This page was last updated on 05/29/2020. Please check back frequently for updates.
Cancer.Net--ASCO’s patient information website has regularly updated information about COVID-19 for people with cancer and cancer survivors in English and Spanish.
Patient Care Information
ASCO has instituted a COVID-19 Clinical Questions Advisory Group to assist in the development of these resource pages. Its membership and declarations are available.
ASCO has developed the patient care guidance available on this page in the following fashion:
- ASCO determines the topics to be addressed based on questions that are received from ASCO members and others, as well as input from ASCO staff and the COVID-19 Clinical Questions Advisory Group.
- For each topic, ASCO staff work with the COVID-19 Clinical Questions Advisory Group to develop guidance in an iterative, collaborative fashion. This guidance refers to and highlights, where possible, evidence published in the peer-reviewed literature as well as guidance issued by national and local health authorities and professional organizations (e.g. Centers for Disease Control and Prevention (CDC), American Heart Association (AHA) and American Society for Radiation Oncology (ASTRO), etc.).
- Once draft guidance is developed for the topic, it is reviewed by ASCO’s Chief Medical Officer and Executive Vice President, who approves all statements regarding patient care.
- Approved guidance is then posted on the page.
The guidance is updated as new information emerges and all content is reviewed periodically in its entirety by ASCO staff to ensure consistency with rapidly changing guidance from other organizations and government agencies. The date of the last review/update is at the top of the page.
Patient Care: How should the care of cancer patients be modified during the COVID-19 pandemic?
DATA: What are the current data on care of patients with cancer and COVID-19? Are patients with cancer more likely to be infected? Do they have more complications?
The CDC is continuously updating its information on COVID-19. For the most up to date general information on the virus and the epidemic, the CDC is best source of information.
Mortality of patients with cancer and COVID-19
The most comprehensive data available to date on the cancer-specific case fatality rate that ASCO could identify is a Report of the WHO-China Joint Mission on Coronavirus Disease published on February 28, 2020. This report indicates that in China, as of the data cut-off (February 20) the case fatality rate for patients with cancer as a comorbid condition and laboratory confirmed infection was 7.6%. This is as compared to: overall 3.8%, no comorbid condition 1.4%, cardiovascular disease 13.2%, diabetes 9.2%, hypertension 8.4%, chronic respiratory disease 8.0%.
Dai et al, Cancer Discov have published a report that compared 105 patients with cancer to 536 patients without cancer who had been hospitalized in Hubei Province, China. Patients with cancer had a higher death rate than those without (Odds Ratio [OR] 2.34, 95% CI 1.15-4.77, p=0.03, 11.43% death rate in patients with cancer). After adjusting for covariates the OR for death was 2.17, p=0.06. The death rate was highest in those with hematological cancer (33.33%, 9 deaths) and lung cancer (18.18%, 22 deaths), although the total number of deaths was small. Patients with metastatic cancer had a higher risk of death (OR 5.58, 95% CI 1.71-18.23, p=0.01).
Deng et al, Crit Care reported an analysis of 44,672 patients with laboratory confirmed COVID-19, of which 107 had cancer. Patients with cancer had a significantly higher risk of death than those without (RR 2.93, 95% CI 1.34-6.41, p=0.006, 6 deaths in patients with cancer).
Miyashita et al, Ann Oncol and Mehta et al, Cancer Discov have reported on the outcomes of patients with cancer and COVID-19 during the outbreak in New York City. Miyashita et al reported that among 334 patients with cancer and COVID-19 who received care in one health system there was a non-statistically significant higher mortality rate for all patients with cancer (Relative Risk [RR] 1.15, 95% CI 0.84-1.57) but did find a significantly higher rate in cancer patients younger than 50 years of age (RR 5.01, 95% CI 1.55-16.2). However, this was based on only 3 deaths in patients with cancer and 23 deaths in those without. Mehta et al reported that among 218 patients with cancer and COVID-19 at a different health system there was a 25% case fatality rate in patients with solid tumors and a 37% case fatality rate (68 total deaths) in patients with hematological malignancies.
