Delays in routine treatment due to Covid-19 can be fatal for cancer patients: Dr Ajay Chanakya Vallabaneni

• Dr Ajay Chanakya Vallabaneni Consultant Surgical Oncology & Robotic Surgeon, KIMS Hospital
• Cancer death mortality rate across the globe is 30% which is far more than Covid 19 infection mortality rate of about 3.5%
• Increasing evidence suggests that COVID‐19 causes higher morbidity and mortality among some types of patients with cancer, especially those receiving intensely immunosuppressive treatments

Among the many affected by the devastating impact of the COVID‐19 pandemic in our society, patients with cancer have paid a very high toll. Increasing evidence suggests that COVID‐19 causes higher morbidity and mortality among some types of patients with cancer, especially those receiving intensely immunosuppressive treatments. Prevention, early detection, and early intervention efforts have been delayed for many. In some hospitals, significant treatment delays have resulted as COVID‐19 cases have overwhelmed patient wards and intensive care units.

The fear of contracting the disease is also preventing the cancer patients consulting their treating clinicians. Consequently, patients who have cancer have presented with more advanced disease, which is more difficult to treat, much less to cure.

A 29 year old homemaker noted to have breast lump and diagnosed to have early breast cancer, avoided hospital visits and delayed her treatment, which resulted in advanced disease with ulceration and lymph nodal involvement making it impossible to conserve her breast and lymph nodes. In another instance, a 55yr old male who was initially diagnosed to have advanced lung cancer later presented with distant spread of the disease to the brain, thus leaving him only with palliative options.

While it is important to note that COVID19 infection across the globe has a mortality rate of about 3.5% which is way less than the cancer death mortality (30%), it is also crucial to understand that the increased susceptibility to Covid among cancer patients is seen in patients on immunosuppressive therapy, and for the rest the risk is similar to a normal person.

With no definitive time frame for this pandemic to rest, cancer treatments are not advised to be delayed due to fear of contracting the infection.

All due measures, like masks, sanitizers and physical distancing, should be religiously followed at all times. Now, with the availability of various vaccines, it raises hope that the pandemic can be controlled.

Although evidence regarding vaccination in patients with cancer is limited, there is enough evidence to support anti-infective vaccination in general  (excluding live-attenuated vaccines and replication-competent vector vaccines)  even in patients with cancer undergoing immunosuppressive therapy.

The level of efficacy may be expected to be generally reduced in certain populations of cancer patients with intense immunosuppression, such as recipients of haematopoietic stem cell transplantation. However, based on data extrapolation from other vaccines and the mechanism of action of the COVID-19 vaccines (not live), it is conceivable that the efficacy and safety of vaccination against COVID-19 may be estimated to be like that of patients without cancer.

The timing of vaccination depends on individual therapy scenarios and may ideally occur before systemic therapy starts. But, if the patient has already started systemic therapy, it is reasonable to vaccinate during therapy. Patients on radiation therapy and surgical treatments can take vaccinations without any concern.

Patients Treatment/Cancer Type

Timing

Hematopoietic Cell Transplantation (HCT)/Cellular Therapy
Allogeneic transplantation Autologous transplantation Cellular therapy (eg, CAR T-cell): At least 3 months post-HCT/cellular therapy Hematologic Malignancies

Receiving intensive cytotoxic chemotherapy (eg, cytarabine/anthracyclinebased induction regimens for acute myeloid leukemia): Delay until absolute neutrophil count (ANC) recovery

Marrow failure from disease and/or therapy expected to have limited or no recovery: When vaccine available

Long-term maintenance therapy (eg, targeted agents for chronic lymphocytic leukemia or myeloproliferative neoplasms): When vaccine available

Solid Tumor Malignancies Receiving cytotoxic chemotherapy: When vaccine available
Targeted therapy: When vaccine available
Checkpoint inhibitors and other immunotherapy: When vaccine available
Radiation: When vaccine available
Major surgery: Separate date of surgery from vaccination by at least a few days

Physical distancing measures, masks, face shields, sanitizers and other hygiene measures are still required during the pandemic, including for patients with cancer, and should certainly accompany the vaccination strategies. Patients and their attendants need to shed their fear of infection and seek for cancer treatments following vaccination and adhering to safety protocols.