed that as our institutions increase telehealth [efforts], there's definitely a subpopulation of patients who still want to come [into the clinic] because they don't feel comfortable with using technology. [Teleheath is] one of the best ways to reduce the risk of getting COVID-19.

Other things that we can do, from a cancer standpoint, is if a high-risk patient with many comorbidities [comes into the clinic], we can start with dose reductions in chemotherapy. We can also use lower intensity chemotherapies. You can also get a good assessment of the [patient's] physical fitness by doing a geriatric assessment. Other things that can be done include delaying treatment, when possible. If patients have low-risk, hormone-positive breast cancers, you can use hormone-based therapies and delay surgeries or other exposures that could increase the risk of COVID-19.

There's also this evolving recommendation from the Infectious Diseases Society of America about giving COVID-19 testing prior to administering any immunosuppressive chemotherapy. We have started to implement that at Moffitt Cancer Center; prior to a patient’s first cycle [of chemotherapy] we test patients for the infection. This is especially important because don't know the impact of giving chemotherapy to an asymptomatic patients with COVID-19.

Those recommendations continue to evolve. Many questions remain. For example, do we [test patients for infection] before every treatment or only if they've gone outside? We don't know all of the answers yet; however, right now, we're at least starting with testing for the virus prior to the initiation of chemotherapy. Also, for patients who are on very stable treatment, such as trastuzumab (Herceptin) or maintenance therapy, and they've been doing very well, [there is a consideration for] decreasing the frequency of in-person visits.

What resources are available for caring for geriatric patients with cancer during this time?

Yes, many geriatric assessments are available; there's a laundry list of them. We developed a short screen for our clinic because geriatric assessment can be very difficult to do and having good resources to be able to do that quickly is important. Among some of the first [assessments] that were developed, is the CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) score; this is available on the Moffitt website. Another is called the CARG (Cancer Aging Research Group) score and that one can be done online.

Several physical assessments are also available; I like the Timed Up and Go test because it's an easy assessment to do and can be done by a medical assistant in the clinic. The CRASH and the CARG scores are have been validated and used for a long time. The Senior Adult Supplement Screening Questionnaire (SAOP3) is the one that we use in clinic.

What is your advice for patient-provider discussions on the risks of COVID-19?

In many cases, the oncologist is the doctor that these patients see most frequently. It's our duty to inform our patients of the risk of COVID-19; it’s something that can impact their treatment. It is also important to go over the trajectory of COVID-19 in the community. A few months ago, New York had far higher cases of infection than Florida did, but now the trajectory in Florida is increasing. As such, the trajectory of COVID-19 in each respective community must be taken into account; that impacts risk of infection with the virus.

Reference

Sam C. Management of the senior adult population in the COVID era. Presented at: OncLive Saturday Spotlight: Institutional Perspectives in Cancer; June 27, 2020. Accessed July 2, 2020.