Severity and complications in patients with cancer and COVID-19
The most detailed report currently available that compares data on COVID-19 course of illness in patients with cancer to those without cancer ASCO could identify is Liang et al, Lancet Oncol. This paper, reporting on a prospective cohort of 1571 patients with COVID-19, 18 of which had a prior history of cancer, found that patients with a history of cancer had a higher incidence of severe events – defined as the percentage of patients admitted to an intensive care unit requiring invasive ventilation, or death – compared with other patients. It did not establish a definitive increase in incidence of COVID-19 infection. According to correspondence related to the report Xia et al (Xia et al, Lancet Oncol), these 18 patients represent a heterogeneous group and are not an ideal representation of the entire population of patients with cancer. A report by Guan et al, Eur Respir J analyzed 1590 patients and appears to be an updated analysis of the same cohort reported by Liang et al found a HR of 3.50 (95% CI, 1.60–7.64) for admission to intensive care unit, or invasive ventilation, or death in patients with malignancy (18 patients) compared to those without. Difficulties in interpreting these data have also been expressed by the Editors of the Journal of Clinical Oncology (Cannistra et al, JCO).
A systematic review and meta-analysis reported by Wang et al, Aging (Albany NY) identified four studies that addressed the severity of complications in patients with malignancy. In the meta-analysis, the odds ratio of severe complications was 2.29 (95% CI 1.00-5.23) for patients with cancer.
In the report by Dai et al, Cancer Discov mentioned in the previous section, patients with cancer were significantly more likely to require ICU admission (OR 2.84, 95% CI 1.59-5.08, p<0.01), have higher rates of severe/critical symptoms (OR 2.79, 95% CI 1.74-4.41, p<0.01). After adjustment for covariates, the ORs were 1.99 (p<0.01) and 3.13 (p<0.01) respectively.
In the report by Myashita et al, Ann Oncol mentioned in the previous section, patients with cancer were significantly more likely to require intubation (RR 1.89, 95% CI 1.37-2.61) based on 37 intubation events in 334 patients with cancer and 314 in 5,354 patients without.
Two new studies have been released in abstract form at the 2020 ASCO Annual Meeting that provide additional data on morbidity and mortality associated with COVID-19 infection in patients with cancer.
Incidence of COVID-19 among patients with cancer
Yu et al, JAMA Oncol reported on 1524 patients with cancer admitted from December 30, 2019 to February 17, 2020 to an oncology department of a hospital in Wuhan, China. The authors found that the infection rate among the patients with cancer (0.79% (12 of 1524 patients; 95% CI, 0.3%-1.2%) was higher than the cumulative incidence in the community served by the hospital (0.37%). Five of the 12 patients were undergoing anti-cancer therapy at the time of hospital admission. In a similar study, Rogado et al, Clin Transl Oncol reported a cumulative incidence of COVID-19 among 1069 patients with cancer admitted to a hospital in Madrid, Spain of 4.2% (45/1069), as compared to a cumulative incidence rate of 0.63% for Madrid as a whole.
Prevalence of cancer in patients with COVID-19
Desai et al, JCO Glob Oncol identified 11 studies of patients with COVID-19 that reported on the prevalence of cancer in those patients via a systematic review. They found an estimated prevalence of cancer of 2% (95% CI, 2%-3%) in patients treated for COVID-19. Emami et al, Arch Acad Emerg Med reported a similar review and meta-analysis and identified 10 studies and found a prevalence of malignancy of 0.92% (95% CI, 0.56%-1.34%).
However, higher prevalence of cancer in patients with COVID-19 has been seen in studies not included in the systematic reviews due to publication date. Montopoli et al, Ann Oncol reported that among 9,280 patients with COVID-19 treated in 68 hospitals in Veneto, Italy, 8.5% had a diagnosis of cancer.
Data related to specific cancer types
He et al, Leukemia reported on a cohort study of 128 patients with hematological cancers with COVID-19 infection compared with a contemporaneous set of 226 health care providers with COVID-19 infection as a comparison group. There was no significant difference in the proportion of patients with hematological cancers vs. health care providers (10% vs. 7%, p=0.322), but there was a significant difference in case fatality rate (62% vs. 0%, p=0.002). Most of the patients had either acute myeloid (39%) or acute lymphoblastic leukemia (20%); 59% had received chemotherapy, with a median interval from the end of the last cycle of chemotherapy of 9 days (range 7-19 days).
