|GERIATRIC ONCOLOGY SECTION
|Year : 2020 | Volume
| Issue : 5 | Page : 71-75
Management of geriatric cancer patients during the COVID-19 pandemic
Department of Medical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
|Date of Submission||04-Apr-2020|
|Date of Decision||08-Apr-2020|
|Date of Acceptance||09-Apr-2020|
|Date of Web Publication||25-Apr-2020|
Department of Medical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Physiological vulnerabilities greatly impact the outcome of coronavirus disease 2019 (COVID-19) infection. The COVID-19 infection results in far more serious illness in patients with compromised physiological reserve (older patients, infants, and pregnant women) and in those with preexisting or poorly controlled comorbidities. The COVID-19 infection can be life-threatening in older patients with cancer, but there are no standard guidelines or individual hospital data regarding methods or policies implemented to guide clinicians. Evolving clinical experience suggests that cancer patients with COVID-19 have more serious complications, such as intensive care admission from severe pneumonia or sepsis and a greater case fatality rate. Cancer history portends the highest risk of serious events. Considering the evidence for a clear association for older age and higher levels of comorbidity with more severe COVID-19 symptoms and adverse outcomes, the concept of risk mitigation is highly relevant to older patients with cancer. Chronological age alone cannot be relied on to ascertain the true biological status of an individual, and a comprehensive geriatric assessment (CGA) provides a multidisciplinary diagnostic process that encompasses several objectively evaluable domains to reliably and objectively assess medical, psychosocial, and functional limitations. With formal assessment tools, previsit questionnaires and appropriate training can reduce this burden on the clinician performing the initial CGA. This would enhance overall capabilities in reliable use of recommendations regarding treatment for comorbidities, geriatric syndromes, supportive care, drug interactions, and toxicities. Routine use of CGA would mitigate most of the risks related to biological vulnerability. Measures to reduce hospital visits such as shorter radiotherapy fractionation and conversion of intravenous to oral systemic regimens can be considered. Proactive discussions regarding end-of-life and hospice care at isolation facilities should be discussed in the management of older patients with cancer and COVID-19 infection. Oncologists should make an extra effort to educate and provide additional guidance to help patients and caretakers making hard decisions regarding withholding anticancer treatment to mitigate the risk of viral infection.
Keywords: Cancer, coronavirus disease 2019, elderly, geriatric, health policy, COVID, SARS-CoV-2, older
|How to cite this article:|
Pinninti R. Management of geriatric cancer patients during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3, Suppl S1:71-5
| Introduction|| |
As of April 4, 2020, more than a million patients have unfortunately acquired novel coronavirus disease 2019 (COVID-19). About 199 countries have reported cases, and nearly 60 thousand patients have lost their lives as a direct consequence of the infection. There are concerns that the COVID-19 pandemic could incapacitate health-care systems to serve other health ailments and the experiences fromfirst-response countries (China, Italy, and Spain) have shown that hospital leadership and individual providers are facing increasingly difficult decisions regarding hospital resource allocation in order to limit the strain on auxiliary services such as intensive care units, transfusion capacity, and operation theaters. Physiological vulnerabilities greatly impact the outcome of the COVID-19 infection, resulting in far more serious illness in patients with compromised physiological reserve (older patients, infants, and pregnant women) and in those with pre-existing or poorly controlled comorbidities. The COVID-19 infection can be life-threatening in older patients with cancer, but there are no standard guidelines or individual hospital data regarding methods or policies implemented to guide clinicians. In this review, we would try to rationalize the general precautions and discuss the available data regarding risk mitigation and optimizing oncology care without compromising oncologic outcomes in geriatric cancer patients.
| Available Evidence Regarding the Association of Age, Cancer, and the Pandemic|| |
Despite similar presenting symptoms of fever with accompanying cough and sputum, older patients compared with young and middle-aged individuals appear to have a more complicated clinical course with more severe pneumonia, an increased requirement of supplemental oxygen, high levels of inflammatory markers, and multiorgan dysfunction. Older patients also experienced much faster clinical deterioration with a shorter time from the first symptom to intensive care admission and death compared to the younger patients. In addition, patients with cancer also deteriorated more rapidly than those without cancer (median time to severe events was 13 days versus 43 days; P < 0.0001 (hazard ratio [HR], 3.56; 95% confidence interval [CI], 1.65–7.69). Compared to the overall community, older patients are at a higher chance of acquiring the COVID-19 infection, likely as a direct consequence of weakened immunity and higher rates of comorbidities such as cancer, diabetes, cardiac illness, and respiratory ailments.
