Is Cancer Elective? COVID versus Cancer

As a cancer specialist, like many others who care for patients with cancer, I was faced with the unimaginable dilemma of responding to the pressure to limit “non-essential” care. How? Who? When? For how long? These are the questions that immediately flooded my mind and still haunt me as I think about my previous patients, those currently being cared for by our team of expert oncologists, and new patients seeking our care. This is something we never trained for or dreamed of ever having to face. Cancer centers all over the world have to deal with this medical and largely ethical dilemma. It is a struggle for cancer centers to continue to provide much needed cancer care while preparing and providing care for the community as they face the wrath of this pandemic coming their way. On the one hand, cancer is inherently life threatening. How can we possibly “defer” its care? What guidelines, if any, should we follow? On the other hand, patients with cancer may have higher risk of mortality if they contract COVID-19, and cancer treatment itself may increase that risk. 4 The most comprehensive data available to date on the cancer-specific case fatality rate is a Report of the WHO-China Joint Mission on Coronavirus Disease published on February 28, 2020.5 This report indicates that in China, as of the data cut-off (February 20, 2020), the case fatality rate for patients with cancer as a comorbid condition and laboratory-confirmed infection was 7.6%.  This is as compared with: overall 3.8%, no comorbid condition 1.4%, cardiovascular disease 13.2%, diabetes 9.2%, hypertension 8.4%, chronic respiratory disease 8.0%. 6 By deferring care, are we protecting patients with cancer or are we delaying much-needed treatment for their cancer? These decisions continue to be difficult to make and are based primarily on a case-by-case risk-benefit analysis. In general the guiding principle for these decisions depends on the nature of the cancer itself and its “aggressiveness”. 7 Patients who are not harmed by deferring their cancer treatment, such as those with indolent slow-growing cancers, perhaps can have their treatment safely deferred for 8-12 weeks until their risk of contracting COVID-19 is lower and their cancer treatment less likely to adversely influence their outcome should they become infected with the virus. The decision with most cancers, however, is more agonizing.