Cook et al, Br J Haematol have reported a high rate of mortality among patients with multiple myeloma with confirmed COVID-19 infection in the United Kingdom. Out of 70 patients identified via clinical audit at multiple institutions, 41 (54.6%) died, with a median time from onset of symptoms to death of 8.5 days. However, the median age of patients who died was 78 years.
No reliable evidence regarding patients with any other specific histology (e.g. breast, lung), therapy (e.g. immunotherapy, tyrosine kinase inhibitors), or subpopulation of patients with cancer (e.g. children, elderly) has been identified. As further evidence becomes available, ASCO will update this page.
GENERAL CARE: What are the recommendations for general care of patients with cancer?
ASCO encourages anyone caring for patients with cancer to follow the existing CDC guidance where possible:
- General health care facility and health care professional guidance
- Clinical care guidance
- Home care guidance
- High-risk subpopulation guidance
In addition to the general CDC guidance, the following practice points may be considered:
- Patients should be informed regarding the symptoms of COVID-19, and trained in proper handwashing, hygiene, and minimizing exposure to sick contacts and large crowds.
- At this time, no specific evidence or guidance on mask use by patients with cancer has been published. Patients and clinicians are urged to follow the CDC’s general guidance on mask wear — which now recommends that everyone should wear a cloth face cover when they go out in public — as well as guidance from local health authorities. There is no guidance or evidence to suggest that N95 masks are required.
- For cancer patients with fever or other symptoms of infection, a comprehensive evaluation should be performed, as per usual medical practice.
CANCER-TYPE SPECIFIC GUIDANCE: How should care for patients with cancer types (e.g. breast cancer, lung cancer) be affected?
ASCO does not have guidance specific to management of any cancer type, except as described in the sections below. However, ASCO will link to such guidance as other organizations publish it.
- Breast cancer
- The American Society of Breast Surgeons has published guidance on triage, prioritization, appropriate care, and reentry into therapy for patients with breast cancer available on its COVID-19 resource center.
- The American College of Surgeons has published guidance on triage of patients with breast cancer for surgery.
- An American multi-organizational panel has published recommendations on the triage, prioritization and treatment of breast cancer (Dietz et al, Breast Cancer Res Treat). An international group has also published recommendations on the same topic (Curigliano et al, Breast)
- An American group from Johns Hopkins Women’s Malignancies Program has published guidance on care for patients with breast cancer (Sheng et al, JCO Oncol Pract)
- The European Society of Medical Oncology (ESMO) has published guidance on care for patients with breast cancer (de Azambuja et al, ESMO Open)
- Gastrointestinal cancers
- An American group of oncologists has developed recommendations for minimizing risks to patients with gastrointestinal malignancies. (Lou et al, JCO Oncol Pract)
- The US Colorectal Cancer Alliance has published guidance on care for patients with colorectal cancer (Marshall et al, Colorectal Cancer)
- A French multi-institution group has published guidance on care for patients with peritoneal tumors (Glehen et al, J Visc Surg)
- ESMO has published guidance on care for patients with pancreatic cancer (Catanese et al, ESMO Open) and colorectal cancer (Vecchione et al, ESMO Open)
- Genitourinary cancers
- Canadian guidance on prioritizing systemic therapy in patients with genitourinary malignancies has been published. (Lalani et al, Can Urol Assoc J)
- An editorial in European Urology has presented considerations for the triage of patients for urological surgery, including patients with genitourinary malignancies (Stresland et al, Eur Urol)
- The Canadian Urologic Oncology Group and the Canadian Urological Association have published guidelines for care of patients with prostate cancer (Kokorovic et al, Can Urol Assoc J)
- Wallis et al, Eur Urol conducted a systematic review that provides guidance on the potential risks associated with delaying therapy for various genitourinary cancers.
