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
1. World Health Organization (WHO): Coronavirus Disease (COVID-19) Pandemic
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4. Peng Zhou, Xing-Lou Yang, Xian-Guang Wang, et al: A pneumonia outbreak associated with a new coronavirus of probable bat origin, Nature, Feb 13th, 2020
5. New England Journal of Medicine: Coronavirus (COVID-19) A collection of articles and other resources on the Coronavirus (COVID-19) outbreak, including clinical reports, management guidelines, and commentary, New England Journal of Medicine (Link: https://www.nejm.org/coronavirus)
6. American Society of Clinical Oncology (ASCO) Coronavirus Resources (Link: https://www.asco.org/asco-coronavirus-information?cid=DM4727&bid=39524253)
7. COVID-19 Clinical Oncology Frequently Asked Questions (FAQs) (Link: https://www.asco.org/sites/new-www.asco.org/files/content-files/blog-release/pdf/COVID-19-Clinical%20Oncology-FAQs-3-12-2020.pdf?cid=DM4727&bid=39524253)
8. Masumi Ueda, Renato Martins, Paul C. Hendrie, et al: Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal, Journal of the National Comprehensive Cancer Network (NCCN), Mar 16th, 2020
9. American Society for Transplantation and Cellular Therapy Response to COVI-19 (Link: https://www.astct.org/connect/astct-response-to-covid-19)
10. Coronavirus Disease COVID-19 Recommendations by European Society for Blood and Bone Marrow Transplantation
11. Sociedade Brasileira de Oncologia Clinica (SBOC): Especial SBOC coronavírus (COVID-19) (Link: https://coronavirus.sboc.org.br/coronavirus/)
12. Charles E Rosenberg: What is an Epidemic? AIDS in Historical Perspective, MIT Press on behalf of American Academy of Arts & Sciences, Daedalus, 1989
13. Photo by Visuals on Unsplash
The pandemic of covid-19 brought new challenges in the treatment of cancer. This way, it's necessary to think about all the complications that adjuvantes therapies against cancer may bring to a organism that is already susceptible to infection by Coronavirus due to cancer. So, it's responsability of the physicians reflect if the treatment against cancer in this moment will not bring more harms than benefits to the pacients.
The current world health scenario is pandemic. We have learnt a lot about prevention by these months. Simple behaviors; “washing hands”, “using mask”…- nonetheless, we must think about this broadly. In cancer, e.g.; the majority of them have cure, but mostly, their majority can be avoided by healthy habits practicing. Prevention should be emphasized by all nations, firmly, with government and non-government campaigns and influence. Not only now, with the respiratory transmission of coronavirus; but also in a non-pandemic scenario. Washing hands, healthy foods, exercise, no smoking, no drinking… Thus, lots of suffering will be avoided.
The COVID-19 pandemic haven't just changed the cancer scenario, but it has changed the whole medicine itself (at least, in 2020; we can make a parallel between our actual episode and the AIDS epidemic in the 1970 decade). Every single day, articles are being published about this subject, saying completely the opposite about recent articles about COVID-19, after all, it's a new disease and no one really knows the impact in the human body. We have manners to prevent it (washing your hands, using masks, avoid personal contact, for example), and the government must provide information about it to its society to decrease the number of new cases. When we talk about cancer, we analyze the relation between cancer and the virus and its impact on genes and the patient health status.
In 2020, the new COVID-19 pandemic has been challenging not only medicine by itself, but also its most promising fields. When we talk about Oncology, it’s not different: today, for instance, the worldwide crisis creates doubts about the benefits and the side effects for continuing treatments and diagnosis tests. In the future, will we be able to use these informations in our favor at the same time science shows us what was wrong and what was right? What are going to be the impact, for example, of the non realization of screening cancer, as mammography and colonoscopy?
In the face of the COVID-19 pandemic, 2020 has been a challenging year in the medical field, and certain specialties, such as Oncology, end up facing more complicated dilemmas. Oncologic patients are not only more likely to meet worst outcomes when infected with SARS-CoV2 – due to cancer systemic manifestations or immunosuppressive treatments -, but also usually need surgery or chemotherapy which cannot be postponed and have the potential for increasing these patients’ vulnerability. In this context, the increasing importance of precision medicine in cancer management is emphasized, allowing more effective results with minimal side effects.
The COVID-19 pandemic has changed a lot in our routines. Social distancing is now the most effective way to look after everyone and ensure health systems stay available. However, for care providers, that’s a complicated line to draw: how well can we perform our job and still manage to keep our patients safe, especially for those who already have a more fragile health, such as the elderly or the oncological patients? One thing is for sure, this pandemic is leading us to the consolidation of individualized medicine and decision making and not just in the oncology field.
The most recent coronavirus identified, causes the infection called COVID-19, which can cause acute respiratory syndrome, among other manifestantions. People with systemic arterial hypertension, diabetes mellitus, heart disease, lung disease, cancer and other conditions that cause decreased immunity are at greater risk of developing the most severe form of the infection. New challenges have arisen in the treatment of cancer in the context of the pandemic, mainly regarding treatments and screening tests that may not be being performed, since some procedures are now considered elective - mammograph and colonoscopy. It is important to keep in mind that some forms of aggressive cancers can evolve in this context, making future treatments more difficult and possibly causing deaths. In fact, a huge ethical dilemma.
