What to do when cancer patients receive chemotherapy during COVID-19 pandemic?

 

by Passakorn Wanchaijiraboon, MD.
Assistant Director, Cancer Excellence Center, Prapokklao Hospital, Chantaburi

Even if “cancer” is a lead cause of global death, i.e. over 9 million people a year, second only to coronary disease, it is possible to be cured if early diagnosis and right treatment choice, whether it is chemotherapy or so-called chemo or radiotherapy.

“COVID-19 (co-vid-nine-teen) is a new emerging infectious disease identified at the end of December 2019 and has spread to other countries around the world until now.  The dreadful fear of COVID-19 is the number of infected and fatal cases are on the rise day by day.  The latest number of fatal cases globally are more than 300,000*

Why are there so many fatal cases?

One answer is because COVID-19 is easily transmitted through secretions similar to influenza group.  What’s important is there has no specific vaccine and treatment.  If infected people have better immune system, the symptoms may not be severe and a chance of recovery is fast.  On the contrary, if infected people have low immune system with underlying or pre-existing diseases, such as diabetes, high blood pressure, chronic renal disease, the symptoms may be severe and a chance of death is more than other people.

Cancer is one of serious co-morbidities since cancer patients are at risk of getting infection more than common people, particularly patients on chemotherapy or radiotherapy because they are at their weak health status and low immune.

Therefore, during the COVID-19 pandemic, cancer patients should be closely monitored, especially those who are receiving chemotherapy or radiotherapy.  What should patients in this group do during COVID-19 pandemic.  This article will find you the answers with Passakorn Wanchaijiraboon, MD., Assistant Director, Cancer Excellence Center, Prapokklao Hospital, Chantaburi.

 

Q:   Many cancer patients realize that they are at risk of getting infection more than other people.  Therefore, what should they do during the COVID-19 pandemic?

A:   First of all, for better understanding as well as visualizing the concept, I would like to classify cancer patients into 3 groups as follows:

       Group 1: This group is those suspicious of having abnormal tumors in the body and “a likely chance of having cancer.”  This group also includes recently diagnosed patients but not yet started the treatment plan.

       Group 2: This group is cancer patients who have partially started their treatment plan, like surgery to remove tumors, and are waiting for adjuvant therapy, e.g. chemotherapy, radiotherapy, to increase the curability rate.

       Group 3: This group is cancer patients who have completed their treatment plan but are on regular follow-up.  After the treatment course is completed, there will be regular visits every 3 months for the first year, then every 4 months in the second year and every 6 months – 1 year in the 3rd, 4th and 5th year.

       Therefore, we have to know which group we are in.  If you are in Group 1, you are encouraged to visit a doctor to undergo treatment process because in the setting of cancer, the earlier cancer is detected and treated, the better the chance of its being cured due to early and right treatment regimen.  However, during this period, the most common problem is patients are often afraid that if they visit the hospital, they may be at risk of getting COVID-19.  So, they will wait until COVID-19 is slowing down.

       I see that cancer is more dreadful as it never stops growing if untreated.  Now, we do not infect with COVID-19 but are suspicious of cancer or just diagnosed of cancer.  Therefore, you should come and consult with a doctor first.  Also, if you want to be sure that the hospital you will be visiting is safe from COVID-19, please search for information.  If there are no COVID-19 cases there, it means the chance of getting COVID-19 is less than having cancer for sure.

Q:   Group 2 is cancer patients on treatment, like chemotherapy, radiotherapy, what to do during the COVID-19 pandemic?

A:    I prefer that the group 2 patients continue their treatment because doctors give chemotherapy to cancer patients after surgery or patients are in the treatment process because we want to achieve a complete cure from cancer.  We have to tell you that patients with early diagnosis and at early stage of cancer have a better chance of free from cancer.

Generally, doctors will prescribe 2 – 3 cycles or more of chemotherapy, of which lasts 1 – 2 days or more and with a time interval, depending on the treatment plan.  Therefore, we cannot exactly determine how many cycles of chemotherapy will be administered, depending on type and stage of cancer and patient’s response to the treatment.  Consequently, patients must receive each cycle of chemotherapy.  If unable to come, please directly consult with the doctor or his treatment team.  Do not miss the treatment without asking the doctor first.