- A British group has published guidance on care for patients with urothelial cancer (Patel et al, Clin Oncol (R Coll Radiol))
- Gynecological cancers
- The editors of the International Journal of Gynecological Cancer have published guidance for management of patients with those cancers. (Ramirez et al, Int J Gynecol Cancer)
- The National College of French Gynecologists and Obstetricians have published recommendations for the surgical management of gynecological cancers during the COVID-19 pandemic (Akladios et al, J Gynecol Obstet Hum Reprod)
- An American multi-institutional group has published recommendations for anti-cancer therapy and surveillance for recurrence of patients with gynecological cancers (Pothuri et al, Gynecol Oncol)
- Head and neck cancer
- The French Society of Otorhinolaryngology, Head and Neck Surgery (SFORL) and French Society of Head and Neck Carcinology (SFCCF) have published consensus recommendations on the management of patients requiring head and neck cancer surgery (Fakhry et al, Eur Ann Otorhinolaryngol Head Neck Dis)
- The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium has published detailed cancer-site specific recommendations for triage for head and neck cancer surgery (Head et al, Head Neck)
- Hematological malignancy
- The American Society of Hematology has released guidance related to several different malignancies.
- The Seattle Cancer Care Alliance has published guidance on managing patients with hematological malignancies (Percival et al, JCO Oncol Pract)
- Multiple Myeloma
- A Brazilian task force has published recommendations on the management of patients with lymphoid malignancies (Perini et al, Hematol Transfus Cell Ther)
- The French Society for the fight against Cancers and Leukemias in children and adolescents has published guidance on management of young patients with acute lymphoblastic leukemia (Baruchel et al, Bull Cancer)
- An Australia/New Zealand consensus statement on care for patients with lymphoma, chronic lymphocytic leukemia and myeloma is available (Di Ciaccio et al, Intern Med J)
- Hepatocellular carcinoma
- The International Liver Cancer Association (ILCA) has released guidance related to are of patients with hepatocellular carcinoma.
- Lung cancer
- An American group published new recommendations on the management of lung cancer (Singh et al, JCO Oncol Pract). An international group has published similar recommendations (Dingemans et al, J Thorac Oncol)
- A panel assembled by the journal Chest has published recommendations on management of lung nodules and lung cancer screening (Mazzone et al, Chest)
- The Thoracic Surgery Outcomes Research Network has published guidance on triage for thoracic surgery for patients with thoracic malignancies (Ann Thorac Surg)
- The American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Tumor Section and the Society for Neuro-Oncology (SNO) have published general guidance on care of patients with brain tumors and brain metastases (Ramakrishna et al, J Neurooncol)
- Guidance specific to management of patients with glioma has been published by two international multi-disciplinary groups (Mohile et al, Neuro Oncol, Bernhardt et al Neuro Oncol)
- Skin cancer
- An Italian group from the Policlinico Universitario A. Gemelli Hospital has published detailed recommendations on the triage of patients with skin cancer (Tagliaferri et al, J Eur Acad Dermatol Venereol)
- The United States Cutaneous Lymphoma Consortium has published recommendations on the treatment of cutaneous lymphoma (Zic et al, J Am Acad Dermatol)
- Multiple cancer types
- An Australian group has published detailed guidance on multiple cancer types (Segelov et al, JCO Oncol Pract)
SUBPOPULATION-SPECIFIC GUIDANCE: Is there any guidance specific to subpopulations of patients with cancer?
- Elderly Patients
- Pediatric Patients
- A multi-organizational group has published recommendations on care for pediatric patients (Sullivan et al, Pediatr Blood Cancer)
TESTING FOR COVID-19: What information is available on testing for COVID-19?
ASCO has prepared a special report, A Guide to Cancer Care Delivery During the COVID-19 Pandemic. This report provides guidance on testing for COVID-19 in both patients with cancer and in care providers.
ANTI-CANCER THERAPY FOR PATIENTS WITH COVID-19 INFECTION: Should cancer therapy be delayed in patients who are infected with COVID-19?
Patients receiving anti-cancer treatment and infected with influenza and other viruses are potentially at risk for serious complications such as pneumonia and hospitalization. In a paper by Zhang et al in Annals of Oncology, an association between anti-cancer therapy in the past 14 days and severe effects of COVID-19 infection was reported (HR=4.079, 95%CI 1.086-15.322, P=0.037) in 28 patients. Although these data are limited, interrupting anti-cancer treatment in patients with active COVID-19 should be strongly considered as continuation of treatment may lead to further immunosuppression and risk for serious complications.
