Published on: November 26, 2020
With more runway needed before full implementation of a COVID-19 vaccine, as a cancer patient, you may be anxious if the risk of contracting SARS-CoV-2 is increased considerably. Since cancer is an ongoing chronic illness, it is reasonable to assume you might be more vulnerable. So is it really better to return to the hospital to seek treatment, screening and therapy, or safer to avoid the pandemic still at large?
We ask Dr. Hsieh Wen-Son, medical oncologist at Farrer Park Hospital, to weigh in on the pros and cons for cancer patients’ return duing the COVID-19 pandemic.
He said that assuming this would already be wrong as patients with cancer have a diverse array of primary tumor subtype and stages, affecting a heterogeneous group of patients of all ages with varying underlying medical conditions which result in very different cancer prognoses and outcomes.
The term ‘cancer’ encompasses a myriad of diseases, thus it would be inaccurate to label all cancer patients as members of the population who are ‘vulnerable to COVID-19’.
“There is no quick fix, one-size-fits-all solution for cancer patients because each cancer patient is unique. Age, gender or tumor subtype,stage, co-existing medical conditions, and previous treatments are important parts in defining the risk factors for cancer related outcomes and COVID-19 infection risk," Dr. Hsieh explained.
The main objective here, according to Dr. Hsieh, is that we must individualize the treatment and follow-up plans for each cancer patient taking into consideration of the risks and benefits for ongoing treatments and need for monitoring of a patient’s condition for progression or recurrence of his/her cancer.
Interrrupting cancer treatments can have dire consequences. For example, Dr. Hsieh notes that retrospective studies dating from the 1980s and 1990s showed that breaks during radiotherapy are associated with a higher rate of loco-regional recurrences in patients with head and neck and non-small cell lung cancer.
“In many instances, the risk of dying from cancer is higher than the risk of fatal SARS-CoV-2 disease; a fact that must be discussed with you, against your risk situation,” he said.
This would be what Dr. Hsieh refers to as “the risk/benefit balance”. It is where the oncologist assesses your risks of a poor outcome from either worsening of your cancer or from contracting COVID-19 infection if the treatment or therapy course were continued.
“There must be a multi-disciplinary discussion with you. Because some systemic therapies such as hormonal or targeted therapies are not, in principle, associated with increased risk of complications of COVID-19 and should therefore be used as recommended by guidelines while others treatments such as traditional cytotoxic chemotherapies will suppress the immune system and are more likely to increase the risk of poor outcomes due to COVID-19 infection,” Dr. Hsieh adds.
While more studies are still needed to ascertain and support possible infection outcomes or contraindications to oncologic treatments, Dr. Hsieh said oncologists are using a combination of available evidence and common sense to determine the best course for each patient.
What is promising is that the advancements in health screening, diagnostic methods, treatment modalities and relevant supportive measures for cancer patients today, provide oncologists and their patients with more options to better chart a course that suits each patient. “The difference,” Dr. Hsieh says, “depends on you and the cancer.”
For instance, adjuvant therapy is an important phase of the treatment course because even if the surgery was successful at removing all visible cancer, microscopic bits of cancer sometimes remain and are undetectable with current methods. It is often used after primary treatments, such as surgery, to lessen the chance of cancer coming back. Thus an adjuvant—chemotherapy, hormone, radiation, immunotherapy or targeted—therapy is needed to decrease the risk of recurrence.
So for a young patient with breast cancer in stage three, the patient would need to continue adjuvant therapy in spite of the ongoing pandemic because it can greatly increase the chances of survival. On the other hand, an elderly patient with advanced lung cancer may have to consider less toxic alternatives or even a possible delay in treatment so as to limit the patient’s exposure and not compromise immunity to a possible infection.
Asked whether seeking care for signs or symptoms which can suggest an early cancer can wait, Dr. Hsieh recommends acting quickly.
“Always wise to do this fast. At an early stage, cancer is likely to be curable,” he added.
However, patients who are well and are just on routine follow-up after completion of previous cancer treatment can delay visits to the hospital until the risk of contracting COVID-19 has decreased.
Besides assessing your risks, another key consideration Dr. Hsieh reminded us to note is that it also depends on the local prevalence of COVID-19 and the kind of protective screening precautions in place. In Singapore, hospitals are very safe in general due to the extensive screening and follow-up that is performed on staff, patients, and visitors. Of course the caveat, Dr. Hsieh says, is that these measures lower but does not eliminate risk completely.
In the earlier part of the year, plausible concerns were already raised that diagnostic pathways and cancer treatment modalities may expose patients to a greater risk of acquiring SARS-CoV-2 than would be the case if patient stayed at home with social distancing.
“But with more experience since SARS and H1N1 as well as over the past some 8 months since COVID-19 infections began, there are greater steps made toward preventing and protecting population infection in Singapore,” Dr. Hsieh observed.
He said that sweeping changes have also been made in cancer management for all cancer types. The considerations include abbreviation of radiotherapy, switching from intravenous to oral chemotherapy regimens, and the avoidance of immunotherapy when possible and enhanced precautions at hospitals and medical facilities. In Singapore this is augmented by adoption of additional protective measures and more public education about personal hygiene.
“Much more thought and preparation has gone into the reconfiguration of cancer care services to maximize patient safety. The general heightened sense of awareness like social distancing, frequent handwashing, more available hand sanitizer stations as well as compulsory mask-wearing, all help,” he adds.
Dr. Hsieh also said that there are ways to vary the course of therapy. “In situations where the risk/benefit balance of an adjuvant systemic chemotherapy is controversial or uncertain, it may be wiser to decide against that treatment during the COVID-19 pandemic. Other examples include altering treatment regimens reduce the number of visits to the hospital or conversely, the use of weekly regimens with low risk of immunosuppression which despite being associated with a higher number of visits may lower the risk of COVID-19 infection.”
He also advised: “Remember that your course of healing and recovery from cancer is a personalized journey. It is different for every patient. Any online data and ad-hoc patient experiences shared no matter how intimate are likely unreliable because it is necessarily not backed by scientific evidence and likely not applicable to you as it is not based on your condition and state of health.”
Without the long-term data to appreciate the effect of treatment interruption on cancer control and survival, Dr. Hsieh said that we will need to use what information is available to optimize the treatment for each patient, keeping in mind that overall health of each patient is the priority.
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