1. Eastman, Peggy

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The new coronavirus COVID-19 pandemic is disrupting life for cancer patients and survivors and causing them fear about exposure to the virus and heightened anxiety about interruptions to their cancer care. At a time of extreme pressure on hospitals and emergency services, they are also concerned about being denied treatment if they become infected with the virus.

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To address these concerns, the National Coalition for Cancer Survivorship (NCCS) held a webinar with Otis W. Brawley, MD, MACP, FASCO, FACE, Bloomberg Distinguished Professor of Oncology and Epidemiology at the Bloomberg School of Public Health at Johns Hopkins University. The wide-ranging webinar was conducted by NCCS CEO Shelley Fuld Nasso, MPP, and included detailed questions and answers.


Brawley is the former Chief Medical and Scientific Officer of the American Cancer Society. At Hopkins, he heads a broad research effort on cancer health disparities at the School of Medicine, the Bloomberg School of Public Health, and the Sidney Kimmel Comprehensive Cancer Center. He is a member of the National Cancer Institute Board of Scientific Advisors and the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine.


In his introductory remarks, Brawley noted that since COVID-19 is new and screening has not been robust, much remains to be discovered about its effects on those who are infected. "I can only say that 20 percent of people who get symptomatic end up going to the hospital and less than half of them end up in near respiratory arrest, or respiratory arrest requiring a ventilator."


"This is a really difficult time," he emphasized. "My recommendation to anyone who has cancer or anyone who lives with someone who has it is to stay indoors, stay away from other people, do all the things we have been talking about: handwashing, avoid people by six feet if you have to go out."


Right now, he noted many hospitals are not doing adjuvant chemotherapy for breast, colon, and lung cancer because of the need to weigh two key factors against each other. These are the odds that a patient will relapse in the future without the adjuvant chemotherapy versus the odds that the cancer patient is going to contract COVID-19 and have a bad outcome in the present day.


"Keep in mind, if we lower their white count and they get the coronavirus, that is a ticket to not doing well with the disease," said Brawley. "So many hospitals and clinics are only giving chemotherapy to people who truly need chemotherapy right now."


"I am personally very concerned about people who got adjuvant chemotherapy for breast cancer or colon cancer a year or two ago and have finished that," he added. "We know that their immune systems are still damaged, if not totally recovered, from that adjuvant chemotherapy, so I worry about them, but I have no data on them; I don't think anybody has data."


He recommended that cancer patients have an honest conversation with their physicians about the necessity of getting adjuvant chemotherapy right now.


"There are some patients where adjuvant chemotherapy is gong to reduce the risk of relapse by maybe 10 percent, and maybe that patient's risk of getting COVID-19 is high and the risk of not doing well is high, so a 10 percent risk reduction is not worth it," he said.


But on the other hand there are patients for whom adjuvant chemotherapy may reduce the risk of relapse by 40-50 percent. "There are certain patients who should get the adjuvant chemotherapy right now, and we are giving them that adjuvant chemotherapy, but there is a bunch of patients who can forego it," noted Brawley.


There is some evidence that people who have hematologic diseases-leukemias and lymphomas-are at higher risk from COVID-19 than people who have solid tumor diseases, said Brawley. He added that some data from China show that patients with gastrointestinal and lung cancers and patients with metastatic tumors are at both higher risk of contracting COVID-19 and higher risk of not doing well with the virus, compared to the normal population.


Brawley noted many patients with metastatic cancer are still receiving their treatments "because the feeling is that if we let the disease grow during this period of time, it would be inappropriate." Now that it looks as if the coronavirus shutdown is going to last for a longer period of time, Brawley said most oncologists are choosing to give chemotherapy to patients with metastatic disease unless it is quiescent, which he said happens sometimes with breast cancer.


Asked about whether in-home infusions are an option for some cancer patients, Brawley cited safety concerns. Certain drugs can be administered at home by a visiting nurse or a professional skilled at infusions, he noted; however, "certain drugs I think ought not to be administered at home."


For example, he cited the taxanes, paclitaxel and docetaxel; some 3-5 percent of patients have allergic reactions to them, so they need to be in a medical environment-a hospital or physician's office. "Also, many of these cancer drugs are themselves carcinogens," so there are concerns about people in the house and their exposure to leftover drugs.


