Overcoming uncertainties and ethical dilemmas
James Fleck: Anticancerweb 23 (03), 2020
According to the World Health Organization (WHO), the COVID-19 data updated on March 22nd, 2020 globally pointed to 294,110 confirmed cases and 12,944 deaths. Recently classified as a pandemic, already reached 187 countries with a fatality rate (FR) of 4.4 %. Eventually, the FR may change with greater availability of tests and a better understanding of their sensitivities; however, it will remain a high-risk disease for immunocompromised patients and unhealthy elderly people. The most relevant complication is a coronavirus-related severe acute respiratory syndrome (SARS-CoV2), which is associated to respiratory failure and need up-to 3 weeks of mechanical ventilation support. Additionally, in cancer patients COVID-19 infection is also associated to a higher probability of multiple organ disfunction syndrome due to a widespread tissue distribution of angiotensin converting enzyme-2 (ACE-2), the functional receptor for SARS-CoV2. The immunosuppressive state due to malignant disease and its treatment also contribute to the observed higher-risk of complications. Recently, Lancet Oncology published a detailed information about the first 18 cancer patients diagnosed with COVID-19. Severe events, described as invasive ventilation and Intensive Care Unit (ICU) admission or death, were higher in cancer patients (39%) than the observed 8% in patients without cancer ( P=0.0003). However, cancer patients were older and more likely to have a history of smoking, which may contribute to an epidemiologic bias.
In a very near future, more robust data will be available. As the disease progresses, it will create strong dilemmas in cancer treatment decision-making. Cancer surgery is not considered elective and should be performed immediately in most of the cases. However, delay may apply when a good alternative is available, like neoadjuvant endocrine therapy in early-stage hormone receptor-positive, Her2-negative breast cancer. Adjuvant treatment should proceed due to its curative intent, however comorbidities, NNT and use of multigene tests will play an important role in determining each patient’s prognosis and risk of relapse, advising on the best suitable treatment. Cancer screening like mammograph and colonoscopy should be postponed. Patients with aggressive hematologic malignancy are urged for life-saving treatments. Stem cell transplantation and cellular immunotherapies are curative interventions for many with aggressive disease and cannot be delayed in specific cases. For patients who are candidates for allogeneic stem cell transplantation, a delay may be reasonable if the patient is currently well controlled with conventional treatment. Clinicians are encouraged to follow the recommendations provided by the American Society of Transplantation and Cellular Therapy and the European Society for Blood and Marrow Transplantation. Any cancer patient in deep remission who are receiving maintenance therapy, stopping chemotherapy may be an option. Prophylactic growth factors as would be used in high-risk chemotherapy regimens as well as prophylactic antibiotics may be of potential value at this particular moment. Treatment of metastatic disease would be based on the benefit, using evidence-based impact on overall survival, DFS, quality of life and performance status in a shared-decision making with each patient. Enrollment in clinical trials should be limited for those more likely to benefit the patient. Whenever possible, patients should be treated on outpatient basis. As the pandemic progresses, increasing ethical conflicts over the availability of hospital beds will be expected, imposing greater agility in the criteria used by doctors to define the terminality of cancer patients, as well as the beneficence or obsolescence of the proposed interventions. An unprecedent international effort has been provided by international agencies, specialty societies and medical journals to provide information on how do deal with cancer patients in the COVID-19 pandemic. American Society of Clinical Oncology (ASCO) has compiled a COVID-19 Clinical Oncology Frequently Asked Question (FAQs), which has been very useful as a collective intelligence effort on the web to support our daily decisions in caring for cancer patients.
A worldwide epidemic (pandemic) is an event, not a trend. It triggers an immediate and generalized response. As a social phenomenon, Rosenberg well-described its public character of dramatic intensity. It follows an archetypical pattern. It starts at a moment in time, proceeds on a stage limited in space and duration, follows a plot line of increasing and revelatory tension, moving to a crisis of individual and collective character, then slowing-down toward closure. The present pandemic also illustrate a new geographic integration of the society, review of human values and lessons to learn, that we hope would not go on denial.
NNT = Number Needed to Treat, DFS = Disease-free Survival
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13. Photo by Visuals on Unsplash