Cancer care is not elective and must be maintained throughout the COVID-19 pandemic. However, early evidence from small studies in China and Italy show that cancer patients are at increased risk of severe illness if they develop a COVID-19 infection. While it’s impossible to detail every possible medical scenario, some broad suggestions for keeping patients, medical professionals, and the community safer during the pandemic can be made.
Dr. Ronit Yarden, the Colorectal Cancer Alliance’s Senior Director of Medical Affairs, in collaboration with Dr. John Marshall, Chief of the Division of Hematology/Oncology at Medstar Georgetown University Hospital, and Dr. Benjamin Weinberg, a medical oncologist at the same center, recently published a paper in Future Medicine for medical providers suggesting ways to temporarily modify colorectal cancer treatments during COVID-19. The goal is to limit the risk of COVID-19 to patients and providers. Some of the paper’s recommendations are summarized below.
All of the recommendations found below should be carefully considered by the patient and his or her medical team before implementation.
Avoid clinic and hospital exposure
Every trip to a clinic or hospital that is filled with people carries some risk of exposure to COVID-19. Medical providers are quickly changing in-person visits to “telemedicine” visits. It is appropriate to manage most oral regimens without in-person clinic visits. While these virtual doctor visits are imperfect, lacking the “human touch,” they have proven to be an effective bridge during the pandemic. It’s even possible that telemedicine visits will permanently replace in-person visits in some circumstances, including long-term follow-up care.
Reduce the chance for experiencing adverse effects that may lead to emergency room visits or hospitalization
Many colorectal cancer treatments can induce nausea, vomiting, diarrhea, mucositis, and fever, among other ailments, which may result in emergency room visits and hospitalization. While it is difficult to predict which patient will develop side effects, doctors can monitor kidney and liver function to reduce risk. In addition, genetic testing for mutations in the genes DPYD and UGT1A1 can identify patients who cannot metabolize certain chemotherapy drugs, putting them at risk of side effects. It’s also been shown that lowering treatment doses can reduce side effects that may lead to ER visits and hospitalization. In colorectal cancer, there is little evidence that dose intensity carries a survival advantage.
Skip treatment cycles
Skipping a single treatment cycle is unlikely to have a major impact on outcomes, but can reduce the risk of contracting COVID-19 during a hospital visit. Certain therapies, such as bevacizumab when given as maintenance or pembrolizumab when given as chronic therapy, could be skipped for a month or more due to their long half-lives—meaning they stay in the bloodstream for a long time.
Drop the intravenous therapy and maintain with oral medications
Treatments given through infusion require hospital visits. When possible, the infusion of 5-FU/LV-based therapies (FOLFOX, FOLFIRI, or FOLFIRINOX ) should be modified to capecitabine, an oral therapy similar to 5FU that was shown by several studies to be superior. The addition of oxaliplatin to 5FU ( in FOLFOX and FOLFIRINOX) adds only a relatively small improvement. One could justify starting with oral therapy and adding oxaliplatin later, depending on the impact of the pandemic. Doctors will have telemedicine visits to monitor patients.
Spread out mediport flushes
Many patients have their mediport flushed every month. If there is no other reason for the patient to come to the hospital, flushing can occur every 6 to 8 weeks.
Use short-course radiation when possible
For rectal cancer, standard care in the U.S. requires pre-surgery radiation delivered daily over 5 to 6 weeks. When appropriate, we recommend that short-course radiation be used for pre-surgery treatment of rectal cancer. Newer technologies, including stereotactic radiosurgery, have shorter treatment schedules, so we would recommend using these techniques for palliative radiation where available.
Consider ctDNA for adjuvant decision making
Primary surgeries for colorectal cancer will continue over the next few months, and adjuvant therapy decisions will follow. If available, we recommend circulating tumor DNA (ctDNA) testing to assist in adjuvant therapy decision making. ctDNA testing detects minimally residual disease. Some companies are offering in-home sample collection. While not definitive or established, a positive ctDNA test could require chemotherapy, even during the pandemic. A negative test will be more difficult to apply but could justify delaying treatment or being less aggressive.
Delay surgeries when appropriate
The delay of pre-planned surgeries for patients who received neoadjuvant therapy for removing a primary tumor, or surgeries to remove metastatic growths or perform stoma reversals, should be discussed and evaluated for risk by a multidisciplinary care team and the patient. During the pandemic, hospital and ICU resources will also be considered. Delays in surgery are unlikely to have a major negative impact on a given patient, apart from the anxiety of waiting, which should not be minimized. Revised plans should be agreed upon by the patient and his or her medical team.