The dilemmas facing cancer doctors and patients in the coronavirus pandemic

“Oncologists are in a very particular predicament right now,” says Dr. Siddhartha Mukherjee.

Silver Leo has been trying to keep her young children, ages 3 and 9, entertained at home since March 13, when their public schools in Alexandria, Virginia, announced closures. Child care is a challenge for a lot of parents these days, but particularly for Leo. She has metastatic breast cancer, and the lingering effects of her weekly chemotherapy infusions make it difficult to stay high-energy — and risky to leave the house.

“Some of their friends are still having playdates, and doing this sort of ‘small group social isolation’ thing” says Leo, 40. “I have to explain to them that their mom has cancer, so they can’t have any playdates at all.”

Leo cannot even risk allowing anyone in her immediate family, including her husband, to go to the grocery store right now.

Courtesy of Silver Leo

Courtesy of Silver Leo

There’s a troubling amount we still don’t know about the novel coronavirus and the disease it causes, Covid-19. One thing we can say for certain is that the disease poses a far greater health risk to those with compromised immune systems, including cancer patients in treatment. For them, Covid-19 can be much more severe and more likely to be fatal. This isn’t up for debate; it’s a resounding warning, and one that the Centers for Disease Control and Prevention highlights as a case for widespread social distancing.

There are limited data on Covid-19 outcomes among the immunocompromised, but according to a special March 17 preprint report from the National Comprehensive Cancer Network, early reports out of China show that patients with cancer infected with Covid-19 have a 3.5 times higher chance of mechanical ventilation, ICU admission, or death compared with patients without cancer.

It’s a major concern, given there are about 650,000 patients with cancer who receive chemotherapy in the United States each year.

Cancer doctors face a “particular predicament”

Given that the virus is spreading in the US, the question about whether to continue immune system-suppressing cancer treatments during the Covid-19 pandemic appears to have no clear cut answers.

“Oncologists are in a very particular predicament right now,” says Dr. Siddhartha Mukherjee, a hematologist and oncologist at Columbia University Medical Center and Pulitzer Prize-winning author of The Emperor of All Maladies. “Because on the one hand, you don’t want to delay treatment, but you also don’t want to expose patients to risk.”

“I’m very worried about my patients,” says Narjust Duma, an oncologist at University of Wisconsin Carbone Cancer Center who treats patients with advanced lung cancer. “Even with regular influenza, my patients could get very sick. But these treatments are keeping them alive.”

Chemotherapy does to cells what the coronavirus pandemic is doing to the population: It goes after everyone.

Although chemo drugs vary in terms of their effects on immune function, the risks of the treatment damaging healthy white blood cells — the body’s best defense against viruses — can become life-threatening.

Oncologists like Duma are acutely aware of the risks of their immunocompromised patients contracting Covid-19. But they’re also aware that stopping or canceling chemo, for many patients, could present more certain dangers.

Flattening the curve — and managing cancer care

Under normal circumstances, oncologists usually give patients undergoing chemo a list of recommendations that echo the advice we’ve all been hearing for weeks: wash your hands as often as possible, stay away from crowds, dine at home, don’t touch your face, don’t shake hands.

But these are not normal circumstances. Oncologists and patients are seeking further guidance, and that guidance isn’t one-size-fits-all.

“Patients have no choice but to take the Covid pandemic into account in their treatment decisions,” says Dr. Noel Brewer, a researcher in health behavior at the University of North Carolina Gillings School of Global Public Health. “It is no longer optional.”

The American Society of Clinical Oncology (ASCO) has put out a series of FAQs for the more-than 45,000 oncologists who defer to them for practice guidelines. But the organization has written that, “At this time, no specific recommendations can be made … for delay in therapy or choosing alternate therapy in the context of Covid-19 infection.”

Accordingly, oncologists, nurses, care teams, and hospital administrators have been working to address each patient individually.

Individual treatment decisions should consider factors such as the stage of the cancer, the specific type of chemotherapy they’re receiving, and the risk of cancer recurrence if treatment should be delayed, ASCO says. There is currently no evidence to suggest a benefit to delaying chemo in light of Covid-19 risks, the group says, although there may be cases in which adjuvant chemotherapy, meaning chemotherapy that’s given in combination with another type of treatment, such as surgery or radiation, may be appropriate to delay.

Marc Lippman, a researcher and breast cancer oncologist at Georgetown University Medical Center, argues that, at least in the context of breast cancer, treatment delays aren’t appropriate. “Delaying chemotherapy out of a fear of coronavirus is a total misunderstanding of risks and gains,” he says. “We know from a lot of studies that if you delay the administration of chemo, it’s less effective. Chemotherapy should not be delayed. Far more women will be harmed than possibly disadvantaged by the risk of the virus in my view.”

Having practiced oncology for decades, Lippman’s assessment stems from his view that the drugs typically used to treat breast cancer in the adjuvant setting aren’t known to be as immunosuppressive as, say, some of the regimens used to treat leukemia or lymphoma.

“But, obviously, it’s still their choice,” Lippman says of his patients.

As of this past weekend, one of Lippman’s patients, a 36-year-old woman with breast cancer who requested her name not be used to protect her privacy, had made her own decision to skip her chemotherapy infusion on Wednesday.