It is unclear how long a delay after the infection has resolved may be necessary before initiating/restarting anti-cancer therapy, but treatment should not be resumed until symptoms of COVID-19 have resolved and there is some certainty the virus is no longer present (e.g., a negative SARS-Cov-2 test), unless the cancer is rapidly progressing and the risk: benefit assessment favors proceeding with cancer treatment. In the absence of cancer-specific guidance, the CDC has issued recommendations on discontinuing transmission-based precautions for patients with COVID-19; initiating/resuming anti-cancer therapy once transmission-based precautions are no longer necessary would be reasonable. The United Kingdom National Institute for Health and Care Excellence (NICE) has published rapid guidance on the delivery of anti-cancer therapy that suggests treatment may be initiated or resumed after one negative SARS-Cov-2 test.
SURGERY: Can/should surgery be cancelled or delayed? If surgery is delayed, should patients be started earlier on neoadjuvant therapy if that is an available option?
The CDC’s guidance for health care facilities suggests that “elective surgeries” at in-patient facilities be rescheduled if possible. The American College of Surgeons (ACS) has issued guidance as well and provides additional advice related to triage of patients for surgery relevant to cancer care. However, clinicians and patients will need to make individual determinations based on the potential harms of delaying needed cancer-related surgery; in many cases these surgeries cannot be considered “elective”. Also, if the surgery requires post-operative intensive care, the current capacity of the intensive care units available for that care should be considered as part of decision making. The Society of Surgical Oncology (SSO) has released brief guidance on surgery for cancer for several of different tumor types.
Sud et al, Ann Oncol report on an analysis of a number of sources of data and estimated the increase in five-year mortality associated with a 6 month delay in surgery for various cancers at Stage 1, 2 or 3. They estimated substantial increases (>30%) in mortality for stage 3 disease of multiple types at all ages. The only situations in which little or no increase in mortality was estimated were stage 1 disease of several types (e.g. breast, melanoma) and prostate cancer at any stage in all but the oldest age groups. With respect to prostate cancer, Ginsburg et al, J Urol reported on an analysis of the US National Cancer Database and found no association between delaying radical prostatectomy in patients with prostate cancer by up to 12 months and adverse outcomes.
In some situations (e.g. early stage breast cancer) where neoadjuvant therapy is available but not routinely considered, it may be reasonable to consider neoadjuvant therapy instead of surgery or simply delaying surgery. The risks of tumor progression with delay in definitive surgery should be weighed against the potential added burden on hospital resources, case complexity and patient risk of exposure to COVID-19. However, neoadjuvant therapy that requires clinic visits and clinician-patient contact or that itself is immunosuppressive is associated with risks to the patient that must also be considered.
RADIATION: Can/should the initiation of radiation be delayed? Can radiation be interrupted or postponed if already in progress?
ASTRO has addressed this concern in part on its COVID-19 resource page. ASCO encourages clinicians to follow ASTRO’s current guidance. As noted by ASTRO, if hypofractionated schedules are considered reasonable, they should be considered. ASCO recognizes the risks of delay in treatment for patients with rapidly progressing, potentially curable tumors may outweigh the risks of COVID-19 exposure/infection, but patients receiving radiation for symptom control or at low risk of harm due to alteration of schedule for radiation treatment visits could potentially be safely delayed. Patients should check with their radiation oncologist to determine the most appropriate course of action for their treatment. NICE has published rapid guidance on the delivery of radiation which may be of value.
IMMUNOSUPPRESSIVE THERAPY: Can/should potentially immunosuppressive therapy (except allogeneic stem cell transplantation) be stopped, delayed, or interrupted?
There is no little direct evidence to guide decisions around changing or withholding immunosuppressive therapy in patients with cancer (see Russell et al, Ecancermedicalscience, for a systematic review of the currently available limited and indirect evidence). Therefore, routinely withholding critical anti-cancer or immunosuppressive therapy is not recommended. The balance of potential harms that may result from delaying or interrupting treatment versus the potential benefits of possibly preventing or delaying COVID-19 infection is very uncertain. Clinical decisions should be individualized and consider factors such as the risk of cancer recurrence/progression if therapy is delayed, modified or interrupted; the number of cycles of therapy already completed; and the patient’s tolerance of treatment.
