COVID and Cancer 2
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Last time we covered some aspects related to covid and cancer. Key points included: 1. Cancer patients can take vaccine. It is safe. Effectiveness may be reduced in some cases. 2. Cancer patients are given many other types of vaccines during treatment for decades. So it is not new to give vaccines during cancer treatment e.g. pneumonia vaccine, hepatitis B, yearly influenza vaccine and others. Many vaccines are given post Bone Marrow/Stem Cell Transplant. 3. All current covid vaccines can be considered equivalent for above noted points. 4. CANCER treatment should continue throughout. Delaying or not giving cancer treatment has more harms than advantage. As seen by now in many analyses over last one year, in many publications, society guidelines, and our personal experience too. Including experience of Indian colleagues. Hence we urge all patients to undergo all cancer related treatments including surgery, radiotherapy, chemotherapy, immunotherapy, hormone therapy etc. Even the most aggressive treatment i.e. BMT/SCT have been found to be fairly safe, almost comparable to non covid times.
Are there any patients who are at higher risk?
Ans: Overall data again is in favor of continuing treatment. As the risk of not treating cancer is higher. Very early data seemed to suggest higher risk in lung cancer and aggressive blood cancer patients. However most recent data is not showing the same negative picture. When early data came out in first few months, a lot of analysis was not done. When patients were compared for age, comorbidities, stage like important factors, negative effect of cancer treatment is much much less. For example, age has been extremely strong risk factor, even in non cancer patients. We see today that patients in this second wave, talking about non cancer patients, below age 40, are much more likely to come out of ICU, compared to those above 60. Same way advance stages of cancer, those who are resistant to chemotherapy do worse compared to those who are in early stages, or in remission.
It is important that patients in remission continue to do regular follow up and screening. Now that the second wave has started receding at least in our region, it is important that follow up tests which were postponed need to be taken care of as soon as possible. For example, follow up mammogram and clinical examinations for breast cancer patients, colonoscopy for treated colon cancer patients, and many other patients like multiple myeloma, CML, etc.
Que: Any points more specific for cancer patients?
Ans: One important point I would like to highlight is need for more focus on thrombosis prophylaxis. There are no specific guidelines yet to suggest this however. Good news is that available published literature does not seem to suggest markedly higher thrombosis risk in covid and cancer patients. However Cancer patients in general are at higher risk for blood clotting. Covidinfection also is known to increase thrombotic risk substantially. Hence cancer patients who develop covid infection should preferably be given more emphasis on prophylaxis during and after covid infection. Such as oral anticoagulantsdabigatran, rivaroxaban, epixaban or at least aspirin (perhaps with atorvastatin combination, considering higher risk of arterial thrombosis as well in covid patients). This should be continued for at least 3 months, preferably 6 months. Perhaps with monitoring of D – dimer before stopping. If d dimer is not normal after 3 months, better to continue for 3 more months and then recheck. The anticoagulant doses here are not therapeutic, but prophylactic. With more data and guidelines, above points will have more clarifications.
One additional point and good news is: Pediatric cancer patients seem to have no additional risk related to ongoing covid pandemic. So they should be treated with same standard care, with more confidence.
FOR THOSE WHO DEVELOP COVID, chemotherapy, immunotherapy should be postponed for about 2-3 weeks, since the date of positive test. Not longer, unless they are suffering from active complications post covid, or highly immunocompromised. In general, most oral treatments (not all however) can be continued throughout covid infection e.g. hormone therapy for breast or prostate cancer, most oral agents for CML and CLL.
Same way surgery should be postponed about 4 weeks. Surgery related decision making can be more complex, as some surgeries have higher risk of postoperative lung and complications. For example, a major thoracic or abdominal surgery, cannot be compared with breast cancer surgery.Radiotherapy in most cases can be restarted quickly, within 2 weeks approximately. Radiotherapy involving lung may need separate consideration, especially for those who had lung involvement, even if to a small degree. For large majority of patients however this is not a concern.
May 17,2021. DrChirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedahbad. firstname.lastname@example.org