“I thought of all the different places I would have to touch getting from my house to the clinic,” she says. “The doors, the elevators …”

“We know what would happen if we delayed”

As Covid-19 continues to spread, hospitals are taking drastic measures to care for those who have already been infected with the virus and to protect, at great costs, those who have not. For many hospitals and clinics, including Columbia’s Irving Cancer Center where Mukherjee treats patients, this has meant canceling elective surgeries, postponing routine visits, and requesting that non-urgent patients consider telehealth for their appointments.

For many patients with advanced cancer, though, hospital visits are far from elective and most certainly not “non-urgent.”

Postponing elective surgeries and follow-up appointments should be fairly straightforward decisions, according to the National Comprehensive Cancer Network special report, which lays out guidance for hospital staff to prepare for the coming weeks and months. The more difficult decisions, it reads, are “clinical decisions regarding delay of treatment for patients who are currently undergoing chemotherapy or about to begin.”

“We have a commitment to treat patients as per their normal protocols and not delay any treatments that are required,” Mukherjee says. “This is a time for patients to work closely with their oncologists and then figure out how to appropriately manage their care.”

On March 13 — the day when President Trump officially declared the Covid-19 pandemic a national emergency — Duma met with a patient who had just been diagnosed with advanced small-cell lung cancer, the most aggressive type of lung cancer. “We need to get going on his treatment right away,” Duma says. The patient was already coughing up blood and would continue to do so unless he was treated. “We know what would happen if we delayed.”

What months of social distancing could mean for cancer patients

The biggest deterrent, perhaps, to postponing chemo due to Covid-19 risks is that we just don’t know how long this pandemic, and the response to it, could last. Many patients are okay skipping one or two chemo doses, but if a patient were to delay their chemo treatment right now, it might not be any safer to resume the treatment should they reschedule it for the coming weeks or months.

“This is a dynamic situation,” Mukherjee says. “It might change. But right now, at least in my practice, we haven’t had to make those sort of, you know, terrible bargains thus far.”

For Jamie Hecker, a 54-year-old man with a bone marrow cancer called myelofibrosis, the potentially months-long duration of the pandemic poses a far more serious set of concerns than does skipping a dose or two of his chemo.

Right now, Hecker’s chemo is working well. For about a year, he’s been receiving four injections of the drug Vidaza (azacitidine) in his abdomen for seven days in a row once a month. But if the chemo stops working — which is common after a year or two on the drug, according to Hecker’s oncologist — Hecker would have to turn to his only other available treatment option, a bone marrow transplant.

The transplant would temporarily wipe out Hecker’s immune system, making it one of the riskiest treatments a patient could receive during a global pandemic. This is why, given the risks of Covid-19, ASCO, and the American Society for Transplantation and Cellular Therapy list these transplants as unique cases for which deferrals may, in some cases, be appropriate.

The question of the pandemic’s duration has been especially difficult for Leo in Alexandria, who has already been told she has just three to five years to live. Every treatment and chemo infusion is factored into that life expectancy.

Courtesy of Silver Leo

“With terminal cancer, there’s this sense of time,” she says. “Vacations matter. Being with family and friends matters. Now vacations are all postponed, my elderly parents can’t fly, and I can no longer see my friends because they decided to expose themselves by going to brunch … when you’re not sure how much time you have left, isolation means something different.”

For now, Leo is still going in for her chemotherapy infusions, because, as she says, “cancer doesn’t care about coronavirus.” The malignant cells will continue to spread, social distancing or no social distancing.

What if patients on chemo test positive for Covid-19?

When asked how he would proceed if one of his patients receiving chemotherapy were to test positive for Covid-19, Mukherjee said, “What we would do would be to follow the guidelines for giving chemotherapy in the context of an infection — any infection, Covid or otherwise — which is to wait until the infection is resolved to resume chemotherapy.”

Of course, following these protocols would require more Covid-19 testing kits, which are not currently available in every clinical setting. If there were not a test-kit shortage, doctors would be able to test every patient prior to beginning chemotherapy, symptoms or no symptoms, to determine if they have the virus before compromising their immune systems with chemotherapy. This could be worth considering because the virus has been shown to have roughly a five-day incubation period, meaning symptoms could be delayed.

“Many of our patients who are immunocompromised might show up with tests that are positive, but have no clinical manifestations of disease,” Mukherjee says. “And there are no guidelines for this. This is where we are practicing the art of medicine.”

As more information on this virus becomes available, the hope is that these decisions will become less of an art and more of a science again.

But for now, patients with cancer are living in a state of uncertainty — a state that, for many of them, is already familiar.

Courtesy of Silver Leo

While her treatment has left her less equipped to fight off Covid-19 should she get it, Leo believes the whole cancer experience, somehow, has left her better prepared to handle the pandemic mentally.

“I believe something good will come out of this,” she says. “And believing something good will come out of it is a muscle … it’s something you train yourself into.”

Leo has been training that muscle ever since her terminal diagnosis.

“That ‘something good,’ I hope, is that we will come together as a society. That once after everyone is done with brunch and grandma dies, maybe we can become more aware of what life is about … that it’s not always about distraction and entertainment, but real connection.”

Caroline Hopkins is a Brooklyn-based health and science reporter. She has written for National Geographic, the American Society of Clinical Oncology (ASCO) Daily News, SurvivorNet, and Women’s Health Magazine. She has a master’s degree in journalism from Columbia University.