Cancer and COVID-19 – Opinion – Freeport Journal-Standard

As the majority of the world remains in a tight grip and faces an uncertain future in the midst of the worst pandemic in modern history since La Grippe or the influenza of 1918-1919, the cases of chronic ailments from cancer to heart disease continue and still need to be diagnosed, managed and addressed.

The novel Severe Acute Respiratory Syndrome-Cov-2 commonly and unaffectionately known as COVID-19 or colloquially referred to as coronavirus is reshaping health care across the globe and exposing evident deficiencies and fault lines, particularly in our own US-based health care system. Being both a cancer physician and hospitalist myself on the front line of this epidemic, how should we approach and advise patients with apparent deficient immune systems? What constitutes a deficient immune system? Should cancer treatments and similar treatments be stopped in the face of this pandemic? Should we all just sit around, quarantine for months and halt health care?

It is a simple fact that patients receiving chemotherapy or any immunosuppressing treatment expose themselves to a greater risk of a COVID-19 infection. We have to keep in mind that similar to influenza, not everyone is expected to fall clinically ill requiring hospitalization. Early data from Wuhan, China and Italy indicate that the elderly especially older than 70 years of age with chronic lung disease (asthma, COPD), diabetes, heart disease, chronic kidney disease and cancer are at higher risk for hospital ICU admissions, complications and death.

Current research out of Hutchinson Research Center in Seattle illustrates those with blood cancers particularly non-Hodgkins lymphoma, chronic lymphocytic leukemia and AML and multiple myeloma appear to be at highest risk. Those on any active cancer treatment including chemo, radiation or immunotherapy and those who have undergone bone marrow transplants are also at risk.

We must remember that the risk of immunosuppression can extend even after blood counts normalize after treatment for cancer and in some cases can be long-term. This varies from patient to patient and is widely dependent on many factors from the overall health of the individual, the drugs actually used, how well the patient tolerated treatment and the long term vision and plan of care.

There is no simple blood test to assess the level of immunosuppression or whether someone is absolutely immunosuppressed outside of assessing their white blood percentages and distribution. This is because someone can have normal counts while staying on active chemo or immunosuppressants such as steroids and can remain at high risk for infection such as COVID-19. It is very important for patients to ask their physicians regarding the level of their immunosuppression and the risk of infection because it will vary from person to person.

An article published in February in the journal The Lancet demonstrated from Chinese data of 2,007 cases of hospitalized COVID-19 patients from 575 hospitals showed that both current and former cancer patients were at greater risk from COVID-19 causing ICU admission, ventilation or death and even just simply contracting the virus. This early data also clearly illustrated that a history of smoking, COPD, high blood pressure and diabetes all contributed to infection risk. This is a lesson to cancer doctors to remain cognizant of any cancer patient with any sudden rapid deterioration due to a viral-like illness. The fatality rate is 15% for people older than 80 years of age.

Despite all this data, no cancer patient should routinely cancel their cancer treatments. Business should continue as usual because at the end of the day their cancer needs to be treated and the relative risk of this pandemic alone should not refrain from any patient from receiving life-saving treatment. I do encourage patients to have robust discussions and to have full transparency with their providers because while some treatment situations may need modification, most will not.

All facilities should screen based on current CDC guidelines pertaining to respiratory symptoms while keeping in mind some COVID-19 cases are actually presenting with gastrointestinal symptoms as well and even unexplained conjunctivitis as the only presenting symptom. Males are more susceptible than females to infection presumably because of the increased percentage of ACE2 receptors (entry point for the virus) in the lungs. And contrary to public opinion, the young are getting infected as well, even among the pediatric population.

Any patient with symptoms should be masked and placed in quarantine per CDC guidelines. Any cancer patient, in particular, should contact their doctor if they have fever of 100 degrees or more, deep dry cough, marked fatigue and shortness of breath. Most doctors will advise you to self-quarantine at home and to go to the ER if you are having difficulty breathing or otherwise feeling markedly ill. Most should self-quarantine because we don’t want to panic and overburden the health system with non-critical evaluations. Currently, widespread testing is not yet available and can only happen with a doctor’s recommendation. People cannot go to the ER to be tested and will not be tested.

CDC reported on March 18 that 21-31% of infected individuals require hospitalization. If someone in your household gets sick, use social distancing, sleep in separate quarters, wipe down areas with bleach wipes, wash hands vigorously for at least 20 seconds. Do not bring even a mildly sick family member into any cancer center or health care facility and only bring one visitor if at all to a clinic visit. Cancer patients should try to avoid public transportation if at all possible and if not then take the usual standard precautions.

What are the ways to safeguard your immune system or enhance it? Sleep deprivation is directly linked to immunosuppression. Threshold requirements vary among people however; expect to aim between 6-8 hours nightly. Aerobic exercise also enhances the immune system. A walk, particularly in nature. will nourish the body and soul and has been used as binary therapy in treatment centers. Adequate nutrition is also central to a strong immune system. 70-80% of the immune system resides in the gastrointestinal tract and is directly impacted by the food we eat. Maintain a diet rich in fruits, vegetables, lean protein, no processed foods and plenty of water. Stay up to date on vaccinations, stop smoking and alcohol intake.

One promising area of research may involve cancer immunotherapy itself. A preventative cell-based vaccine currently in phase 1 clinical studies and developed by the NIH will take at least 1 year to reach the public according to Dr. Fauci of the NIH. One form of cancer treatment called CAR T cell therapy may help reduce the level of interleukin-6 which is responsible for cytokine release syndrome (CRS) central to the cause of death in COVID-19.

The IL-6 blocking drug sarilumab is under study. Another approach under study is utilizing plasma from recovered COVID-19 patients as a means of treatment. Currently, there are more than 100 trials worldwide with at least 11 in the USA. Other agents being looked at have been hydroxychloroquine, remdesivir, losartan and aviptadil. While awaiting the results of all such therapies, it’s important to remain calm, use common sense with hygiene, social distancing and above all pray.

Dr. Arshad Shaikh is the director of Hematology/Oncology at the Leonard C. Ferguson Cancer Center in Freeport. He can be reached at mercyloveandservice@gmail.com.