However, the following practice points should be considered:
- For patients in deep remission who are receiving maintenance therapy, stopping chemotherapy may be an option.
- Some patients may be able to switch chemotherapy from IV to oral therapies, which would decrease the frequency of clinic visits but would require greater vigilance by the health care team to be sure that patients are taking their medicine correctly.
- Decisions on modifying or withholding chemotherapy should include consideration of the indication for chemotherapy and the goals of care as well as where the patient is in the treatment course and their tolerance of treatment. For example, the risk/benefit assessment for proceeding with chemotherapy in patients with untreated extensive small cell lung cancer is different from that for patients on maintenance pemetrexed for metastatic non-small cell lung cancer.
- If local transmission affects a particular cancer center, reasonable options may include giving a chemotherapy break for two weeks, arranging infusion at an unaffected satellite unit, or arranging treatment with another facility that is not affected.
- Consider whether home infusion of chemotherapy drugs is medically and logistically feasible for the patient, medical team and caregivers.
- In some settings, delays or modifying adjuvant treatment may pose a higher risk of compromised disease control and long-term survival than in others.
- Prophylactic growth factors as would be used in high-risk chemotherapy regimens as well as prophylactic antibiotics may be of potential value in maintaining the overall health of the patient and make them less vulnerable to potential COVID-19 complications.
- In cases where the absolute benefit of adjuvant chemotherapy may be quite small, and where non-immunosuppressive options are available (e.g. hormonal therapy in ER+ early-stage breast cancer), risk of infection with COVID-19 may be considered as an additional factor in weighing the different options available to the patient.
STEM CELL TRANSPLANTATION: Can/should allogeneic stem cell transplantation be delayed?
In some cases involving patients at high-risk for COVID-19, delaying a planned allogeneic stem cell transplant may be reasonable, particularly if the patient’s malignancy is controlled with conventional treatment. Until further data are available, clinicians are encouraged to follow the recommendations provided by the American Society of Transplantation and Cellular Therapy (ASTCT); and the European Society for Blood and Marrow Transplantation (EBMT) recommendations with respect to stem cell transplantation. NICE has released rapid guidance on stem cell transplantation as well.
The following practice points may be considered:
- It may be prudent to test potential donors for COVID-19 even in an absence of evidence of transmission by blood transfusion.
- As a general precaution, visitation post-transplant may need to be limited and visitors may need to be screened for symptoms and potential exposure.
IMMUNE CHECKPOINT INHIBITORS: Can/should treatment with immune checkpoint inhibitors (e.g. ipilimumab, nivolumab) be delayed or interrupted? Are any special precautions or actions needed with respect to their use?
ASCO is not aware of data specific to immune checkpoint inhibitors and COVID-19 infection. It may be appropriate to adjust to less frequent dosing intervals when different schedules are considered reasonable options and/or are approved in your jurisdiction for the patient’s indication. However, there is preclinical evidence of cytokine storm and/or potentially increase inflammatory reactions and complications such as pneumonitis for some novel immunotherapy agents and T-cell therapy agents. These agents may cause immune-related serious adverse events and immunosuppression may not be advisable as a treatment for those events. The potential harms and benefits of therapy should be carefully considered for each patient. Where possible, COVID-19 testing prior to therapy with these agents is reasonable.
THERAPY FOR INFECTION: Should antiviral therapy or other therapy to treat COVID-19 be considered?
- Prophylaxis – Currently, there is no evidence or published guidance on the use of prophylactic antiviral therapy for COVID-19 in immunosuppressed patients. This is an active area of research and evidence may be available at any time. Prophylactic antiviral therapy directed at other viral infections should be continued according to standard clinical guidelines and institutional practices. Oseltamivir (Tamiflu) is not known to be effective in treatment of COVID-19. ASCO is aware that clinical trials are ongoing or have been reported in brief publications on the prophylactic use of potential antiviral medications (e.g. remdesivir, lopinavir) and anti-malarial drugs such as chloroquine with anti-viral properties, but to date, none of these trials have been specific to patients with cancer. CDC has information that describes the current state of research on therapy for COVID-19. Also, the American Society of Health-System Pharmacists (ASHP) has provided a resource that shows current evidence and known ongoing clinical trials of antiviral therapies.
