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Delaying Cancer Treatment (or Not) Due to COVID-19

Will you need to delay cancer treatment due to the coronavirus (COVID-19) pandemic? While the newness and uncertainties of the pandemic leave it unclear as to whether to go in for treatment or not, there are now some general guidelines on when to either defer or proceed with treatments such as surgery, radiation therapy, chemotherapy, and immunotherapy, as well a recommended approaches for several of the more common cancer types.

Weighing Risks and Benefits

No matter your type or stage of cancer, pursuing treatment or follow-up during the COVID-19 pandemic boils down to weighing the risks of exposure (both for patients and healthcare professionals) and the benefits of treatment. While there are general guidelines, each person and each cancer is unique. For this reason, it's helpful to look at both the potential benefits and possible risks for you as an individual when making care decisions.

Benefits of Cancer Treatment

The benefits of treatment depend on many factors, including:

  • The ability to "cure" a cancer if treated promptly
  • Extending life when a cancer cannot be cured
  • Offering relief of symptoms caused by cancer
  • Avoiding complications of an untreated cancer that could lead to an emergency (such as intestinal obstruction)

Risks of COVID-19 Infection From In-Person Care

There are several potential risks that need to be looked at separately:

  • Risk of contracting COVID-19 during cancer visits: Certainly, the risk of contracting COVID-19 is higher when going to a hospital or clinic than staying at home. The risk of hospital-acquired infections (nosocomial infections) was of concern even before the current pandemic, and infections have been found to cause substantial morbidity (illness) and mortality (death) in people who are immunosuppressed. The level of risk depends on many factors, including the incidence of infection in the community where a person is receiving care. A Chinese study found hospital admission and recurrent hospital visits were potential risk factors for infection with SARS-CoV-2 (the viral strain that causes COVID-19). The rate of infection among patients with cancer was 0.79%, compared to a cumulative infection rate of 0.37% in the city of Wuhan.
  • Risk of serious disease if a COVID-19 infection develops: Based on some estimates from China, people who have cancer and COVID-19 have a higher incidence of severe events (need for ICU admission, ventilation, or death) relative to those without cancer. The risk appears higher in patients who have undergone recent surgery or chemotherapy, or have received a stem cell transplant or CAR-T therapy in the past year. In addition, clotting abnormalities are common in patients seriously ill with COVID-19, and blood clots in people with cancer are already very common.
  • Risk to healthcare providers: Healthcare providers are also at risk when performing procedures on people with cancer who may have contracted COVID-19. The risk varies, but appears to be particularly high for physicians who work with people who have head and neck cancers.

General Recommendations on Delaying Treatment

Medical groups have worked out general guidelines on when cancer treatment may be delayed. These are based on weighing the relative risks of acquiring a COVID-19 infection against the risk of the progression of cancer. In addition, the Centers for Disease Control and Prevention (CDC) has provided interim guidance on health care during the pandemic. This includes:

  • Postponing visits that can be postponed without added risk
  • Exploring alternatives to face to face visits, such as telemedicine options
  • Delaying routine follow-up visits
  • Considering alternative treatment options

When in-person care is needed for treatment, researchers have divided the risk of cancer progression without treatment into high-risk, medium-risk, and low-risk categories. It must be stated again that these are only guidelines, and decisions need to be discussed between you and your oncologist.

A Note on Guidelines

Each person and every cancer is unique. Guidelines are suggestions based on the "average" person with the "average" cancer at the time. While helpful in general, decisions on whether to delay treatment or not must be individualized for each person.

High-Risk (Ideally, No Delay in Treatment)

There are situations in which any delay in treatment could lead to cancer progression. Treatment, even it carries the potential risk of greater exposure to the coronavirus, may well be warranted.

Examples where surgery is warranted:

  • Lung nodules or masses (suspicious for lung cancer) larger than 2 centimeters in diameter
  • Colon cancer when there is a high risk of obstruction
  • Pancreatic mass suspicious for cancer (if pancreatic cancer is considered operable, surgery at this stage may be life-saving)
  • Liver mass suspicious for cancer
  • Ovarian mass suspicious for cancer
  • Bladder cancer that threatens to or has invaded muscle
  • Kidney cancer if greater than stage T1b
  • Stage 1B cervical cancer
  • Sarcomas that are not low-grade

Examples where chemotherapy is warranted:

  • Small cell lung cancer
  • Most head and neck cancers
  • Sarcomas that are not low-grade
  • Testicular cancer
  • Rectal cancer
  • Blood-related cancers (eg. leukemia/lymphomas/multiple myeloma) that are not low-grade

Examples where radiation therapy is warranted:

  • Lung cancer
  • Rectal cancer

Medium-Risk (Delay of up to 3 Months May Be Considered)

In some situations, delaying treatment for up to three months may be encouraged.

