26 June 2020

Managing cancer patients during the COVID-19 pandemic

COVID-19 has impacted all aspects of clinical care globally – no doubt. Amid efforts put in place by national health systems to repurpose existing wards and build new, dedicated hospitals to manage these patients, a perhaps less visible, yet significant, highly vulnerable population has had a great impact: those living with cancer. While this piece will focus on the latter, the clear negative effects that have been observed on cancer screening programs as well as the delay in basic cancer research and early-stage drug discovery activities should also be noted.

On the one hand, most cancer patients cannot wait until the pandemic resolves to receive treatment or undergo surgery; on the other hand, they are at a high risk for contracting and experiencing adverse consequences from the disease. For the past few months, oncologists have therefore been trying to strike a balance between mitigating their patients’ risk of potential exposure and continuing to ensure access to cancer treatment and clinical trials. A critical component is also, of course, ensuring safety of healthcare workers while optimising services.

Major oncology associations like ASCO and ESMO have developed guidelines for cancer care at this extraordinarily challenging time, and multiple articles providing practical advice and recommendations by groups of oncologists and single institutions are also being published. General considerations for healthcare providers include: Can treatment be given in alternative regimens (e.g. less frequent dosing or shorter in duration)? In a less medicalized environment (e.g. local clinics)? Via other modes of administration to minimise patient exposure and maximise resources (e.g. changing intravenous administration to subcutaneous or oral, if available)?

Considering this, it comes without saying that cancer therapies with less intensive treatment visits could gain an advantage over competitors, such as recently approved Merck’s Keytruda at 400 mg six-weekly instead of 200 mg three-weekly. Pharmaceutical companies offering oral drug, shipped directly at the patient’s home, are also better positioned than their counterparts providing IV-infused treatment.

In addition, telemedicine and switching patient consultations and discussions with other health professionals to online or phone rather than face-to-face is also being increasingly adopted.

In cases where treatment cannot be postponed or administered in the outpatient setting, oncologists are required to define and apply prioritization criteria for their patients based on treatment intent and risk-benefit ratio. The type of tumor, the level of immunosuppression associated with an individual therapy as well as potential comorbidities and the impact of COVID-19 transmission in the local community also need to be taken into account.

But what about cancer patients who are suspected or confirmed to have been infected with COVID-19? Among many other initiatives, ESMO has launched an international collaborative project, the ESMO-CoCARE Registry, to quickly gather data and information from healthcare professionals about treatment approaches specifically focusing on this subset. Pooling real-world data will allow oncologists to rapidly gather and share knowledge, which will, in turn, inform patients and caregivers in their decision making.

Reinventing clinical trials

One area of cancer care that has been especially disrupted by COVID-19 is the conduct of clinical trials. Sponsors and investigators now need to comply with regulations and public health guidance to prevent patient and staff exposure to COVID-19 and may hence be unable to fulfil all the pre-specified requirements within the original time frame. Testing/dosing procedures may also be delayed. This may lead to protocol modifications (intentional or unintentional) with potential consequences on comprehensiveness of data gathered and patient accrual.

In general, study coordinators should track any change in enrolled patients’ health, leverage digital tools such as e-signature for informed consent and other paperwork, move to virtual format any consultation that does not necessarily need to take place in person, monitor adverse events and side effects through online portals etc. Just as importantly, patients should be kept abreast of any changes to study procedures and timelines to reduce stress and anxiety as much as possible.

Every cloud has a silver lining

While there isn’t currently a clear end date for this pandemic, what is certain is that many aspects of cancer care will not be the same in the COVID-19 aftermath.

Increasing utilization of telehealth will represent a major paradigm shift from conventional diagnostic and treating practices: new professional clinical roles will start to appear, to ensure clear and transparent communication in every aspect of the patient-physician virtual interaction; psychological support will also become increasingly important alongside pharmacological therapy in the cancer patient journey.

For clinical trials, hope remains that the operational efficiencies achieved during the pandemic will result in more patient-centred approaches also after it, improving time and financial expenditure for all stakeholders involved. The research community is currently evaluating how best to streamline recruitment and treatment procedures while retaining the same scientific integrity and rigour of the pre-pandemic protocols. More flexible study designs and timelines coupled with reduced data collection requirements and fewer in-person visits to the trial sites could highly benefit cancer patients and caregivers without negative consequences on science quality.