Since this post was published, we’ve seen many changes regarding the information we have about Coronavirus. Currently, the disease has caused 730,000 deaths, and its fatality rate according to the WHO may be around 0.6%. The last pandemic of comparable proportions happened 100 years ago, so our social memory of how to behave in such situation is compromised. We are, as a society, learning together how to deal with this pandemic. There is still much to be consolidated regarding the treatment, prevention and management of Coronavirus. Our best perspective is that our conduct get increasingly guided by science, only then will we be driven to the best possible resolution of the situation.
In the face of a pandemic such as COVID-19, it should be pretty clear by now that the postponable should be postponed, therefore maintaining solely interventions that represented an increase in overall survival. Being cancer patients more susceptible to the complications of SARS-CoV2, treatments with curative intent should be maintained, but maintenance therapy for patients in deep remission should be questioned. The less immunocompromised the patients are, the less likely they are to contribute to the ever-growing number of fatalities due to COVID-19.
Another grim aspect of covid-19 and cancer are the diagnoses that would have been made if not for people's fear of seeking medical attention. The number of treatable neoplasias which have been left undiagnosed for lack of investigation (not at the health system's fault, but out of the patient's fear of contamination) certainly will be an alarming statistic we will face in the years to come.
In the COVID-19 pandemic, cancer patients are more susceptible to complications caused by SARS-Cov2, due to comorbidities and immunosuppression. This context requires that the risk-benefit ratio of cancer treatment be considered for patient safety. It is extremely important that health professionals carry out treatment procedures according to the existing evidence on risk-benefit, aiming at a better response by the patient.
It is irrefutable that the pandemic is promoting numerous changes in medicine as a whole, including the cancer field. Although cancer surgery is not considered elective, delays could be applied when there is another option available. In addition to that, new screening counseling and treatment options are being adopted. As a matter of fact, we have already been able to see some effects of the new adjustments such as ethical conflicts, demanding changes not only in the criteria used by doctors to define the terminality of cancer patients but also in the beneficence or obsolescence of the proposed interventions. Hence, 2020 might have completely changed the cancer treatment decision-making.
A significant change that has occurred with the covid-19 pandemic is the drop in demand for medical appointments for cancer screening. Routine gynecological consultations for cervical cancer screening through Pap smears, for example, have been postponed by countless women, and this will have consequences in the future, with a possible increase in the incidence of this cancer and overload of the health system.
Although representing a potential risk group, cancer patients should not stop their treatment on their own. All decisions must include the health team. Despite their condition, cancer patients can increase protection to avoid contact with the virus. Having only one companion, keeping a distance from other people, avoiding treatment sites for longer than necessary, and following prevention advice are some of the propositions recommended.
We are in 2022 and the COVID-19 pandemic still shows reflexes with variants leading to the adaptation of health professionals and their patients. In the oncological context, due to the fear of contamination, the normal course of diagnoses and treatments sometimes suffered interference. In view of this, it has been analyzed how the postponement can reflect on the course and outcome of the different situations. Allied to this, it is observed how important it is to ethically discuss what brings more benefit or harm to the patient, aiming at agility, but at the same time being careful with their situation in the face of the current pandemic moment.
A global sanitary crisis, such as the current pandemic, uncovers multiple issues within our health systems. In a rather speculative vision, since written in the early days of the COVID-19 pandemic, the article presents one of these issues - the interchangeable manner in which different diseases and treatments relate to one another. Now, almost two years later, we can factually see the many consequences of an exhausted health network in the diagnoses and treatment of multiple illness, including cancer. This comes to shine light in the importance of a collective and ethic approach to all actions regarding a patient’s care.
It is interesting to compare the present moment of the pandemic to this writing, since it was written in March 2020, the beginning of this health crisis. Cancer patients are at high risk of serious complications by COVID-19; not only owing to the imunossupressive state caused by the disease itself, but also to its treatment, which also imunossupresses the organism. Therefore, this population needs shared decision making, because the life of these people are more endangered compared to others in the pandemic. Fortunately, the government is aware of this, and people with cancer are prioritized to be vaccinated.
The article highlights the problem involving the treatment of cancer patients within the context of the Covid-19 pandemic, since they are immunosuppressed, they present a high risk of developing more severe cases of the disease. Within the large group of cancer patients, it is necessary to understand which ones cannot have their procedures postponed, such as those that stem cell transplantation and cellular immunotherapies are curative interventions with aggressive disease, or in the case of oncological surgery that is not considered elective and must be done urgently; and those in which a delay may be reasonable (if the patient is currently well controlled with conventional treatment), such as those awaiting allogeneic stem cell transplantation. At the same time, cancer screening, such as mammography and colonoscopy, should be postponed. Each decision must be individualized, according to the characteristics of the neoplasm and the patient in question.
These 2 years of a pandemic we faced made us learn to lead in different ways with things we commonly dealt with before that. We had to relearn how to investigate and treat cancer, to know when it can wait to be investigated and treated, whether or not to change the patient's prognosis. In addition to all this dilemma, we had to learn how the disease can interact with COVID and what the consequences will be.
Currently we are in 2023, and since the beginning of the COVID-19 pandemic our perspective on the disease and its impact on our society has changed a lot. The topic about people who were at higher risk during this health crisis was recurrent, and in this group were the patients who live with cancer and also care providers. Therefore, there were many things we learned through this problem, and one of them is that this pandemic is leading us to the consolidation of individualized medicine and shared decision making, in a way that we can treat as people fairly, like prioritizing this portion of the population to be vaccinated.
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