Examples where surgery may be delayed:

  • Colon cancer when the risk of obstruction due to the tumor is low
  • Low-risk melanoma
  • High-risk prostate cancer (but may begin androgen deprivation therapy)
  • Stage IA2 cervical cancer

Examples where chemotherapy may be delayed:

  • Stage 4/metastatic breast cancer
  • Stage 4/metastatic colon cancer
  • Stage 4/metastatic lung cancer

Examples where radiation therapy may be delayed:

  • Adjuvant radiation for uterine cancer (radiation given after surgery)

Low-Risk (Safe to Delay Treatment for More Than 3 Months)

There are a number of cancers for which delaying treatment for more than three months may be highly recommended at this time. Some of these include:

Examples where surgery can be postponed:

  • Non-melanoma skin cancers (basal cell carcinomas and squamous cell carcinomas)
  • Some postmenopausal breast cancers
  • Prostate cancer that is low or medium-risk
  • Type I uterine cancer
  • Thyroid cancer (most)
  • Bladder cancer that is low-grade
  • Kidney tumors less than 3 centimeters in diameter
  • Cervical cancer that is stage IA1

Examples where chemotherapy can be postponed:

  • Chronic blood-related cancers such as chronic lymphocytic leukemia

Examples where radiation can be postponed:

  • Some breast cancer cases

Recommendations Based on Cancer Type

With some of the more common cancers, resources and guidelines (which are updated often) can be very helpful when considering your treatment decisions. Treatment will depend on the stage and the specific nature of your cancer.

Breast Cancer

How breast cancer is managed during the current pandemic depends on the stage, receptor status, age, and more.

  • Surgery is recommended for people with larger tumors (T2 and higher), positive lymph nodes, HER2 positive tumors, or triple-negative tumors.
  • Surgery may be delayed (but neoadjuvant chemotherapy started) for locally advanced tumors (some stage 3 cancers) or inflammatory breast cancer.
  • Neoadjuvant chemotherapy (chemotherapy right away followed by surgery later) may also be considered with some HER2 and triple-negative tumors.
  • Surgery may be delayed for postmenopausal women who have very early stage (T1), node-negative tumors that are hormone receptor-positive and HER2 negative. Radiation therapy may also be delayed in this situation, but hormone therapy (an aromatase inhibitor or tamoxifen) should be started right away.
  • Breast-conserving surgery (lumpectomy) should be considered over mastectomy when surgery cannot be delayed, due to a lower risk of complications and shorter hospital stay.

Recommendations and guidelines are expected to change frequently during the pandemic. The American College of Surgeons is frequently updating its COVID-19 Guidelines for Triage of Breast Cancer Patients.

Lung Cancer

Lung cancer is most easily treated when discovered in the early stages, and when a tumor is operable, prompt surgery is usually recommended.

In general, surgery for tumors that are known or suspected to be lung cancer and greater than 2 centimeters in diameter should not be delayed.

  • Surgery may be delayed for tumors smaller than 2 centimeters. For large tumors (eg. 5 cm), neoadjuvant chemotherapy (chemotherapy before surgery) may be considered in the meantime.
  • Stereotactic radiotherapy (SBRT) may be considered as an alternative to surgery for people who have early-stage non-small cell lung cancer.

The American College of Surgeons is updating lung cancer treatment recommendations in its COVID-19 Guidelines for Triage of Thoracic Patients.

Colon Cancer

With colon cancer, the decision to delay treatment or not will depend on several issues.

  • Surgery may be delayed for early stage tumors (T1 or T2) that are lymph node negative.
  • Chemotherapy and radiation may be recommended for larger tumors (T3 or T4), followed by surgery at a later date.
  • Surgery will be recommended as soon as possible for tumors that could result in an obstruction or perforation of the bowel (and subsequent emergency surgery)

The American College of Surgeons is updating recommendations for colon cancer treatment in its COVID-19 Guidelines for Triage of Colorectal Cancer Patients.

Gynecologic Cancers

The treatment of gynecologic cancers depends on the stage of the disease.

  • Surgery should be performed as soon as possible for ovarian tumors suspected to be ovarian cancer, or cervical cancer that is stage 1B.
  • Surgery may be delayed for early stage cervical cancer (1A1) or type 1 endometrial cancer (uterine cancer).

The American College of Surgeons is updating information on gynecologic treatment recommendations in its COVID-19 Guidelines for Triage of Gynecology Patients.

Recommendations Based on Type of Treatment

The decision to pause or delay cancer treatment during COVID-19 depends not only on the type and stage of your cancer, but on the recommended treatment itself.

Surgery

Factors that are considered:

  • Emergencies: Emergency surgery should not be delayed.
  • Aggressiveness of the tumor: With some cancers that are aggressive (have a rapid doubling time), a delay in surgery might allow a tumor to grow so that it is no longer operable (or potentially curable). In contrast, a tumor that is less aggressive would be expected to grow much slower such, and delaying surgery may result in less risk.
  • The risk of complications if surgery is delayed: Some colon cancers, for example, may lead to an obstruction if not removed.
  • Complexity of the surgery: Some surgeries, such as those for pancreatic cancer, esophageal cancer, and liver cancer, are associated with a high risk of complications and often a complicated recovery in the intensive care unit. It's thought that a delay in these very complex procedures may be wise, especially if the incidence of COVID-19 is high and resources are limited.
  • Patient location: Some procedures are only done (or if done, may have better outcomes) at larger cancer centers. This might add the risk of traveling to other risks associated with in-person care.

