COVID-19 PANDEMIC : ASCO have released guidance on dealing with the impact of the pandemic on the delivery of cancer care.

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March 30, 2020

SCIENTIFIC

COVID-19 Patient Care Information

https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19

Cancer.Net--ASCO’s patient information website has regularly updated information about COVID-19 for people with cancer and cancer survivors in English and Spanish.

ASCO invited its members to submit questions about issues and challenges they see emerging while caring for individuals with cancer during the coronavirus pandemic. Currently, limited clinical cancer-specific data are available and information is evolving. The following information is based on evidence gathered through PubMed searches of the medical literature, a search of relevant websites with information on infectious diseases (CDC, WHO, IDSA, etc.), and input from clinical oncologists and infectious disease experts. ASCO will update this information as new questions emerge and evidence develops.

Patient Care: How should the care of cancer patients be modified by the COVID-19 pandemic?

DATA: What are the current data on care of patients with cancer and COVID-19?  Are patients with cancer more likely to be infected? Do they have more complications?

The CDC is continuously updating its information on COVID-19.  For the most up to date general information on the virus and the epidemic, the CDC is best source of information (Accessed March 13 2020).

The most comprehensive data available to date on the cancer-specific case fatality rate that ASCO could identify is a Report of the WHO-China Joint Mission on Coronavirus Disease published on February 28, 2020.  This report indicates that in China, as of the data cut-off (February 20) the case fatality rate for patients with cancer as a comorbid condition and laboratory confirmed infection was 7.6%.  This is as compared to: overall 3.8%, no comorbid condition 1.4%, cardiovascular disease 13.2%, diabetes 9.2%, hypertension 8.4%, chronic respiratory disease 8.0%.

The most detailed report currently available that provides data on COVID-19 course of illness in patients with cancer to those without cancer ASCO could identify is Liang et al, Lancet Oncol.  This paper reporting on a prospective cohort of 1571 patients with COVID-19, 18 of which had a prior history of cancer, found that patients with a history of cancer had a higher incidence of severe events – defined as the percentage of patients admitted to an intensive care unit requiring invasive ventilation, or death – compared with other patients. It did not establish a definitive increase in incidence of COVID-19 infection. According to correspondence related to the report Xia et al (Xia et al, Lancet Oncol), these 18 patients represent a heterogeneous group and are not an ideal representation of the entire population of patients with cancer.  

No evidence on care of patients with any specific histology (e.g. breast, lung), therapy (e.g. immunotherapy, tyrosine kinase inhibitors), or subpopulation of patients with cancer (e.g. children, elderly) has been identified.  As further evidence becomes available, ASCO will update this page.

GENERAL CARE: What are the recommendations for general care of patients with cancer?

ASCO encourages anyone caring for patients with cancer to follow the existing CDC guidance where possible:

In addition to the general CDC guidance, the following practice points may be considered:

  • Patients should be informed regarding the symptoms of COVID-19, and trained in proper handwashing, hygiene, and minimizing exposure to sick contacts and large crowds.
  • At this time, no specific evidence or guidance on mask use in patients with cancer patients has been published. Patients and clinicians are urged to follow the USCDC’s general recommendations on mask wear. There is no guidance or evidence to suggest that N95 masks are required.
  • For cancer patients with fever or other symptoms of infection, a comprehensive evaluation should be performed, as per usual medical practice.

TESTING FOR COVID-19: What information is available on testing for COVID-19?

There is no specific guidance with respect to COVID-19 testing in patients with cancer.  Local and state public health directives and guidance on who should be tested and how the tests should be conducted should be followed. 

The Infectious Disease Society of America (IDSA) has published some guidance on testing. (accessed March 13, 2020). The CDC also has information for laboratories here (accessed March 13, 2020).

SURGERY: Can/should surgery be cancelled or delayed?  If surgery is delayed, should patients be started earlier on neoadjuvant therapy if that is an available option?

The  CDC’s guidance for health care facilities suggests that “elective surgeries” at in-patient facilities be rescheduled if possible.  The American College of Surgeons (ACS) has issued guidance as well and provides additional advice related to triage of patients for surgery relevant to cancer care.  However, clinicians and patients will need to make individual determinations based on the potential harms of delaying needed cancer-related surgery; in many cases these surgeries cannot be considered “elective”.

