Coronavirus in Context: An Oncologist Outlines What Cancer Patients Should Know

Hello. I'm Dr. John Whyte, and welcome to Coronavirus in Context. Today we're going to talk about coronavirus and cancer. And my guest is Dr. Richard Schilsky. He is the Executive Vice President and Chief Medical Officer of the American Society for Clinical Oncology. Thanks for joining me today.

Happy to be with you, John.

We've been hearing a lot about patients with cancer are at increased risk for getting coronavirus. Can you help explain to the audience why they're at increased risk?

What we know is that cancer patients may be at an increased level of risk if, as a result of their cancer or its treatment, their immune system is not functioning quite up to snuff. In some cases, the type of cancer may actually diminish the capacity of the immune system. So for example, a cancer like multiple myeloma, which is a disease of cells in the body that normally produce antibodies, in a circumstance like that cancer, patients don't produce antibodies normally, and therefore their immune response to any type of virus or bacteria is reduced.

In other cases, the cancer treatment itself, particularly chemotherapy treatment, can reduce the patient's ability to mount an immune response to an infection. And then, of course, cancer patients in general are sometimes just debilitated because of the extent of their illness. And that by itself, or malnutrition or lack of exercise, all of those can contribute to having a diminished immune response.

What about cancer survivors? Say you're five years out, maybe hopefully even 10 years out. Are you still at increased risk?

Yeah, I think we don't really have any data on that. And it depends a little bit, to some extent, on what was the type of cancer you had and what was the treatment that you underwent in order to get that cancer into remission. So for example, a patient who had leukemia and underwent a bone marrow transplant might well have a prolonged and increased risk, particularly if they're still taking some sort of medicine to prevent rejection of the bone marrow transplant. You know, a breast cancer patient or a colon cancer patient who had a successful surgery and had just a few months of post-operative chemotherapy and is now 5 or 10 years down the road and healthy is presumably not at a greater risk than all the rest of us.

Do people need to do anything differently if they are currently undergoing treatment or if they've had cancer?

Well, certainly if they're undergoing treatment they need to speak with their cancer care team about whether any modifications to the treatment should be made. You know, one of the goals, of course, is to, at this point in time, minimize patients' contact with the health care system in general. You know, we just want people to stay away from hospitals and clinical facilities if they don't actually have to show up there. So that can result in some modifications to treatment plans or scheduled evaluations.

A lot of things are moving to telehealth evaluations right now, and it's possible to just do a check-in with your provider through that mechanism. Sometimes it may be advisable to postpone or modify the particular cancer treatment that you're receiving. But that's a very individualized decision, because obviously the cancer itself requires treatment, and there are risks to interrupting or delaying the necessary treatment.

I'm sure that's causing anxiety on the part of some patients who might have their therapy interrupted. What are you telling patients and caregivers who might be a bit anxious now that their treatment regimen seems to be interrupted?

Well, there's a lot of anxiety, you know, everywhere these days because of all the uncertainty surrounding this viral infection and how it's ultimately going to play out. I think, again, the only thing that I can advise is that patients stay in close contact with their oncologist, with their care team so they understand what are the potential implications of a disruption in their cancer care as it relates to their cancer outcomes. No oncologist wants to interfere with a patient's care unless they think that it's dangerous to the patient at this particular moment in time to continue the scheduled care plan.

So the goal, I think, is always going to be to continue the treatment as close to the original plan as possible, maybe with some modifications about where the patient actually receives the care or receives the evaluations of their cancer or receives their blood tests. But in most cases, we hope that the care will be able to be delivered uninterrupted.

I mean, it could even be correct moving from, for some cancer treatments, infusions to perhaps oral medicines, all to reduce their risk of exposure by coming in to a hospital or treatment center.

That's correct. Some intravenous cancer treatments can actually be administered in the home. But that takes a whole other set of logistical issues that have to be dealt with. There are some IV cancer therapies that can be switched to oral cancer treatments. And the oral medications can be delivered directly to the patient's home with instructions on how to take them. They still need to be monitored closely by their oncologist, but that is an opportunity and an option, in some cases.

Let's talk a little bit about telehealth. I'm an internist by training. I still see patients. And I did some telehealth visits last Friday. It's a little easier when I'm talking about high blood pressure management or even asthma flares, but in cancer, in some ways, for surveillance, we can't feel lumps and bumps, you know, through the video or over the phone. How are you seeing telehealth is different for cancer patients, and how are they responding to it?

Well, I think there's two different scenarios, at least. And you alluded to one of them. So for patients who are on active cancer treatment, the telehealth visit is really a check-in to be sure that they're tolerating the treatment well, not experiencing any unusual or unacceptable side effects, or need guidance from their provider. For patients who have completed their active cancer treatment and are in what you refer to and what we would call surveillance, those are patients who we hope are healthy. We're monitoring them for any possible recurrence of the cancer.

I think, in many cases, we can tell people what to look for and, you know, they can self-examine when that's possible. And oftentimes, of course, a new symptom will be the first clue of a possible cancer recurrence. And those symptoms can be discussed with the provider through telehealth, and then the doctor can make a determination as to whether an evaluation is necessary at that point in time.

And what about primary screening? It's hard enough to get people to come in, as you know, for their colonoscopies. People miss -- Are we telling folks now, let's just wait a few weeks or months?

Yeah, we are advising, and I think most institutions are advising that people just put their routine cancer screenings on hold. And I want to emphasize one thing in particular. A routine screening means that the person is otherwise healthy and has no symptoms that suggest the possibility of a cancer. So the screening is screening for healthy individuals. And because cancers are oftentimes slowly growing, and take, in many cases, years or even decades to develop, it's safe enough to postpone a scheduled screening by at least months. Some people, of course, do it for years --

Yes, I've heard.

-- and not worry about it. But if a patient has a symptom that suggests the possibility of a cancer-- they feel a breast lump, they have bleeding in the stool -- that's not a screening evaluation. That then becomes a diagnostic evaluation. And that has more urgency.

Any tips for the anxiety that cancer patients are experiencing right now? Either fear of catching coronavirus or they're concerned about their treatment is changing or might be changing.

Yeah, that's a tough one because everybody manages their anxieties in different ways. And obviously, you can talk with your doctor. There are a variety of resources that are available, I think some of which we have listed on cancer.net, our patient-facing website, where people can get counseling over the internet and things of that sort.

Stay in contact with family and friends, even at this time of social distancing. I think it's really important maintaining those social contacts. Those are your support networks. You know, eating well, sleeping well, exercising as much as you can. All of these things help to improve everyone's state of mind, and are helping all of us cope these days.

Dr. Schilsky, thank you for your advice today.

Thank you, John. Happy to be with you.

And thank you for watching Coronavirus in Context. I'm Dr. John Whyte.