In addition, before each cycle of chemotherapy, a physical exam and blood test will be performed to determine if the patient is healthy enough to receive chemo in that cycle.

Patients with advanced cancer who had chemotherapy and cancer is controlled should also continue their treatment with the same reason, that is, continuous treatment provides optimal result but treatment regimen can be changed as appropriate.

Therefore, I would like the patients to talk frankly with the doctor “during this time if I do not want to come to the hospital regularly, can you change the treatment to oral medicine so that I can take it at home.”  Some hospitals are offering drug delivery service.  It is even more convenient, minimizing the visit to the hospital.

In conclusion, cancer patients in group 2 who are concerned about COVID-19 pandemic should discuss with the treatment team if the treatment can be changed because you are encouraged to continue the treatment with curative intent from cancer.

Q:   Group 3 whose treatment is completed but is on follow-up phase during the COVID-19 pandemic, what to do?

A:    For group 3 whose treatment is completed; they are on follow-up phase to see if cancer has come back.  In standard cancer treatment, if cancer does not return after 5 years of treatment, the patient is considered as “cancer-free,” except for breast cancer of which its complete cure is at 12 years.

        As mentioned before, if we are during 0-5 years after treatment course is completed, there will be follow-up visits every 3 months, every 4 months at Year 2, and every 6 months to 1 year at year 3-4-5.

        This is because if cancer is diagnosed and free from it since stage 1, it does not mean that cancer is completely 100 % gone as there is still possibility that cancer could return, more or less, depending on its stage and the precautions of the doctor or his team.

        Patients in the first year of follow-up may talk with the doctor or his team to postpone the follow-up visit from 3 months to 4 or 5 months or to 1 year.  From my point of view, it can “delay” but for how long, this depends on the judgment of the doctor and his team, on a case by case basis, but I do not recommend the patients to be loss for follow-up.

        I would like to tell all cancer patients that “COVID-19” is not as dreadful as cancer since if cancer comes back and is detected early, we still have a chance of getting cancer treatment and eliminating it again.

        One more thing, if a visit is postponed, patients should take care of themselves during that period, observing possible abnormalities, e.g. spotting a lump or abrupt and abnormal pain in other parts of the body and not going away even if treated.  If this is the case, visit the doctor or his team before the schedule because cancer may have already returned and may not be from its original site.

        The most important thing for the treatment of cancer during the COVID-19 pandemic is regular communication between patients and doctors and their team.  If you have any questions, ask the doctor immediately.  Nowadays, there are a number of communication channels, such as phone call, Line official of the hospital, or telemedicine, which makes communication even easier.

Q:   How does chemotherapy or chemo affect the body’s immune system?  Is it true that chemo weakens the immune system?

A:   That’s true.  Most chemotherapy (often called “chemo”) has side effects e.g. immunosuppression, weakness, fatigue, but how severity they are depends on the regimen, type of cancer, the patient’s health status during that time.  However, each patient has different side effects and may occur at different timepoints.

       Therefore, cancer patients on chemotherapy have different level of risk to infection, depending on the said factors.  Now, many people are questioning “why does chemotherapy suppress the immune system?”

        Let me explain that currently there are both oral and IV chemotherapy (intramuscular or subcutaneous injection; intrathecal injection, intravenous injection or mixed solution and intraperitoneal injection).  Doctors often administer chemotherapy every 3-4 weeks or less per cycle, depending on cancer stage and patients’ status.

The activity of chemotherapy is to destroy, inhibit or delay the growth and proliferation of cells.  This property is opposite of cancer cells.  Moreover, normal cells also have this characteristic.  Therefore, chemotherapy also impacts normal cells but maybe less effective for normal cells than cancer cells.

Examples of body cells which are proliferated all the times e.g. mucous inside the mouth, intestines, hair, all types of blood cells.  We often see that patients on chemotherapy experience hair loss due to damage to hair cells.  This also happens to decreased number of red blood cells, causing anemia; low platelet counts and if bleeding, it is difficult to stop.  For white blood cells, functioning as the body’s immune system to recognize and fight against germs, if excessively destroyed, the immune system also weakens.

This is why “when given chemotherapy, cancer patients have more chance of getting infection and suffering illnesses.”

