Treating cancer in the shadow of coronavirus

Treatments are being switched around; surgeries postponed. Oncologists are meeting new patients via Zoom or swathed in impersonal protective gear. Both the newly diagnosed and those with metastatic disease worry that going in for lifesaving treatments may just be the death of them. And researchers mourn as clinical trials are put on hold.

Such is cancer treatment in the time of this coronavirus pandemic.

It takes a lot to overshadow the second leading cause of death globally, but a dearth of data, shortage of tests and equipment, lack of any proven treatment or vaccine, and the speed at which the SARS-CoV-2 virus has spread have turned COVID-19 into a much bigger bogeyman than our “old friends” carcinoma, sarcoma, melanoma, lymphoma and leukemia. At least for the time being.

“I don’t want to go to chemo and radiation,” said Amy Sapien of Tampa, Florida, who discovered her breast cancer in February. “I don’t want to have to report to a medical facility. I have asthma and my son’s in treatment for a rare leukemia. I’m more scared of COVID than cancer. At least, we have statistics on cancer.”

Cancer is the devil we know. This new threat? The data is still limited. But it’s growing rapidly, thanks to lightning-fast analysis, open science and the heroic efforts of clinicians and scientists in China, Italy, South Korea and beyond.

Researchers worldwide are working furiously to crack this novel coronavirus, including many at Fred Hutchinson Cancer Research Center in Seattle, ground zero for the U.S. outbreak. From Dr. Trevor Bedford’s genetic maps and models to Dr. Keith Jerome’s serology work to the launch of two new national COVID19-cancer registries, the Hutch and its partners are leading the scientific charge in both research and clinical response to our new dark normal. 

When coronavirus trumps cancer

“It’s very important to protect our staff and our immunosuppressed patients,” said Fred Hutch's Dr. Gary Lyman, a lead investigator on the COVID19-cancer registry study. “If cancer patients get infected, they’re more at risk for life-threatening complications. We want to avoid COVID-19 infection if at all possible.”

Lyman said oncologists across the country are reinventing cancer care for the COVID-19 era, rescheduling noncritical procedures, surgeries and visits; using telemedicine where possible; opting for oral medications over infusions if doable and rewriting policy on the fly to help keep high-risk cancer patients out of the ER and harm’s way.

“These are desperate times which require desperate measures,” he said.

Sapien, diagnosed at 40, had her scheduled single mastectomy this week. But her reconstruction was postponed and her request for the prophylactic removal of her other breast — a common practice — was deemed “elective” and denied.

“Doing a double [mastectomy] increases your operating room reservation, knocking somebody out of a spot,” she said. “They’re trying to use the OR for critical cases. Normally, I would have the choice, but this isn’t a normal time. And I get that.”

Dr. Julie Gralow, who serves as clinical director of the Breast Medical Oncology program at Seattle Cancer Care Alliance and does research for both Fred Hutch and the University of Washington, said she and colleagues are discussing surgery delays and treatment swaps with patients and rescheduling prevention screenings like mammograms, bone-density tests and colonoscopies.

“We are totally triaging,” she said.

Those with fast-growing breast cancers — think triple negative and HER2 positive — receive the exact same standard of care: preoperative chemotherapy. But those who have slower-growing cancers such as ER positive and HER2 negative will mostly likely be put on endocrine (anti-hormone) therapy first instead of having surgery.

“I’m still starting chemo if it’s warranted, but we’re doing the minimum amount of surgery and no reconstruction, not even putting in tissue expanders,” she said. “The more surgery, the higher the likelihood of complication or infection. Our priority at this time is to keep patients out of surgery and out of the hospital. We need to protect the OR space and the ventilators and the potential ICU beds, and we need to preserve resources like masks and gowns and gloves.”

Is it safe to delay treatment or surgery?

Many patients can safely have their therapies delayed or switched around to avoid clinic visits and exposures, Gralow said, adding that there’s "good trial data” on using endocrine therapy preoperatively in postmenopausal women with breast cancer, the most common cancer in women in the U.S.

“In the vast majority of people, preoperative endocrine therapy stabilizes or shrinks the cancer,” she said. “We’ll aim to give it for three to six months to delay the surgery.”

Other breast cancer patients may safely have the order of treatments swapped, as “no trial has ever shown that the order of chemo and surgery impacts survival,” Gralow said.

Those with metastatic cancer, in treatment for life, might also be able to take a “drug holiday,” she said.

“The masks make it hard to bond,” Goulart said. “We’re trying to convey compassion to people at a very difficult time — when they’re first diagnosed or transferring to hospice. Human touch brings that extra element of comfort but we can’t provide that now.”

Nationally, patient advocates and those with stage 4 disease are questioning hospital policies that indicate they’ll be triaged in the worst way — denied a ventilator — should supplies run short. Seattle-area patient advocate Janet Freeman Daily blogged about the health have-nots who’d be left to die and the “horrible ‘Sophie’s Choice’” health-care providers were now being forced to make.

Others were more pragmatic.

“If you get sick and go to the emergency room and you have metastatic cancer,” one doctor advised via social media, “don’t say your cancer is terminal.”