In some situations (e.g. early stage breast cancer) where neoadjuvant therapy is available but not routinely considered, it may be reasonable to consider neoadjuvant therapy instead of surgery or simply delaying surgery.  The risks of tumor progression with delay in definitive surgery should be weighed against the potential added burden on hospital resources, case complexity and patient risk of exposure to COVID-19.  However, neoadjuvant therapy that requires clinic visits and clinician-patient contact or that itself is immunosuppressive is associated with risks to the patient that must also be considered.

RADIATION: Can/should the initiation of radiation be delayed?  Can radiation be interrupted or postponed if already in progress?

ASTRO has addressed this concern in part on its COVID-19 resource page.  ASCO encourages clinicians to follow ASTRO’s current guidance.  ASCO recognizes the risks of delay in treatment for patients with rapidly progressing, potentially curable tumors may outweigh the risks of COVID-19 exposure/infection, but patients receiving radiation for symptom control or at low risk of harm due to alteration of schedule for radiation treatment visits could potentially be safely delayed.  Patients should check with their radiation oncologist to determine the most appropriate course of action for their treatment.

IMMUNOSUPPRESSIVE THERAPY: Can/should potentially immunosuppressive therapy (except allogenic stem cell transplantation) be stopped, delayed, or interrupted?

At this time, there is no direct evidence to support changing or withholding chemotherapy or immunotherapy in patients with cancer. Therefore, routinely withholding critical anti-cancer or immunosuppressive therapy is not recommended. The balance of potential harms that may result from delaying or interrupting treatment versus the potential benefits of possibly preventing or delaying COVID-19 infection is very uncertain. Clinical decisions should be individualized that consider factors such as the risk of cancer recurrence if therapy is delayed, modified or interrupted; the number of cycles of therapy already completed; and the patient’s tolerance of treatment. 

However, the following practice points should be considered:

  • For patients in deep remission who are receiving maintenance therapy, stopping chemotherapy may be an option.
  • Some patients may be able to switch chemotherapy from IV to oral therapies, which would decrease the frequency of clinic visits but would require greater vigilance by the health care team to be sure that patients are taking their medicine correctly.
  • Decisions on modifying or withholding chemotherapy should include consideration of the indication for chemotherapy and the goals of care as well as where the patient is in the treatment course and their tolerance of treatment. For example, the risk/benefit assessment for proceeding with chemotherapy in patients with untreated extensive small cell lung cancer is different from that for patients on maintenance pemetrexed for metastatic NSCLC.
  • If local transmission affects a particular cancer center, reasonable options may include giving a chemotherapy break for two weeks, arranging infusion at an unaffected satellite unit, or arranging treatment with another facility that is not affected.
  • Consider whether home infusion of chemotherapy drugs is medically and logistically feasible for the patient, medical team and caregivers.
  • In some settings, delays or modifying adjuvant treatment may pose a higher risk of compromised disease control and long-term survival than in others.
  • Prophylactic growth factors as would be used in high-risk chemotherapy regimens as well as prophylactic antibiotics may be of potential value in maintaining the overall health of the patient and make them less vulnerable to potential COVID-19 complications.
  • In cases where the absolute benefit of adjuvant chemotherapy may be quite small, and where non-immunosuppressive options are available (e.g. hormonal therapy in ER+ early-stage breast cancer), risk of infection with COVID-19 may be considered as an additional factor in weighing the different options available to the patient.

STEM CELL TRANSPLANTATION: Can/should allogeneic stem cell transplantation be delayed?

In some cases involving patients at high-risk for COVID-19, delaying a planned allogeneic SCT may be reasonable, particularly if the patient’s malignancy is controlled with conventional treatment. Until further data are available, clinicians are encouraged to follow the recommendations provided by the American Society of Transplantation and Cellular Therapy (ASTCT); and the European Society for Blood and Marrow Transplantation (EBMT) recommendations with respect to stem cell transplantation.

The following practice points may be considered:

  • It may be prudent to test potential donors for COVID-19 even in an absence of evidence of transmission by blood transfusion.
  • As a general precaution, visitation post-transplant may need to be limited and visitors may need to be screened for symptoms and potential exposure.

The Fred Hutchinson Cancer Research Center and the Seattle Cancer Care Alliance have provided guidance on stem cell transplantation and COVID-19 that may be of value (accessed March 13 2020).

PROPHYLACTIC ANTIVIRAL THERAPY: Should prophylactic antiviral therapy be considered?