Q:   During this COVID-19 pandemic, should chemotherapy be stopped to prevent from lowering immune system and getting COVID-19 infection at the same?

A:   Chemotherapy is systemic therapy, i.e. to release active substances to bloodstream to destroy cancer cells by inhibiting or delaying the growth of cancer cells.  It is preferred to treat metastasis solid tumors and in blood cancer at all stages.

       In addition to chemotherapy as definitive treatment in metastasis solid tumors and all stages blood cancer, the doctor uses chemotherapy as adjuvant therapy within 6 – 8 weeks after surgery in case of breast cancer, oval cancer and colon cancer, all of which could progress to other parts of the body e.g. spread to lymph nodes.

       Established data are available that if chemotherapy is given to cancer patients within 6 – 8 weeks after surgery, the chemotherapy reaches its optimal during that period, meaning patients have better chance of being cured from cancer.

       There are 2 major groups of patients diagnosed of getting chemotherapy.

       Group 1 Patients who have just been diagnosed of cancer but have not yet started the treatment and they have cancer which is appropriate for chemotherapy.

       Group 2 Patients who have been diagnosed of cancer and should be treated with chemotherapy and just started chemo for 1 – 2 months.

       I believe many cancer patients are making decision if they should receive chemotherapy during this period.  I would like to tell you that before the COVID-19 pandemic, all cancer patients are at risk of getting bacteria, virus, like common cold, influenza more easily than other people.  Therefore, even if during the COVID-19 pandemic, it is just another add-on disease.

      Therefore, what cancer patients should do is to take good care of themselves, good hygiene and prevent themselves from getting any infection.  And more important is to continue keeping up with all the scheduled visits, never miss any visits.  Remind yourself all the times that you undergo treatment process because you want to be completely free from cancer.

      Once again, the administration of chemotherapy does not make you get COVID-19 infection, but not receiving any treatment only makes cancerous tumors grow or advance to life-threatening for sure.

      However, if you are afraid of visiting the hospital during this period, you have to talk frankly with the doctor or his team on a case by case basis. Apart from chemotherapy, there may be other alternative treatments, like targeted therapy, which may decrease side effects of immunosuppression by chemotherapy, for your cancer.  If targeted therapy is not your choice, will the doctor have other treatment available or chemotherapy regimen can be changed?  And how? 

Q:   Which group of cancer patients are prohibited from delaying or never postponing the treatment?

A:    Main type of cancer is solid and hematologic cancer but each cancer type has various stages.  Therefore, no one knows exactly which patients can delay or postpone the treatment or which ones need immediate treatment.

        If chosen, a doctor and his team wish to treat all types of cancer but have to consider which treatments are available for specific cancer type or which ones will minimize the effects on patients’ immune systems or which ones will minimize the hospital visits without compromising the effectiveness of the treatment.

        If asked which cancer patients we do not want to wait or delay treatment, the 100 % answer is patients whose cancer is troubling.  In medical term, we have called “emergency of cancer.”  In this case, if not treated or resolved immediately, patients could die of cancer e.g. cancer tumors blocking the trachea, causing breathing difficulty; cancer tumors blocking vessels causing damaged blood circulation.

        If you have any questions, you are recommended to contact the doctor or his care team right away.  Never make decision on your own because the treatment team must know their patients the best and definitely the context of COVID-19.

Q:   Some cancer patients have made decision to stop chemotherapy but thought of resuming the treatment.  In this case, do they have to restart the whole treatment process or do you have any recommendations?

A:    A cancer patient received chemotherapy for 2 months and decided to stop it by him/herself.  After 6 months, this patient requires to start a new treatment process.  What is the effect?  I have to tell for this case not enough data are available to definitely answer that resuming the treatment would be the same chemotherapy and if the same chemo is used, it is doubtful that it will be as effective as before.

        In general, 2 – 3 cycles of chemotherapy will be given but the exact cycles cannot be determined.  Chemo is often given around 6 cycles, depending on the type and stage of the cancer and individual response to the treatment.  Therefore, patients must come to receive chemotherapy at every visit because the principle of chemotherapy is the same as hitting a snake.  If we hit the snake, it must be hit until death, meaning the treatment needs to continue to attain its optimal goal, which the patient has a better chance of achieving a complete cure from cancer.

