On a regular basis, oncologists must carefully balance hypothetical risk and benefit. What treatment could maximize someone’s recovery with minimal side effects?
The answer to that question is life-defining for patients. Armed with reason for hope, oncologists will aggressively pursue treatment despite potential hazards. But once remaining options seem more likely to harm than to help, they may counsel for hospice care. “Obviously when we give treatment, we hope it’s going to work,” says Sam Rubinstein, MD, a hematologist at the University of North Carolina’s Lineberger cancer center. “We can’t tell on the front end. It’s not always obvious that the benefit outweighs the risk. And it’s not always true.”
Covid-19 makes that equation even harder to balance. At the pandemic’s onset, health care providers delayed and canceled all but the most urgent treatments and surgeries. Initially, it seemed worthwhile to keep people out of hospitals, for their own safety and to preserve personal protective equipment (PPE). Now, Rubinstein says, “The script has flipped.”
In May, Rubinstein and Warner co-authored an observational study in The Lancet of more than 1,000 people with both cancer and lab-confirmed coronavirus. Predictably, they found that patients with active cancer did worse (although those whose cancer was stable or responding to treatment did better than the most fragile and deteriorating patients). But anti-cancer therapy itself — even if it involved toxic chemotherapy or invasive surgery — did not seem to increase a person’s risk of death, they found. Simply put: Continued cancer treatment doesn’t seem to put people with cancer further in harm’s way — but pausing care, and allowing a cancer to progress unchecked, could.
“We need to keep treating, even in the face of this,” says Trisha Wise-Draper, MD, PhD, associate professor and oncologist at the University of Cincinnati Cancer Center. “Cancer never stops.” In July, Layne Weatherford, PhD, a postdoctoral fellow who works with Wise-Draper presented preliminary findings suggesting immunotherapy (which activates the immune system against cancer) doesn’t worsen complications for people with cancer infected with Covid-19.
“The impact of Covid is not going to be seen now. It will be reflected in survival in the next five or 10 years.”
“Our advice keeps changing. I think that’s been the hardest part for patients,” says Wise-Draper. “They’re watching science unfold in front of their eyes.” She says some people have been too afraid of Covid-19 to come in for treatment. Now they’re hearing that staying away, and putting off care, could be even more dangerous than the coronavirus. “I’m super frustrated. The shifting of what is and isn’t high risk is very unclear to a lot of us,” says Aiello, who has breast cancer. “You want answers and no one has them.”
Oncologists are also deeply worried about the cancer patients who don’t know they’re cancer patients yet.
During the early and widespread lockdowns, routine visits such as dental appointments, mammograms, pap smears, and annual physical exams were delayed. “Everyone was afraid of being overwhelmed,” says Fabio Moraes, MD, a radiation oncologist at Kingston General Hospital in Ontario, Canada. “It was about trying to protect the system from overloading.” Unfortunately, all of those cases are also lost opportunities to catch cancer early — and research has begun to reveal the potential cost of putting them off.
In the United Kingdom, 3,600 additional lives could be lost to breast, colorectal, esophageal, and lung cancer over the next five years due to Covid-19-related delays in diagnosis, according to findings published in The Lancet in July. Another July Lancet study suggested delays as short as two months could be enough for early stage tumors to progress from treatable to untreatable.
“We’re pretty sure there will be an increased wave of cancer cases coming,” says Moraes. “The impact of Covid is not going to be seen now. It will be reflected in survival in the next five or 10 years.”