At this time, there is no evidence or published guidance on the use of prophylactic antiviral therapy for COVID-19 in immune suppressed patients. This is an active area of research and evidence may be available at any time.  Prophylactic antiviral therapy directed at other viral infections should be continued according to standard clinical guidelines and institutional practices. Tamiflu is not known to be effective in treatment of COVID-19.  ASCO is aware that clinical trials are ongoing or have been briefly published on the use of potential antiviral medications (e.g. chloroquine, remdesivir, lopinavir) but to date none of these trials have been specific to patients with cancer and all have been in patients with suspected or confirmed infection, not in the prophylactic setting.

OTHER THERAPY: Are there any other therapies that should be delayed, interrupted, or stopped?

At this time, ASCO cannot provide specific guidance on any other form of cancer therapy.  As more data becomes available, this information will be updated. In general, however, any decisions to postpone, discontinue or modify necessary systemic cancer therapy should consider the overall goals of treatment, risks of cancer progression if treatment is postponed or interrupted, patient tolerance of treatment and the patient’s general medical condition. Each decision requires an individualized risk/benefit assessment. 

CANCER SCREENING: Can/should members of the community continue recommended cancer screening activities (e.g. screening mammography)?

To conserve health system resources and reduce patient contact with health care facilities, ASCO recommends that cancer screening procedures that require clinic/center visits such as screening mammograms and colonoscopy be postponed for the time being. Clinical care teams are advised to carefully weigh the risks and benefits of pursuing elective procedures, such as screening procedures, at this time.

DIAGNOSIS AND STAGING: How can/should diagnosis and staging interventions (e.g. imaging visits, biopsy) be modified by the ongoing COVID-19 pandemic?  Is there any evidence that COVID-19 infection influences the ability to diagnosis or stage disease (e.g. chest imaging for potential lung cancer)?

In general, as recommended by the CDC, any clinic visits that can be postponed without risk to the patient should be postponed.  This may potentially include patients who are suspected clinically of disease at low risk of rapid progression (e.g. minor suspicious findings on mammography).

ASCO is aware of no evidence that that COVID-19 infection interferes with or has an effect on the diagnosis and staging of cancer.  In a patient newly diagnosed with cancer, it is reasonable to limit staging procedures only to those that are most necessary to inform development of the initial care plan. Should evidence become available, this statement will be updated.

SURVEILLANCE: Can/should patients receiving ongoing surveillance (e.g. imaging for detection of recurrence, active surveillance for existing disease) have that surveillance delayed/interrupted?

In general, as recommended by the CDC, any clinic visits that can be postponed without risk to the patient should be postponed.  This likely includes routine surveillance in patients considered to be at relatively low risk of recurrence and those who are asymptomatic during the follow-up period. In situations where existing recommendations provide frequency ranges for interventions (e.g. every 3-6 months) it is reasonable to delay scheduled interventions to the longest recommended frequency duration.

NEUTROPENIC FEVER – How can/should care for patients experiencing potential neutropenic fever be affected by the ongoing COVID-19 pandemic?

ASCO recognizes there are two aspects to care of patients with potential neutropenic fever in relation to COVID-19: prophylaxis and acute care. 

  • Prophylaxis – it may be reasonable for patients at risk for neutropenic fever to be prescribed growth factor for treatment regimens at a lower level of expected risk (e.g. >10% risk) in order to minimize the risk of neutropenic fever and the potential need for emergency care, with instructions for neutrophil count monitoring and regular contact with their health care team. 
  • Acute Care – it may be reasonable in the current situation to prescribe empiric antibiotics in patients who are febrile and neutropenic but clinically stable, as determined by tele-evaluation or by phone.  Where possible, further evaluation is best done outside of the emergency department.  

Disclaimer

Answers to questions about COVID-19 published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) for voluntary, informational use by providers in the rapidly evolving novel coronavirus crisis. This information does not constitute medical or legal advice, is not intended for use in the diagnosis or treatment of individual conditions, does not endorse products or therapies, recommend or mandate any particular course of medical care, and is not a statement of the standard of care. New evidence may emerge between the time information is developed and when it is published or read. The information is not comprehensive or continually updated. This information is not intended to substitute for the independent professional judgment of the treating provider in the context of treating the individual patient. ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions. Use of the information is subject to the complete ASCO website Terms of Use.