        As always repeated in this article, if you cannot return for chemotherapy as scheduled, please talk directly with your doctor or his treatment team.  Do not miss a visit spontaneously.

Q:   If patients on chemotherapy get COVID-19, how severe is the symptoms compared to other people?

A:   I believe that if cancer patients are infected with COVID-19, the symptoms may be severe and complications and death are likely more than other people, particularly patients receiving chemotherapy due to low immune system.  In addition, the treatment for this patient group is rather complicated and takes more time than infected people without underlying disease who are healthy and good immune system.

       Consequently, all cancer patient groups must always be healthy to stay away from infectious diseases and be fit to undergo further treatment processes effectively.

       If having cancer, patients should be aware that cancerous cells will not stop growing or go away by themselves if not properly treated.  Therefore, cancer requires immediate treatment if curative treatment will be achieved while COVID-19, even if easily transmitted, can be prevented and cured as well.

       As a result, if you are cancer patients at any stage, during this COVID-19 pandemic, the most important recommendation is to strictly follow the instructions of the doctor and his team, never miss a scheduled visit, never lose the follow-up, as well as keep yourself healthy by following:

  • Eat healthy diet, enough protein and energy for your body’s daily need.
  • Avoid very tasty diet, including excessive hot or cold diet.
  • Take proper exercise regularly.
  • Drink clean water sufficiently.
  • Take enough rest.
  • Avoid travelling to crowded areas where there are lots of people gathering at the same time.
  • Avoid being exposed or contacting with patients with infectious diseases.
  • Keep good personal hygiene; Eat fresh and hot food; Use your own cutlery.
  • Maintain social distancing.
  • Wear clothing mask or face mask every time leaving the house to avoid being exposed to droplets from secretions, e.g. sneezes, saliva
  • Wash your hands correctly and frequently with soap for 20 seconds each or use alcohol gel instead if water is not available, particularly before and after wearing masks, before meal, after using the toilet, after coughing and sneezing.

In addition, you must observe any abnormalities.  If you have these symptoms, e.g. high fever, frequent coughing, sore throat, breathing difficulty, dyspnes, muscle pain, and fatigue, you must go to the hospital to get tested to find out if you have COVID-19 infection.  If yes, then you can undergo treatment process in a timely manner to reduce its severity and complications, including death.  

* WHO reported global COVID-19 cases of 4,248,389 cases with 294,046 deaths* (Information as of 15 May 2020).

 

 

 

References NARONG KEERATIVITAYANANT.

-Department of Disease Control, Coronavirus disease 2019 (COVID-19) (https://ddc.moph.go.th/viralpneumonia/g_km.php), 14 May 2020.
-Asst. Prof. Dr. DUNYAPORN TRACHOOTHAM, Dentistry. Eat Well Kills Cancer Eat Smarter Cancer Goes Away. Bangkok: AmarindHealth AmarindPublishing, 2017.
-Assoc. Prof. Chaiyoth Theeraphakawong, MD. Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, When to receive chemotherapy (https://www.si.mahidol.ac.th/th/healthdetail.asp?aid=321), 14 May 2020.  
-Lect. Narong Keerativitayanant, MD. Division of Chemotherapy, Department of Medicine, Faculty of Medicine Siriraj Hospital, Live Happily with “Chemo” (https://www.si.mahidol.ac.th/th/healthdetail.asp?aid=739) , 14 May 2020.
-Centers for Disease Control and Prevention, Coronavirus Disease 2019 (COVID-19), (https://www.cdc.gov/coronavirus/2019-ncov/about/index.html), 14 May 2020.
-ESMO, Cancer patient management during the COVID-19 pandemic (https://www.esmo.org/guidelines/cancer-patient-management-during-the-covid-19-pandemic), 14 May 2020.
-National Cancer Institute, Coronavirus: What People with Cancer Should Know(https://www.cancer.gov/contact/emergency-preparedness/coronavirus), 14 May 2020.
-World Health Organization, Coronavirus disease (COVID-19) Situation Report -115
(https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200514-covid-19-sitrep-115.pdf?sfvrsn=3fce8d3c_4), 15 May 2020.

 

NPM-TH-0627-06-2020