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Should Cancer Treatment Be Continued During the Pandemic? A Case-by-Case Discussion Is Required

With Florian Lordick, University Cancer Leipzig (UCCL), Germany

20 Mar 2020

Ensuring the continuum of cancer care is the cornerstone in oncology, and this has become a major priority during the COVID-19 pandemic over the last weeks.

Some questions have been raised on whether to continue or not cancer treatments in some patients, to limit their risks of possible exposure to the infection when they access or travel to hospitals for visits or therapies.

According to Professor Florian Lordick from the University Cancer Cancer Leipzig (UCCL), Leipzig, Germany, ESMO Director of Education, risks related to COVID-19 should be balanced against tumour control and discussed on a case-by-case basis.

Are cancer patients more at risk of COVID-19?

This is a difficult question because evidence collected so far is not robust. There was one nationwide analysis from China published in Lancet Oncology in February, that suggested that cancer patients are maybe at a higher risk for the COVID-19 infection. However, there were also comments on the same journal criticising the methodology of that analysis, reporting about a very heterogeneous cancer population, with low numbers of observations. Currently, it is not clear if and to which degree patients with cancer are actually at higher risk.

There are some groups of patients who are likely to be at a higher risk for serious infections, including cancer patients with: malignant heamatological diseases like acute leukemia and lymphoma; with a long duration of leukocytopaenia (low number of white blood cells) which can be caused either by the disease or by treatments; low immune globulin levels like in multiple myeloma; long-term immunosuppression, for example, by corticosteroids or monoclonal antibodies like rituximab. At particular risk, also, are certainly patients who are receiving allogenic stem-cell self-transplant and other cellular therapies

Is cardiovascular co-morbidity in cancer patients a risk factor for severe events related to the infection with COVID-19?

What is known from all data published from China, Korea and Italy so far is that older patients with co-morbidities are at a higher risk of severe complications of COVID-19. This means that age as well as other health conditions, such as heart failure or diabetes or chronic pulmonary disease, are important factors to be discussed when assessing the risk in cancer patients

In some countries where the spread of the pandemic is massive, specific measures have been taken to reduce access to hospitals to cancer patients, for example, by giving high priority only to patients receiving treatment for an active disease while postponing follow-up visits. What are the measures adopted in your institute in Germany?

Currently, we are expecting the pandemic wave to increase over the next weeks, so we are deciding case –by case if treatment has to be initiated and a visit really needs to be done. We are performing individual risk-benefit assessments in patients before making any decision. For some patients, there is no urgent need to start treatment now and we can also be flexible to postpone follow-up visits for many of them. In many cases, when the benefits for the patient to undergo anti-cancer treatment outweigh the risks of being potentially exposed to the virus while travelling from home to the hospital and back, we are choosing to continue therapy or initiate new therapy, if necessary.

A different case is to manage treatment in a patient who has a COVID-19 infection. In this case, we would put any cancer treatment on hold as long as the infection is not cured. However, in some very specific – and hopefully very rare – situations where there is a very urgent vital need related to the oncology disease, one might have to consider to give anti-cancer treatments despite the viral infection. I have not any direct experience on this as, fortunately, there are no such cases in my practice at the moment.

In Lombardy, Italy, some hospitals are now “COVID hospitals”, where citizens who are coronavirus-positive are treated, including cancer patients, whereas major cancer centres – have been reorganised to be COVID-free cancer hubs taking care of cancer patients who are coronavirus-negative on behalf of the other hospitals in the Region. Do you think that such a measure should be applied to other hospitals and countries in Europe?

In Germany, like in many other countries, all hospital-based cancer treatments are integrated into general hospitals. Consequently, to create a cancer hub which is clean from the infection is probably much complicated. Maybe such a solution is more feasiblewhere “stand-alone” cancer hospitals are available. But even there healthcare staff may face some issues in catching all those patients who have the COVID-19 infection, as some of them may be asymptomatic or oligosymptomatic. In that case, a massive testing of anyone who accesses the hospital would be required. This can be done, in theory, but requires enormous resources that may not be available in all healthcare systems. Not to talk about limited sensitivity and potentially false-negative test results.

In Germany, we are creating specific areas for infective patients within the hospitals, separate from others, where we can take care of patients until they test negative to the coronavirus. Also, elective operations and procedures have been reduced to a considerable extent, in order to limit visits and gain space at hospitals for the probably increasing number of COVID-19 patients in the next weeks.

How has the COVID-19 pandemic changed the working routines of oncology teams? Are teams required to be flexible and re-organise their routine?

Medical teams in oncology and in other fields are required to be flexible and re-organise their daily routines. Staff training is an essential step to manage any potential scenario due to the pandemic. In my practice, the whole staff got a full training on how to behave, how to protect themselves and others in and outside the hospital. Of course, we are doing the same with our patients, giving them all the information which is necessary to put basic measures in practice to protect themselves from the risk of infection.

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