Evolving clinical experience suggests that cancer patients with COVID-19 have more serious complications, such as intensive care admission from severe pneumonia or sepsis and a greater case fatality rate (CFR). This was reported in the retrospective case study of 28 cancer patients with COVID-19 infection at three hospitals in Wuhan, China. The main conclusion from the study stated that cancer patients who had received anticancer therapy within the preceding 14 days had a higher risk of developing severe events when they were infected with COVID-19 (HR, 4.079; 95% CI, 1.086–15.322; P = 0.037). Liang et al. published the outcomes of a cohort of 18 patients with cancer and COVID-19 infection. They echoed the prior observation that patients with cancer who had received chemotherapy or surgery (within 30 days before infection) had a numerically higher risk (75% vs. 45%) of severe events than those who did not receive chemotherapy or surgery. After adjusting for the potential confounding factors such as age, smoking, and other comorbid illnesses, cancer history portended the highest risk of serious events (odds ratio [OR], 5.34; 95% CI, 1.80–16.18; P = 0.0026). Among patients with cancer, older age was the only risk factor for severe events (OR, 1.43; 95% CI, 0.97–2.12; P = 0.072).
Despite such grave concerns, for many patients with cancer, the probable survival benefits of receiving treatment still far outweigh the risks of death from COVID-19. Early estimates from China suggest an overall CFR of 2%, increasing to 8% for people in the 70-79 year age group, and 15% for those ≥80 years of age, but these rates probably reflect the capability of individual health-care system adaptability and should not be universally used to make health-care policy decisions., CFR in European countries with better health-care access appears much higher than expected as compared to the China experience.
| Mitigation of Risk and Counseling in Geriatric Cancer Patients|| |
Considering the evidence for a clear association for older age and higher levels of comorbidity with more severe COVID-19 symptoms and adverse outcomes, the concept of risk mitigation is highly relevant to older patients with cancer. Clinicians should hold open discussions regarding the risk–benefit considerations with their patients before embarking on cancer therapy. The available evidence is not robust, and the risks related to COVID-19 should be balanced against tumor control and discussed on a case-by-case basis. Despite several challenges for the application of evidence-based medicine in these testing times, clinicians should overcome their inherent biases, perceptions, and barriers by relying on descriptive evaluations of health status and geriatric screening tools into their routine oncology practice while counseling geriatric cancer patients.
We recommend the following steps in evaluating geriatric cancer patients for antitumor therapy.
Selecting older patients for cancer therapy
Chronological age alone cannot be relied on to ascertain the true biological status of an individual, and a comprehensive geriatric assessment (CGA) provides a multidisciplinary diagnostic process that encompasses several objectively evaluable domains to reliably and objectively assess medical, psychosocial, and functional limitations. Most of the risks related to biological vulnerability can be mitigated with the routine implementation of geriatric assessment in clinical practice. There is a general perception that these tools cannot be applied during the clinic hours and their applicability is limited to clinical trials focusing on geriatric patients as they are highly resource and time-intensive. Performing a CGA obviously takes more time than an assessment that is based on clinicians' intuition and experience. To complete the process fully may take up to 2 hours. However, formal assessment tools, previsit questionnaires, and appropriate training for a number of health and social care professionals (including voluntary care sector) can reduce this burden on the clinician performing the initial CGA. This would enhance overall capabilities in reliable use of recommendations regarding treatment for comorbidities, geriatric syndromes, supportive care, drug interactions, and toxicities. [Table 1] enumerates several scales validated for the CGA.
|Table 1: Several domains of physical and mental health that are evaluated with comprehensive geriatric assessment|
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Reducing the risk of exposure and embracing the concept of social distancing in the clinic
Caregivers and health-care providers should adapt the present systems to minimize the need for older patients to visit clinics for routine cancer care. Embracing “virtual” assessments conducted by videoconference and/or telephone can enhance the capability of the health-care system to deliver cancer care in the situation of enhanced quarantine; isolation and hospitalizations are anticipated. Multidisciplinary case conferences coordinated “virtually” can sustain the management of complex patients and provide better adaptability based on the prevailing situation. Mandatory measures such as reducing the number of visitors; recording the travel and contact history of all visitors; performing temperature testing at hospital entrances, outpatient clinics, and hospital wards; and providing opportunities for online consultations for symptom management can enhance the social or interpersonal distancing to mitigate the risk of infection. Encouraging appointment-based scheduled hospital visits, avoiding visits for routine or long-term follow-up, and postponement of non-urgent outpatient visits such as those for therapy response assessment scans can further minimize the exposure to hospital clinics. Many of the components of the CGA can be completed by the patient and the caregiver before the actual assessment by the clinician; this would significantly reduce the time spent in the actual CGA, thus decreasing the risk of infection transmission.
Emphasis on personal protective measures such as bringing disinfectant and wearing a mask and patient and family education for infection prevention is also needed. Promoting active community participation and highlighting reliable sources to impart COVID-19 education should be made for dispersing information for risk mitigation. Societies should harness digital technologies to mitigate isolation and loneliness resulting from social and physical distancing. These methods of isolation, promoted to “flatten the curve” of the epidemic, have a disproportionately negative impact on older patients who experience increased anxiety and reduced access to physical and mental care.