- Treatment for Infection – The US National Institutes of Health (NIH) has guidance on therapy for infection. These guidelines are changing rapidly and should be reviewed prior to considering therapy. The Reagan-Udall Foundation for the Food and Drug Administration’s page on COVID-19 provides information on clinical trials that are beginning or underway. There has been one randomized controlled trial published to date of remdesivir for the treatment of hospitalized patients with COVID-19 infection (Beigel et al, N Engl J Med)
IMPACT OF CONCOMITANT MEDICATIONS ON COVID-19 OUTCOMES: Are there any concerns or issues surrounding concomitant medications for patients with cancer?
In addition to the guidance presented below, the NIH has guidance on concomitant medications that may be relevant to patients with cancer. It is changing rapidly and should be reviewed frequently.
- Cardiac medications – The American Heart Association has issued a statement recommending that treatment with RAAS antagonists (e.g. ACE inhibitors) be continued at the present time. In addition, three recently published papers in the New England Journal of Medicine did not find any evidence of increased harms from ACE inhibitor therapy; see Jarcho et al, N Engl J Med for an editorial summary and links to the papers.
- G-CSF – G-CSF should be used judiciously and in accordance with ASCO guidelines. Prophylactic use with highly myelosuppressive immunotherapy would still be justified to avoid neutropenia or myelosuppression which may put the patient at higher risk of infection with COVID-19. In the case of patients with active COVID-19 requiring GCSF for neutropenic fever or neutropenia, there are limited or no data. Judgement needs to be exercised depending on the clinical situation. See section below on neutropenic fever and neutropenia for additional information.
- Other medications – ASCO will provide information as it becomes aware of it to help clinicians and patients make decisions about other medications. See Russell et al, Ecancermedicalscience, for a systematic review of the currently available limited and indirect evidence on several medications that are used in patients with cancer.
IMMUNE COMPROMISE IN SURVIVORS: How should care of survivors of cancer with long term immune suppression (e.g. hypogammaglobulinemia) be altered?
ASCO recognizes that patients with long term immune suppression may be at increased risk of infection. However, at this time no recommendations can be made to alter care for these patients beyond the care they would normally receive. These patients should follow all of the general measures (e.g. social isolation) advised by the CDC to minimize their exposure to potential infection. Patients who receive intravenous immunoglobulin should continue to receive it at the prescribed dose and schedule.
OTHER THERAPY: Are there any other therapies that should be delayed, interrupted, or stopped?
At this time, ASCO cannot provide specific guidance on any other form of cancer therapy. As more data becomes available, this information will be updated. In general, however, any decisions to postpone, discontinue or modify necessary systemic cancer therapy should consider the overall goals of treatment, risks of cancer progression if treatment is postponed or interrupted, patient tolerance of treatment and the patient’s general medical condition. Each decision requires an individualized risk/benefit assessment.
NEUTROPENIC FEVER AND NEUTROPENIA: How can/should care for patients experiencing potential neutropenic fever and neutropenia be affected by the ongoing COVID-19 pandemic?
ASCO recognizes there are two aspects to care of patients with potential neutropenic fever in relation to COVID-19: prophylaxis and acute care.
- Prophylaxis – It may be reasonable for patients at risk for neutropenic fever to be prescribed growth factor for treatment regimens at a lower level of expected risk (e.g. >10% risk) in order to minimize the risk of neutropenic fever and the potential need for emergency care, with instructions for neutrophil count monitoring and regular contact with their health care team.
- Acute Care for Potential Neutropenic Fever – It may be reasonable in the current situation to evaluate the potential for neutropenic status in the febrile patient by telemedicine or by phone to determine whether a patient should be evaluated in the clinic or sent to the emergency department.