Radiation Therapy

Whether or not radiation therapy can be delayed also depends on several factors. In addition, there may be different options that could result in fewer visits and, consequently, lower exposure risk.

  • Radiation used with "curative" intent, perhaps in place of surgery, should not be delayed.
  • Stereotactic body radiotherapy (SBRT) involves the use of a high dose of radiation to a small area of tissue (or sometimes several, such as small brain metastases), often in one visit. This likely does not need to be delayed.

When radiation should not be delayed, a hypofractionated schedule (higher doses of radiation with fewer visits) may sometimes be considered.

Chemotherapy

For the roughly 650,000 people with cancer who receive chemotherapy each year, the potential side effects, especially the risk of infection due to bone marrow suppression, has been of significant concern.

It's too soon to know exactly how chemotherapy affects people who develop COVID-19 (other than the small studies that show an increased risk in people who have had recent chemo). So far, there isn't any solid evidence that specific chemotherapy drugs should be avoided. Interestingly, cytotoxic chemotherapy was found to reduce the risk of severe adult acute respiratory syndrome in the lab (in vitro studies). There are not, however, any studies that define how this may affect people who develop COVID-19 while on chemotherapy.

There may be options to pause or change the planned course of chemotherapy for some people. For example:

  • Patients in deep remission on maintenance chemotherapy may pause that maintenance treatment
  • A two-week break may not affect outcomes in some chemotherapy regimens
  • Oral forms of chemotherapy may be used as an alternative to an intravenous infusion
  • Home infusions may be given in some situations
  • A person may be able to switch their treatment center if the incidence of COVID-19 is very high at their usual location
  • Medications to increase white blood cell counts (such as Neulasta or Neupogen) may be considered if they are not already being used. Preventive antibiotics may also be considered.

Immunotherapy (Checkpoint Inhibitors)

It's unknown at this time how the use of checkpoint inhibitors (such as Keytruda, Opdivo, and Tecentriq) may affect people who develop COVID-19. Since these medications can sometimes cause dramatic improvement with some advanced cancers, most oncologists are recommending that the drugs be started or continued. That said, in some cases, they may be given less frequently.

A primary concern has been the potential side effects of checkpoint inhibitors that can include inflammation of the lungs (pneumonitis). This could make it difficult to distinguish an adverse reaction from the symptoms of COVID-19.

Another type of immunotherapy, CAR-T cell therapy, has also led to significant improvement for some people with cancer, but is associated with significant immunosuppression. This means it will likely not be recommended during this pandemic.

Clinical Trials

Many clinical trials have either ended or stopped accepting patients in light of COVID-19. But there are several recommendations for people who are in these trials to make it easier to continue:

  • Making arrangements with a local healthcare provider (to avoid travel) who can then perform exams or arrange scans or blood tests
  • Shipping medications to patients rather than having them dispensed on-site at the center performing the clinical trial
  • Reducing the frequency of labs and scans

If you are in a clinical trial, it may be helpful to talk to the study investigator to determine what they recommend if you should develop COVID-19 and require hospitalization. With many of the smaller trials, your medication may not be on the pharmacy formulary where you are hospitalized, and most will not allow you to bring your own medication. With some of these medications, missing doses may result in loss of control of cancer growth, and when restarted, are not as effective.

Non-Treatment Visits

In-person visits for following up or monitoring treatment may be delayed or modified to reduce the risk of COVID-19 exposure. For example, blood draws, scans, and bronchoscopy procedures may be pushed back. A delay in follow-up care and tests to screen for recurrence is currently recommended for anyone who doesn't show cancer symptoms.

For those who have a chemotherapy port, the American Society of Clinical Oncology states that a period of up to 12 weeks may pass between flushings.

If Delayed, When Will Treatment Begin or Resume?

A major question that cannot currently be answered is how long it will be until exposure in clinics and hospitals will be less of a concern. Many people coping with cancer fear that delays will be lengthy and that exposure will be a significant risk until there is either a vaccine or evidence of herd immunity.

It's critical to continue communicating with your doctor about what may be best for you as an individual with your specific cancer. Lack of communication can further increase the anxiety of living with cancer during a pandemic. Fortunately, many oncologists and other providers who care for people with cancer are recognizing this need, and some have tried to actually increase contact (by phone or online).

A Word From Verywell

Coping with the current COVID-19 pandemic in addition to cancer may feel like a double whammy of stress. That said, some of the restrictions that the general public is only now adapting to (social distancing, wearing a mask, avoiding people who have infections) may be old hat to you. It's common for cancer survivors to comment on social media that people finally understand how they've been living for a long time.

If you do need to pursue treatment right away, it can be frightening to think about potential exposure. Some people have found that focusing on treatment being a "break" from staying at home helps to some degree. If you will be delaying treatment, make sure to discuss the risks and benefits carefully with your doctor so that you are comfortable with the choice.

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