Adapting the anticancer therapy
Measures to reduce hospital visits such as shorter radiotherapy fractionation and conversion of intravenous to oral systemic regimens, for example, capecitabine in place of infusion 5-fluorouracil, can be considered. The general perception of avoiding palliative chemotherapy to avoid placing a strain on hospital services should be discouraged as treatment delays may lead to worsening performance status and loss of the window of opportunity to treat. In patients who had already undergone curative oncological surgeries, adjuvant therapy should proceed with priority given to selecting and propagating the least toxic therapy with the greatest benefit-to-risk ratio. Cancer surgery, despite being considered a non-elective procedure and prioritized, may still be delayed due to the limited availability of intensive care beds, staff, and personal protective equipment. The adaptability of current practice to compensate for such delays should be coordinated through multidisciplinary boards done on virtual platforms to establish priority groups for surgery, systemic anticancer treatments, and radiotherapy. Multidisciplinary case conferences should prioritize adjuvant therapy for head-and-neck, colorectal, and breast cancers where delay in the initiation of adjuvant therapy could adversely impact overall outcomes.
However, triage should be dynamic and considerate of the health-care system capability and the evolving situation in the community. As an effort to reduce undue stress on health-care systems in areas with an anticipated health-care emergency, oncologists should exercise refrain and prioritize care for oncological emergencies, including diseases with an imminent risk of early mortality (such as acute leukemia) or substantial morbidities (such as spinal cord compression). [Table 2] provides a conceptual framework for prioritizing the use of cancer-directed therapies in geriatric patients during the ongoing COVID-19 pandemic.
|Table 2: A conceptual framework for prioritizing the use of cancer-directed therapies in geriatric patients during the ongoing COVID-19 pandemic|
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Prevention and early treatment of the toxic effects of chemotherapy
Adequate management of non-cancer medical conditions, avoiding unnecessary polypharmacy, discovering situations for risk of fall, proper goal-directed nutritional interventions, specific interventions to reduce the impact of several geriatric syndromes (cognitive impairment and confusional syndrome, sleep cycle disturbances, and loss of sphincter control), oral prophylaxis and hygiene, attention to mucositis, effective antiemetic prophylaxis, and rescue medications for breakthrough emesis and pain are few interventions that should be implemented for symptom management to avoid repeated hospitalizations. The use of hematopoietic growth factors (filgrastim and darbepoetin alpha) can reduce the incidence of febrile neutropenia and transfusion support. Physicians should also consider chemotherapy dose reductions, especially if therapy remains palliative to reduce the risk of cytopenia and resultant hospitalizations for supportive care.
Antiviral therapy and unique challenges with polypharmacy in older patients
There is presently no approved antiviral therapy for COVID-19 infection. Overwhelmed with ever-increasing societal and political pressures, health-care systems have formulated therapy algorithms for prophylaxis and therapy with hydroxychloroquine (HCQ) and other drugs (remdesivir and favipiravir). These drug regimens (dosing, frequency, and duration) have not been through traditional clinical testing and are based on anecdotal evidence at best., The clinician should be supplementing clinical judgment with essential evidence-based tools such as the American Geriatrics Society Beers Criteria to screen for polypharmacy and for potentially inappropriate medication use in older patients. Medication interactions are further exacerbated in the presence of compromised organ function or reduced physiological reserve in older patients. For example, HCQ-induced neuropsychiatric adverse events are potentiated with concomitant administration of CYP3A4 inhibitors; therefore, clinicians should exercise caution or avoid HCQ in older patients with chronic seizures or epilepsy, cardiac rhythm abnormalities, and those with glucose-6-phosphate dehydrogenase deficiency.
Intensive surveillance and treatment
Considering the susceptibility and high mortality with COVID-19, infectious disease specialists have advocated several strategies that include patient education regarding personal hygiene measures, intensive attention with frequent surveillance testing, and aggressive infection control policies in hospital wards to reduce the chances of acquiring the infection in older patients with cancer. Greater emphasis should be on the implementation of prevention measures. Patients with cancer and COVID-19 disease should be isolated and be referred to specialized COVID-19 facilities. In patients with cancer and COVID-19 disease, systemic anticancer treatments should be discontinued until complete resolution of symptoms.
| Conclusions|| |
With the uncertain trajectory of the COVID-19 pandemic, the strain on hospital resources cannot be foreseen and the heavy reality of rationing of care will force clinicians to prioritize treatments most likely to be successful and focus attention on patients who are likely to benefit the most. As per available retrospective data from the first responding countries (China and Italy), patients with comorbidities on ventilatory support have very dismal outcomes and older patients with cancer who acquire COVID-19 infection are unlikely to be any better when it comes to surviving mechanical ventilation. Proactive discussions regarding end-of-life preferences and hospice care at isolation quarantine facilities should be discussed in the management of older patients with cancer and COVID-19 infection. Oncologists should make an extra effort to educate and provide additional guidance to help patients and caretakers making hard decisions regarding withholding anticancer treatment to mitigate the risk of viral infection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]