This post is updated regularly. It was first published on March 20.
The American Society of Clinical Oncology (ASCO) and the National Coalition for Cancer Survivorship (NCCS) are working together to provide information about how coronavirus 2019 (COVID-19) could potentially affect the health and cancer care of people diagnosed with cancer. Below are answers to cancer survivors’ frequently asked clinical questions about COVID-19 from ASCO Chief Medical Officer and Executive Vice President Dr. Richard Schilsky. Individual names were not used in connection with preparing these FAQs. NCCS will provide answers to general questions about COVID-19 and patient advocacy on its website, canceradvocacy.org. NCCS’ mission is to advocate for quality cancer care for all people touched by cancer. ASCO represents nearly 45,000 oncology professionals who care for people living with cancer.
We hope this information is helpful to you.
Dr. Richard Schilsky
Chief Medical Officer and
Executive Vice President, ASCO
Shelley Fuld Nasso
Chief Executive Officer, NCCS
Q1: Can you briefly describe what it means to be 'immune compromised'?
The term ‘immune compromised’ refers to individuals whose immune system is considered weaker, more impaired, or less robust than that of the average healthy adult. The primary role of the immune system is to help fight off infection. Individuals with compromised immune systems are at a higher risk of getting infections, including viral infections such as COVID-19. There are many reasons that a person might be immune compromised: health conditions such as cancer, diabetes, or heart disease, older age, or lifestyle choices such as smoking can all contribute to weakened immune systems. Patients with cancer may be at greater risk of being immune compromised depending on the type of cancer they have, the type of treatment they receive, other health conditions, and their age. The risk of being immune compromised is typically highest during the time of active cancer treatment, such as during treatment with chemotherapy. There is no specific test to determine if a person is immune compromised, although findings such as low white blood cell counts or low levels of antibodies (also called immunoglobulins) in the blood likely indicate an immune compromised state.
Q2: Does a history of cancer raise your risk for health complications from COVID-19 (SARS-CoV-2)?
It appears that patients with cancer and survivors of cancer may be at higher risk of health complications from COVID-19. This is not surprising given that this group of individuals is often immune compromised. There is also evidence from one study (Liang et al, Lancet Oncol, http://dx.doiorg/10.1016/S1470- 2045(20)30096-6) that reported patients with a history of cancer had a higher incidence of severe complications, including needing intensive care unit care, mechanical ventilation (being on a breathing machine) or death, compared with other patients who did not have cancer. This is just one study though, and the small number of cancer patients in that study (18 patients) cannot necessarily be generalized to all patients with cancer.
Q3: Does having received chemotherapy or radiation in the past raise your risk for getting COVID-19 or having a more serious course of illness?
To date, no evidence is available to suggest that any cancer treatments raise your risk for getting COVID-19 any more or less than anyone else who is exposed to the virus. There is some evidence that patients with cancer may experience more serious COVID-19 infection if they acquire it, likely because cancer and cancer treatment can contribute to weakened immune systems which can then lead to a reduced ability to fight off infections. Patients who are getting treatment for cancer also interact with the health care system more frequently than the general population, so more exposure in that setting may contribute to a higher risk of getting an infection, but that is not known with certainty at this point. Patients are advised to speak with their cancer care team about whether non-essential clinic visits can be skipped, re-scheduled, or conducted by telephone or videoconferencing. Keep in mind, however, that skipping a treatment for cancer because of concerns about the risk of infection with COVID-19 is a serious decision and something that should be discussed with your oncologist.
Q4: Should cancer survivors follow the general public health recommendations issued by the CDC?
Absolutely. The general public health recommendations issued by the U.S. Centers for Disease Control and Prevention (CDC) make good sense at any time, but more so during times such as the COVID-19 outbreak. Things like keeping social distance, frequent and proper hand washing, avoiding large crowds, keeping surfaces clean and disinfected, and not touching your face when your hands are not thoroughly washed are all good strategies for anyone, but maybe even more important for cancer patients and survivors who may be immune compromised. The CDC is keeping on top of the situation and there is no specific reason that any additional measures like wearing a facemask, or other apparatus when you are not sick, is needed if you are already following the advice they are giving. You can find the CDC guidance here on its website.
Q5: What advice do you have for patients who are on oral cancer therapies such as TKIs?
Cancer is a serious condition that requires treatment. Regardless of the type of treatment, the best advice is to talk with your cancer care team about whether or not any modifications to your cancer treatment regimen are necessary. In the absence of any symptoms or signs of COVID-19 infection, continuing your cancer treatment is likely to be the best course of action.
Q6: Are people who are on endocrine therapies, such as for breast or ovarian cancers, at more risk for getting COVID-19 or having a more serious illness?
There is no specific evidence to suggest that endocrine therapies can raise the risk for getting COVID-19 or having a more serious illness. Most endocrine therapies do not suppress the immune system.
Q7: If a cancer patient or cancer survivor feels some early symptoms such as fever or cough, should they contact their medical oncologist or primary care physician?
If on active cancer treatment, then patients should contact their treating oncologist by phone and make any arrangements as needed. If not on active treatment, then cancer survivors should contact their primary care doctor by phone and make any arrangements as needed.
Q8: If a person is about to start cancer therapy, should they consider postponing treatment due to COVID-19?
There are many factors to consider when making an important decision such as postponing cancer treatment in order to avoid a potential infection with COVID-19. Patients should talk with their treating oncologist about the risks of postponing treatment versus the potential benefit of decreasing their infection risk. Things to discuss include the goals of cancer treatment, the likelihood that the cancer will be controlled with the treatment being planned, the intensity and side effects of the cancer treatment, and the supportive care that is available to reduce the side effects of treatment.
