What To Do When A Cancer Patient Tests Positive For COVID-19?

When 45 year old Roopa (name changed) was diagnosed with breast cancer a few weeks ago, she was found to be a good candidate for upfront surgery and a lumpectomy was performed. About 15 days after surgery, she complained of body ache and approached our hospital to ask if this was a side-effect of her surgery. Upon further investigation, she was also found to be suffering from a loss of taste and smell and was immediately referred for a COVID-19 test. Her COVID-19 test result was positive, and put a halt to any further cancer treatment.

Just as we have come up with a better understanding about challenges and possibilities of day to day life during the pandemic, the treatment of cancer has also had to adapt to navigate through the current challenges.

Typically after surgery, chemotherapy and/or radiation is planned to reduce the risk of relapse. Anti-cancer treatments like chemotherapy, targeted therapy and immunotherapy have an adverse effect on the immunity status of a cancer patient making them prone to the infection and also worse outcomes if they have COVID-19. In fact, from the beginning of this pandemic there have been many studies that have come out to highlight this fact.

In general, we would postpone cancer treatment until a patient has fully recovered from COVID-19, a similar approach that we follow for other forms of infections such as the flu.

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Some adaptations that medical oncologists have had to make to deal with patients who have both cancer and COVID-19 are as follows:

Ensure continuity of consultation and treatment via teleconsultation

In cases of mild COVID-19 symptoms where the patient is not admitted to a hospital, teleconsultation is helpful to understand how the patient is recovering and when further cancer treatment can be planned. Patients with symptoms not requiring hospitalization are asked to continuously monitor their health. They are asked to check their oxygen saturation routinely. We also suggest a full blood workup and chest CT scans before any cancer treatment can be initiated, to ensure that they are medically fit to withstand cancer treatment.

Timely cancer treatment is the key to success. Patients and their families must understand that cancer treatment cannot be delayed beyond a reasonable period. They should not let fear and rumours guide their decisions otherwise the disease can do more harm by progressing in absence of treatment. Patients shouldn't fear that treatment will mean multiple visits to the hospital. Even once treatment has begun, teleconsultation can help enable continuity of care and allow routine follow-up to be done without the patient having to visit the hospital multiple times and risk exposure to other people.

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Checking for modified treatment protocols

From online consultations to change in chemotherapy protocols, oncologists have had to make a number of changes to cope with the new normal. If a patient requires chemotherapy, there is emphasis on reduced dosing schedules or conversion to oral chemotherapy. If a patient needs radiotherapy, shortened cycles are used. We oncologists are making decisions by weighing the benefit the treatment will provide in terms of survival of the patient, and on the other hand weighing the risk posed by treatment to the patient's health. Everything needs to be highly customized for the patient, depending on their circumstances.

If a patient is diagnosed in early stages of breast cancer, as per ESMO(European Society for Medical Oncologists) and other guidelines, patients who are hormone receptor positive have an option to avoid chemotherapy entirely if the prognostic test indicates that they fall under the low risk category. In Roopa's case, we were able to do a test called CanAssist Breast, offered by OncoStem. This test is done on the tumour sample removed during surgery and hence the patient does not need to undergo any additional procedure. The result was low-risk and hence we were able to completely avoid chemotherapy and put Roopa directly on hormone therapy which is not immunosuppressive.

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Additional focus on mental health

Being diagnosed with cancer poses a great amount of emotional trauma and anxiety on patients. Imagine the compounded stress of being diagnosed with COVID-19? Moreover, the COVID-19 pandemic has caused many inconveniences for patients suffering from cancer, such as transport restrictions, the diversion of healthcare resources to COVID-19, etc. Due to social distancing norms and the limited number of people allowed into hospitals, the whole experience can be quite isolating and lonely for the patients. They tend to miss the physical and emotional support and the presence of their loved ones while undergoing treatment. Since there is a possibility of asymptomatic transmission of the disease, hospitals are following strict measures to minimize the risk of infection. Doctors and nurses have been mandated to follow adequate distancing from the patients. To deal with all these changes, hospitals should offer all cancer patients the services of a psycho-oncologist trained to counsel patients and their caregivers, to deal with the stress and anxiety

(Dr Krishna Prasad, Chief Medical Oncologist at Mangalore Institute of Oncology)

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