- Acute Care for Known Neutropenic Fever – Standard guidelines for care of neutropenic patients, including isolation, should be followed regardless of COVID-19 status. Rapid COVID-19 testing should be used, if available, to determine level of PPE necessary for caregivers and appropriate location in the facility for continued care. In the absence of rapid testing, manage the patient for neutropenic fever per standard guidelines under the presumption of COVID-19 infection.
CANCER-RELATED ANEMIA: How can/should care for patients at risk for or experiencing cancer-related anemia be affected by the ongoing COVID-19 pandemic?
- Prophylaxis – Considerations should be given to erythropoietin-stimulating agents, where serious and/or symptomatic cancer/treatment-related anemia is anticipated, and the agents are deemed to be safe. Prophylactic transfusion in asymptomatic patients based on laboratory values should be avoided if possible.
- Acute Care – Transfusion should be given where serious and/or symptomatic cancer/treatment-related anemia occurs in accordance with usual practice. The American Society of Hematology’s (ASH) previously issued Choosing Wisely guidance recommends not transfusing more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, non-cardiac in-patients). When considering transfusion, the specific patient circumstances (e.g. elderly, congestive heart disease) should be considered and may warrant a higher hemoglobin threshold, particularly for patients on ventilatory support with diminished oxygen-carrying capacity. As blood donation may be affected by community public health measures, the local blood supply must be considered as part of decision-making. Consideration should be given to simultaneously initiating erythropoietin-stimulating agents where they are deemed safe.
CENTRAL VENOUS CATHETERS/PORTS: How can/should the central venous catheters/ports be maintained? Can flushing be delayed?
There is evidence that flushing can occur at frequencies as long as every 12 weeks with no notable increase in adverse events or harms. If patients can flush their own devices, that should be considered, although the process of training may itself be a source of exposure and access to sterile supplies at home may be limited.
ADVANCE CARE PLANNING: Should we discuss code status with patients on active treatment?
Proactive advance care planning is important for all cancer patients, especially now with the additional risk of COVID-19. This discussion has become more urgent than ever in this pandemic with the risk that your patient may be admitted emergently to the hospital and cared for by another team without your ability to participate, advise, and guide an end of life discussion. ASCO urges oncologists to engage in advance care planning discussions with their patients and encourages the use of advance directives or other expressions of end of life preferences, as well as clear documentation of these conversations.
The following resources are available from the Center to Advance Palliative Care™ and Respecting Choices®:
For cancer patients with COVID-19, who are at increased risk of needing mechanical ventilation or ICU care, a POLST conversation is appropriate. See National POLST for more information.
CANCER SCREENING: Can/should members of the community continue recommended cancer screening activities (e.g. screening mammography)?
To conserve health system resources and reduce patient contact with health care facilities, ASCO recommends that cancer screening procedures that require clinic/center visits such as screening mammograms and colonoscopy be postponed for the time being. Clinical care teams are advised to carefully weigh the risks and benefits of pursuing elective procedures, such as screening procedures, at this time.
DIAGNOSIS AND STAGING: How can/should diagnosis and staging interventions (e.g. imaging visits, biopsy) be modified by the ongoing COVID-19 pandemic? Is there any evidence that COVID-19 infection influences the ability to diagnose or stage disease (e.g. chest imaging for potential lung cancer)?
In general, as recommended by the CDC, any clinic visits that can be postponed without risk to the patient should be postponed. This may potentially include patients who are suspected clinically of disease at low risk of rapid progression (e.g. minor suspicious findings on mammography).
ASCO is aware of no evidence that that COVID-19 infection interferes with or influences the diagnosis and staging of cancer. In a patient newly diagnosed with cancer, it is reasonable to limit staging procedures only to those that are most necessary to inform development of the initial care plan. Should evidence become available, this statement will be updated.
SURVEILLANCE: Can/should patients receiving ongoing surveillance (e.g. imaging for detection of recurrence, active surveillance for existing disease) have that surveillance delayed/interrupted?
In general, as recommended by the CDC, any clinic visits that can be postponed without risk to the patient should be postponed. This likely includes routine surveillance in patients considered to be at relatively low risk of recurrence and those who are asymptomatic during the follow-up period. In situations where existing recommendations provide frequency ranges for interventions (e.g. every 3-6 months) it is reasonable to delay scheduled interventions to the longest recommended frequency duration.