Q9: I have a central venous catheter/port. What should I do about flushing it regularly?
There is evidence that flushing can occur at intervals of up to every 12 weeks with no increase in adverse events or harms. Speak with oncology care team about the flushing schedule that is right for you and ask if you may be able to flush the port yourself should it become necessary.
Q10: I am a survivor of cancer who receives regular scans/imaging/tests to detect potential recurrence. Should I keep getting this testing?
In general, as recommended by the CDC, any clinic visits that can be postponed without risk to the patient should be postponed. This includes routine surveillance visits to detect cancer recurrence. In many cases, the recommended frequency of these visits is already considered a range (e.g. 3 to 6 months), so extending the time between evaluations may still be within the recommendations. If you develop a new symptom that might indicate cancer recurrence you should contact your cancer care team and not wait for the next scheduled evaluation.
Q11: What else can I do to help fight COVID19?
The most important thing you can do is follow the public health guidance provided by the CDC and your state and local health departments, as mentioned in Q4.
Another way to help would be to consider participating in research studies such as the Beat19 study or this study at Stanford. These are studies that nearly anyone can participate in and they seek to learn more about what happens before, during and after you have symptoms of COVID-19.
Q12: Is there anything I can do to improve my general health and my immune system?
You should follow the recommendations of your care team and general recommendations for a healthy lifestyle. Don’t use tobacco products, eat a well-balanced diet rich in fruits and vegetables, exercise regularly, get enough sleep and follow public health guidelines on social distancing and hand washing.
The editors of the Journal of Cancer Survivorship have written a commentary that provides a list of additional sources of support for survivors.
Q13: If I have a delay in care, or if for some reason I need to change providers to receive care, is there anything I should do with respect to my medical records?
If you need to change providers you should arrange for copy or transfer of your medical records to your new provider. Transferring the most complete record set possible is desirable, but certain parts of the record are particularly important, such as the pathology report that established your cancer diagnosis, reports of any surgeries or radiation treatment performed as part of your cancer treatment, a summary of any chemotherapy treatments administered, and the results of your most recent scans, x-rays, or other cancer evaluations.
Q14: I am in the process of diagnosis and staging for cancer. What should I do?
Given current circumstances regarding availability of medical services and in the interest of patient safety, it may be necessary to forego some of the procedures and tests customarily done to establish the extent of spread of the cancer (stage). Patients should discuss with their oncologists what diagnostic and staging tests are likely to be most informative in developing an initial treatment plan and should prioritize obtaining those tests if possible.
Q15: I want to get a second opinion on my diagnosis or recommended therapy, but second opinions are not possible right now. What can I do?
We encourage second opinions but recognize they may be difficult to schedule at this time. If a second opinion can be obtained by telephone or telehealth consultation, then that should be considered a reasonable alternative to no second opinion at all.
Q16: I have several comorbidities as well as cancer. Am I at higher risk for COVID-19? Does it matter if those comorbidities are controlled by medication?
Patients with comorbidities, such as hypertension, cardiovascular disease, pulmonary disease, chronic kidney disease, obesity, and diabetes, appear to be at particularly high risk of serious complications from COVID-19. Most reports have not described the extent to which these comorbidities were controlled by medication or lifestyle change at the time of onset of COVID-19 infection. It is reasonable to assume, however, that comorbidities that are well controlled by medication are less likely to predispose a person to severe complications from COVID-19.
Q17: Does smoking and/or vaping increase the risk of COVID-19?
ASCO is not aware of specific data relating current or former vaping to risk of COVID-19 or risk of complications from this illness. However, it is reasonable to assume that smoking, vaping, or other behaviors or exposures that cause lung injury might increase the risk of complications from COVID-19.
Q18: Do most people have long-term effects from COVID-19?
It is too soon to say what the long-term effects of COVID-19 will be. However, it is already clear that some patients develop complications in multiple organ systems, including neurological complications, kidney failure, heart attack or heart failure, and blood clots. These serious complications could have long-term consequences, but extended patient follow-up is needed to understand the long-term effects.
Q19: What about antibody testing to see who has been exposed to or is immune to COVID-19?
Antibody testing is just now becoming available. It tests whether a person has been exposed to the SARS-COV-2 virus. It is too soon to say whether a positive antibody test means that a person has any form of immunity to the novel coronavirus.
Q20: It has been said that COVID-19 can cause lung scarring. Are there other diseases that cause lung scarring? Will this increase the chance of a person developing lung cancer in the future?
Many acute and chronic pulmonary infections can cause scarring, as can chronic lung inflammation from smoking, occupational exposure to dust or asbestos, or autoimmune disease. Whether scarring increases the risk of lung cancer is more likely related to the underlying cause of the scarring (for example, smoking or asbestos exposure) than to the scarring itself.
Q21: What are the recommendations for retesting of COVID-positive patients before restarting chemotherapy?
It is unclear how long a delay after the infection has resolved may be necessary before beginning or restarting cancer treatment. Treatment should not be resumed until the symptoms of COVID-19 have resolved and there is some certainty the virus is no longer present, specifically, a negative SARS-Cov-2 test, unless the cancer is rapidly progressing and the risk-benefit assessment favors proceeding with cancer treatment.
NCCS will provide answers to general questions about COVID-19 and patient advocacy on its website, canceradvocacy.org.