Cancer Treatment During COVID-19 Pandemic: A 'Patient-by-Patient Basis'

Allyson Ocean, MD

Research regarding the pathogenesis of the novel coronavirus 2019 (COVID-19), treatment for those who contract the virus, and containment strategies for patients at greatest risk of developing severe complications from COVID-19 are evolving, explained Allyson Ocean, MD.

"We have to take it on a patient-by-patient basis. There are some patients who I don't want to give chemotherapy to because they're elderly and their cancer is stable. There are other patients who need treatment because they're sick and symptomatic from [their cancer]," said Ocean.

In an interview with Oncology Nursing News' sister publication, OncLive, Ocean, an associate attending physician, NewYork-Presbyterian Hospital, and associate professor of clinical medicine at Weill Cornell Medicine, provided insight on the pathogenesis of COVID-19, explained how the outbreak has impacted treatment plans for patients, and shed light on the work being done to develop a treatment and/or vaccine for the virus.

OncLive: What do you know about the risk that COVID-19 poses to patients with cancer?

Ocean: We know that patients who have cancer are at a higher risk of contracting COVID-19. They're also at a higher risk of getting sicker from COVID because of their compromised immune systems. Not every patient with cancer has a compromised immune system. However, on the whole, patients who are undergoing chemotherapy, those who are on immunotherapy, or those who have had a transplant are at the highest risk of contracting COVID-19 and related complications.

What is being done to reduce the risk of the virus to patients with cancer, especially in New York, which has the highest number of cases in the United States?

These are challenging and scary times for patients who are dealing with cancer because they have another battle to fight, in terms of trying to avoid COVID-19. We’re trying to figure out who is most at risk. [For these patients at greatest risk], we're trying to modify their treatment regimens in a way that will minimize their exposure [to the virus]. By that I mean, we need to minimize the number of patients from coming into the medical facilities, having to travel, having to take transportation, etc. We’re trying to minimize all those patient encounters, where they could potentially get exposed to the virus.

For some patients who come in every couple weeks for chemotherapy, we might increase that interval to every 3 weeks. I have changed certain eligible patients who are coming in to get intravenous chemotherapy to oral chemotherapy.

We're making sure patients are protecting themselves and social distancing. [Patients should be] washing their hands frequently and wearing a mask and gloves whenever they go out. I tell my patients, "Wear both a mask and gloves." [Patients should] stay inside as much as they can and for as long as they can. All my patients, for the most part, tell me they haven't been outside in 5 weeks, which is great, because that's how they're not going to get sick. If they don't come into contact with the virus, they are not going to get the virus. That's the key point.

One of my friends described this virus very well, and it's a perfect analogy. They said, "The virus is like glitter. When my kid plays with glitter, it's everywhere. There are little sparkles everywhere. Think of the virus particles as glitter particles; they're everywhere. If you go outside, you definitely expose yourself because you don't know where that glitter is, so you have much more of a chance of contracting the virus."

How has NewYork-Presbyterian Hospital responded to the pandemic?

I am so fortunate that my hospital is at the epicenter [of action] and is doing an amazing job of protecting everyone in the hospital, from the staff to the patients. I'm not surprised. It's one of the best hospitals in the nation for a reason. We are well equipped to handle all COVID-19—related issues and those that are not related to COVID-19. One of the hardest parts about all of this is that during this time, people with other conditions, such as heart disease, lung disease, kidney disease, or are involved in a motor vehicle accident, must be taken care of as well. All teams must be prepared [to administer] COVID-19–related treatment and treatment unrelated to COVID-19. Our institution has done an excellent job to make sure we're containing [the virus] and treating patients effectively.

This is a really hard time. Our staff is working nonstop on the frontlines, exposing themselves and risking their own lives to take care of everybody, and they do it with such care. I've been at this hospital for 20 years. These people are the family of these patients for whom none of their families are there. [Our staff are treating these patients] as if they were their own family members, which warms my heart. That's the only good in this situation right now for these very sick patients who are in the hospital.

What do we know about the pathogenesis of the virus?

There's so much we don't know about the virus. It can manifest in different ways. An important research paper was just published in Lancet from researchers at Weill Cornell Medicine, which showed that the virus works by activating the complement pathway. That pathway triggers the immune system. It's also the pathway that deals with clotting. When complement gets activated in our bodies, it leads to small vessels forming blood clots called microthrombi. Researchers did autopsies and biopsies on patients who passed away from COVID-19 and found that [the virus] wasn’t causing the problems in the lungs that we thought it was causing.

