Especially vulnerable elderly cancer patients

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March 12, 2020: For oncologists and other doctors caring for cancer patients, the COVID-19 pandemic represents a dynamic clinical challenge that changes on a daily basis and can sometimes be overwhelming, experts say.
"Oncology physicians are well versed in caring for immunosuppressed cancer patients of all ages," Merry-Jennifer Markham, MD, acting chief of the Division of Hematology and Oncology at the University of California, told Medscape Medical News Florida in Gainesville.
However, he emphasized that during this COVID-19 outbreak, "we must be especially diligent in detecting symptoms and exposure, and we must recognize that our older cancer patients may be especially vulnerable."
Markham noted that cancer patients who are on active treatment are immunosuppressed and are more susceptible to infection and complications of infection. "While we don't yet have much data on how COVID-19 impacts cancer patients, I have to suspect that patients undergoing active cancer treatment may be especially vulnerable to the more serious disease associated with COVID-19. ", said.
In fact, a recent report from China published in Lancet Oncology supports it. The authors suggest that cancer patients have a higher risk of COVID-19 and have a worse prognosis if infected than those without cancer.
Common sense rules
The common sense rules apply to all cancer patients, regardless of age, Markham said. Measures include thorough hand washing, staying home when sick, and avoiding sick contacts.
Markham, who serves as an expert spokesperson for the American Society for Clinical Oncology, provides information on what cancer patients need to know about COVID-19 on Cancer.net, the society's website for cancer patients.
"Unfortunately, this COVID-19 outbreak is happening quickly and in real time," said Markham. "The entire medical community is learning as we go, rather than having the luxury of years of evidence-based literature to guide us."
Another expert agrees. "Unfortunately, there isn't much data on how COVID-19 affects cancer patients," Cardinale Smith, MD, PhD, director of Quality for Cancer Services at Mount Sinai Health System, New York City, said in an interview. .

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"We need to minimize the risk to patients and minimize our own exposure by treating this situation as if it were a really bad flu season," Smith told Medscape Medical News. "Some patients have had a bad result, but the vast majority have not. The best we can do is stay calm and focus."
At Mount Sinai, for cancer patients, routine non-urgent appointments are rescheduled for May, Smith said. Those on active treatment are screened by phone 24 to 48 hours before arrival, after which they undergo a full risk assessment in an isolation room. People with respiratory infection receive a mask.
"The patients are very anxious and concerned about COVID-19," said Smith, who has young children and an elderly father at home. "We don't have all the answers, and this can increase anxiety."
To help calm fears, social workers asking cancer patients who express anxiety to discuss their concerns and provide information. A one-page booklet on the flu and COVID-10 is available in the waiting room.
The MyChart web portal gives patients access to up-to-date information on COVID-19 precautions and provides links to the hospital's website and the US Centers for Disease Control and Prevention. USA Patients who are not feeling well can talk to someone or get answers if they have additional questions.
In advising patients, Smith advises them to use "great caution" and be creative in efforts to minimize risk. "My suggestion is to use FaceTime and Skype to connect and communicate with your community," he said.
Some churches are conducting services via teleconferences to minimize risk, and senior centers offering yoga and other classes are also beginning to provide services virtually, he said.
China Facts
A report published Feb. 14 in Lancet Oncology appears to be the first analysis in the literature to focus on COVID-19 in cancer patients.
"Cancer patients are more susceptible to infection than people without cancer because of their systemic immunosuppressive status caused by malignancy and cancer treatments such as chemotherapy or surgery," write the authors, led by Wenhua Liang. , MD, from Guangzhou Medical University. However, in correspondence published in Lancet Oncology, other experts in China question some of Liang and colleagues' findings.

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Liang and colleagues' report refers to a prospective cohort of 1,590 patients with COVID-19.
There were laboratory-confirmed cases of COVID-19 in 2007 among patients admitted to 575 hospitals across China as of January 31. Of these cases, 417 were excluded from the analysis due to insufficient information on the history of the disease.
The team reports that of 18 cancer and COVID-19 patients, 39% had a significantly increased risk of "serious events." In comparison, of 1572 COVID-19 patients who did not have cancer, 8% had a significantly higher risk (P = 0.0003). These events included rapid clinical deterioration requiring admission to intensive care; invasive ventilation; Or death
Cancer patients experienced a much faster deterioration in clinical status than those without cancer. The median time to serious events was 13 days, compared to 43 days (age adjusted hazard ratio (HR), 3.56; P <.0001).
The analysis also shows that patients who underwent chemotherapy or surgery in the past month had a 75% risk of experiencing clinically severe events, compared to a 43% risk for those who had not received recent treatment.
After adjusting for other risk factors, including age and smoking history, advanced age was the only risk factor for serious events (odds ratio (OR), 1.43; 95% confidence interval (CI) , 0.97 – 2.12; p = 0.072), say the study authors.
Lung cancer patients did not have a higher probability of serious events compared to patients with other cancers (20% vs. 62%, respectively; P = .294).
Liang and colleagues conclude that these findings provide "a timely reminder to physicians that more attention should be paid to cancer patients in the event of rapid deterioration."
The team also proposes three strategies for managing cancer patients who are at risk for COVID-19 or any other serious infectious disease. They recommend that the intentional postponement of adjuvant chemotherapy or elective surgery be considered for patients with stable cancer living in areas where the disease is endemic. Stricter "personal protection provisions" may also be in place for cancer patients or cancer survivors. Finally, for cancer patients who have COVID-19, especially those who are older or who have comorbidities, more intensive surveillance or treatment should be considered.

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However, in the Lancet Oncology comments, other authors in China say these findings should be interpreted with caution.
One group suggests that increased susceptibility to COVID-19 in cancer patients could be the result of higher rates of smoking compared to patients without cancer. "Overall, the current evidence remains insufficient to explain a conclusive association between cancer and COVID-19," says Huahao Shen, PhD, of the Zhejiang University School of Medicine, Hangzhou, Zhejiang, and colleagues.
Another group suggests that the significantly higher mean age of cancer patients compared to noncancerous patients (63 years versus 49 years) may have contributed to a poor prognosis.
These authors, led by Li Zhang, MD, PhD, and Hanping Wang, MD, of Peking Union Medical College and the Chinese Academy of Medical Sciences, Beijing, emphasize that cancer patients need online medical advice and that critical cases should be identified and treated
"In endemic areas outside of Wuhan, decisions on whether or not to postpone cancer treatment must be made on a patient-by-patient basis and according to patient risk and prevailing status because delays could lead to tumor progression and, ultimately, to poorer results, "they write.

The study was funded by the China National Science Foundation and the Key Project of the Guangzhou Scientific Research Project. Liang and his co-authors, Shen and his co-authors, Zhang, Wang, and Smith have disclosed no relevant financial relationships. Markham has relationships with Aduro Biotech, Lilly, Tesaro, Novartis, and VBL Therapeutics.

Lancet Oncol. Published online February 14, 2020.

Lancet Oncol. Published online March 3, 2020. Shen et al, comment; Zhang et al.

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