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.