Previously, it was thought that these patients were experiencing acute respiratory distress syndrome (ARDS), which is essentially lung failure. It turns out the lung failure was not due to ARDS. It was actually due to these microthrombi that are overwhelming the lungs, which is preventing the patient from being able to breathe. These are very interesting and important data that’ll hopefully lead to better treatments such as anticoagulation. Right now, we know that this virus triggers the immune system. It triggers the complement system and it causes microthrombi process throughout the body that can affect many organs.

How has the virus impacted your treatment plans for patients?

Patients are scared that their cancer is going to get worse during this time of the crisis. I'm scared that they're going to die of COVID-19. Most of my patients are not at an immediate risk of dying of cancer, but they very well could be at an immediate risk of dying of COVID-19 if they get it. That's a discussion I have to have [with my patients].

We do so many visits via video now. I kind of negotiate with [my patients]. I might tell them that it's not in their best interest to come in this time for chemotherapy. Usually, I have this discussion with older patients rather than younger ones, because I don't want an 80-year-old who is stable on weekly or every-other-weekly chemotherapy to come in and get exposed to the virus when their cancer is completely stable—if not in remission. Perhaps, it's time to take a little break from the treatment, so they don’t have to come in. I have these dialogues all the time with my patients. I try to console them and say that’s going to be okay. Unfortunately, we just don't know [what the best way to approach care is].

One thing that we're doing, and what a lot of centers are doing, is collecting data on the changes we're making to patients' regimens, so we know how these changes impact their outcomes. So many patients are having their regimens changed; they can get through this crisis, even though we know it's going to affect their outcome in some way. We just don't know how significantly.

Eventually, we'll publish those data so we can show what the impact of these changes are. It would be wonderful to show that these chemotherapy breaks didn't affect patients so negatively. There are large databases that are [being used] to collect information on how treatment changes are affecting patient outcomes.

Could you shed light on the research being conducted to develop a vaccine and/or treatment for COVID-19?

There are so many ongoing efforts. There are over 300 trials on non-vaccine treatments alone. There are probably many more with vaccines. Having a definitive treatment or a vaccine for COVID-19 is what’s going to get us back to normalcy. I'm not too familiar with all the vaccine efforts, but that there are amazing researchers working on this effort internationally.

Different hospitals are using immunosuppressive agents and interleukin inhibitors for patients who are in the intensive care unit (ICU), are really symptomatic, and have severe COVID-19 symptomatology. There are trials going on with remdesivir, hydroxychloroquine, and azithromycin. We don't have any solid data yet about the usefulness of these medications in [treating patients with] COVID-19. Though, there are people that have been helped by these medications. In order for us to recommend [these medications] across the board, we need more data. My personal feeling is that hydroxychloroquine is probably more useful earlier on in the illness rather than when someone is [severely ill]. I haven't prescribed it for anybody, and I wouldn't do that until we have more evidence [with it].

In terms of prevention, there are other measures I'm learning about on social media from pulmonologists, and from anesthesiologists in the ICU about proning patients because they oxygenate better that way. There are other ways that that our frontline doctors are helping patients with COVID-19 other than through medications.

Earlier, you mentioned telemedicine. Will it retain its role following the pandemic?

I absolutely think it's going to retain its role. [Telemedicine] should have been used more previously than it than it ever was before. We can now bill for video visits, whereas before we could not build for phone calls or log that as an individual healthcare visit. Now, we can. Sometimes it's a pain because the patients, especially some of the older patients, don't have access to the internet or the computer—or they're not savvy with the log-on information.

However, most people can figure it out. I set up a lot of virtual visits throughout the day. I joke with some patients if they go over time because of these technical difficulties. I'll joke with the next person and say, "Similar to in person, I'm running late." Even through video visits I run late because I like to take a lot of time with everybody. However, some of that time is getting the system to work. For the most part, all of my colleagues have it [figured out] now. It's going to be the future.

Should there be a national license for healthcare professionals, so that they can more easily help care for patients in overwhelmed areas?

Absolutely. It can only mean good things if we have a system like that. I'm so appreciative of all of these healthcare workers that are being brought into New York City to help with the crisis. It’s upsetting to hear that there could be more if they didn't have to go through a strong credentialing process to get here. These healthcare workers are working wherever they are, and they're verified; they’re strong providers. We should be able to say, "Go and practice in our emergency room" as if it were their own. That doesn't happen so smoothly now. I understand that there are reasons why we have to verify [these providers] and make sure that they are qualified to enter the hospital they're not licensed in. However, there should be a national license and it should be mandatory. This pandemic is teaching us a lot about the future.