The following information is compiled from the American Society Clinical Oncology (ASCO), American Society for Radiation Oncology (ASTRO), and the Centers for Disease Control and Prevention (CDC) for managing patients with cancer in the context of the COVID-19 pandemic. Clinicians and patients must make individual determinations based on the potential harms of delaying needed cancer-related interventions and risks of accessing the healthcare system with potential exposure to COVID-19.
Are patients with cancer more likely to be infected? Do they have more complications?
Based on data from China in the early part of the disease, the case fatality rate (CFR) for patients with cancer as an underlying condition and laboratory-confirmed COVID-19 was 7.6%.
This compares with the following CFRs:
- Overall = 3.8%
- No comorbid condition = 1.4%
- Chronic respiratory disease = 8.0%
- Hypertension = 8.4%
- Diabetes = 9.2%
- Cardiovascular disease = 13.2%
Currently, no data exist regarding risk by specific cancer type, therapy, or patient sub-population.
What are the recommendations for general care of patients with cancer?
Patients should be educated regarding signs/symptoms of COVID-19, proper handwashing, and cough hygiene, infection control within the home, and minimizing exposure to sick contacts and large crowds.
There is no specific evidence or guidance on mask use in patients with cancer patients at this time.
Patients with cancer should have emphasized the importance of contacting their oncologist or care coordinator with new onset fever or other symptoms of infection.
Any new symptoms of infection, with or without fever, should have a comprehensive follow-up evaluation per usual medical practice.
Can/should surgery be cancelled or delayed?
Per CDC, "elective surgeries" at in-patient facilities be rescheduled if possible.
Clinicians and patients 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".
Can/should the initiation of radiation be delayed? Can radiation be interrupted or postponed if already in progress?
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. Patients receiving radiation for symptom control or at low risk of harm due to postponing treatments, could potentially be safely delayed. For additional information, see the American Society for Radiation Oncology (ASTRO) COVID-19 resource page.
Can/should potentially immunosuppressive therapy be stopped, delayed, or interrupted?
There is currently no direct evidence to support changing or withholding chemotherapy or immunotherapy in patients with cancer, and routinely withholding critical anti-cancer or immunosuppressive therapy is not recommended. Potential harms resulting from delaying or interrupting treatment versus potential benefits of possibly preventing or delaying COVID-19 infection must be discussed with your oncology and evaluated on a case-by-case basis.
Can/should allogeneic stem cell transplantation be delayed?
For 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.
Should prophylactic antiviral therapy be considered?
There is currently no evidence or published guidance on the use of prophylactic antiviral therapy for COVID-19 in immune suppressed patients.
How can/should diagnosis and staging interventions (e.g. imaging visits, biopsy) be modified by the ongoing COVID-19 pandemic?
CDC recommends that in general, 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).
Can/should patients continue receiving ongoing surveillance (e.g. imaging for detection of recurrence, active surveillance for existing disease)?
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.
How can/should care for patients experiencing potential neutropenic fever be affected by the ongoing COVID-19 pandemic?
According to ASCO, there are two approaches to neutropenic fever among patients with cancer in relation to COVID-19:
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.
We recommend discussing this issue with your provider in advance so you have a plan and know how to proceed in the setting of neutropenic fever.