Brawley was asked about how cancer survivors who have completed treatment should think about regularly scheduled scans, testing and follow-up appointments, and what role telehealth plays for them. He said that people who do not have aggressive tumors such as fast-growing lymphomas and breast cancers, should talk with their physicians about a prudent course of action. The doctor "is probably going to say they could delay the every-3-month or every-4-month CT scan looking for relapse right now," said Brawley. "The risk of patients being out and about while going to the doctor and the doctor's office is such that those scans for surveillance can in most cases be put off. You can miss one; we'll catch up in July or August when things are a little bit better."


Patients who have fast-growing cancers like Burkitt's lymphoma that went into complete remission in the last few months who are getting every-3-month scans need to talk to their physicians, said Brawley. "For them, I think it is worth the risk and they ought to be getting those CT scans still. But it's going to depend on the disease. Most people can skip going to the doctor." At Hopkins, Brawley noted that most of the outpatient follow-up "is being done by video conferencing right now, and that is working out well."


Asked whether cancer patients should wear N95 masks for protection from COVID-19, as hospital and emergency services personnel do, Brawley answered that his personal opinion (not an official public health recommendation) is that it is a good idea, but only if the mask is worn correctly.


"I like the idea of cancer patients wearing N95 masks, but on the other hand I'm worried they're not going to have them fitted correctly," he said. In that case, patients might fiddle with the mask, thus bringing their hands up to their faces-which could put them at greater risk of becoming infected than if they did not have a mask.


Metastatic cancer patients and those considered terminal are concerned about whether they would be denied needed treatment such as ventilators if they become infected with COVID-19, and asked whether they should withhold information about their health status for fear of being denied treatment.


"I am not aware that rationing of ventilators is happening in the United States at this time," said Brawley. "I really do encourage people to be very honest with their health care providers about their past medical issues. Some elements of their past medical history are going to be incredibly important." For example, he noted some drugs should not be used in patients with metastatic cancer, even if it is in remission, so patients need to be open and honest about their health.


As for patients with terminal cancer, some of whom can live with stage IV cancer for years, Brawley was similarly encouraging when it comes to treatment for COVID-19, should it be necessary.


"Terminal cancer, in the mind of an emergency room doctor, I believe, is someone who has cancer and is going to die of that disease over the next 6-8 weeks or sooner," said Brawley. This, he said, is distinctly different from stage IV cancer. He cited a patient of his who has lived with metastatic cancer (breast to brain) for more than 18 years.


Asked about health disparities in COVID-19, which is causing a higher death rate in African Americans, Brawley said, "I think Dr. [Anthony] Fauci was incredibly appropriate in talking about those disparities. I think the only thing we can do right now is to try to make sure that every human being, no matter what their race or ethnicity or credit score is, has adequate care-for all things." (Anthony Fauci, MD, is the longtime Director of the National Institute of Allergy and Infectious Diseases, a member of the President's coronavirus task force, and a globally recognized expert on infections diseases.)


Brawley noted that for cancer patients one of the bad spillover effects of the COVID-19 pandemic is its chilling effect on cancer clinical trials.


"Almost all the cooperative groups have shut down accrual to most of their trials," he said. "At the major universities, the laboratories have all been shut down. We're all on ice-that's going to set us back at least 3-4 months after the [post COVID-19] reopening." And the setback could even be as long as 6 months, he predicted. "This is a huge problem for all cancer, there's just no way of getting around it. We do need to be in a position where we can start it up as quickly as possible afterwards."


COVID-19 has raised many questions which need research answers. These include studying cancer and non-cancer patients who contract the virus and recover over time to see if there are any late effects. For example, Brawley noted that people who contracted the Spanish flu during the 1917-1919 pandemic were at higher risk of Parkinson's disease.


Finally, Brawley was asked if there is any positive silver lining in the COVID-19 pandemic. "The medical community has come together and been united in a way that I haven't seen," he responded. "I think we've got a much greater respect for nurses and the laboratory personnel, even those who clean the floors in the hospital. I think the human aspect has come out of a lot of us, so that's perhaps the one big positive."


He added that "we all need to try to be supportive of each other and try to prevent the spread of this disease until we can come up with some type of a vaccine, which would be useful in preventing people from getting sick from it."


Peggy Eastman is a contributing writer.