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May 6, 2020
Assessing and Treating Patients During the COVID-19 Pandemic
By Lisa Kottschade, APRN, MSN, CNP
It’s no secret that oncology advanced practitioners (APs) have played an essential role in the management of oncology patients, from initial diagnosis to end of life. Symptom management from cancer treatment makes up a large part of our daily routine. Upending that routine is a novel virus that can spread like wildfire with even just one exposure, has no known vaccine, and has killed healthy people. During the COVID-19 pandemic, we’ve learned new phrases such as “social distancing” and “shelter in place.” Many medical facilities have restricted access to health care to emergent/urgent care only, with much of that being done by telemedicine.
While these changes are necessary, these are also challenges for cancer patients. Unfortunately, cancer isn’t going to wait for this pandemic to be over to return to the status quo. Patients on active cancer therapy usually require
some level of pretreatment bloodwork, symptom assessment, and physical exam. All of these, including often the actual treatment itself, require the patient to be onsite, potentially exposing both them and the providers caring for
them to COVID-19.
As oncology APs, we were thrust into this new world of navigating not only oncology care, but also deciphering how to keep our patients safe, managing their side effects from treatment, recognizing possible symptoms of COVID-19, and distinguishing between the two accurately. No problem, right?
Is it COVID-19 Related or Treatment Related?
As we learn more about the ways that patients infected with COVID-19 can present with symptoms, we find increasing overlap with adverse events of cancer therapy. Many health-care systems have instituted patient screenings at clinic/hospital entrances, including symptom assessment and active temperature taking.
Symptom assessment usually includes questions such as, “Have you had a fever within a particular time period, a cough, shortness of breath, diarrhea, nausea, etc?” While these are relatively good COVID-19 screening methods for non-cancer
patients, many of our patients can experience one or more of these symptoms from their treatment or the cancer itself. Current protocol at most institutions has dictated that patients who screen “positive” for any of these initial
questions and/or have an objective screening fever must be turned away and potentially self-quarantined (if minimally symptomatic) or sent for COVID-19 testing (and have a negative result) prior to having medical care at that particular
facility. As you can imagine, sending away a cancer patient who may potentially have a neutropenic fever to “self-quarantine” without being medically evaluated could have fatal consequences.
Another element of challenge is the use of immune checkpoint inhibitors (ICIs). The use of ICIs in the cancer population accounts for roughly 50% of treatment regimens in oncology (Haslam & Prasad, 2019). These agents given by themselves are not considered “immune suppressive”; in fact, they are quite the opposite and can cause immune overactivation. But the multitude of possible immune-related adverse events can cause symptoms similar to COVID-19, including fever, diarrhea, dyspnea, and cough. Again, delays in treating the immune response of ICI-related side effects can cause significant morbidity and mortality. Probably one of the most troublesome side effects to manage during this time is pneumonitis. While the overall incidence of ICI pneumonitis among patients is relatively low (2.7%–6.6%;
Nishino, Giobbie-Hurder, Hatabu, Ramaiya, & Hodi, 2020), its symptoms and radiologic findings are sometimes indistinguishable from those of COVID-19 pneumonia.
What if My Patient Develops COVID-19 While on Treatment?
The short answer is we don’t have all the answers. Just as with any infection, an immunocompromised patient who develops COVID-19 is at greater risk for complications from the virus than those with an intact immune system. With this in mind, we should be very careful to try to avoid and to prevent cytopenias to the extent that we can by modifying anticancer therapy without compromising efficacy, especially in curative situations (i.e., adjuvant/neo-adjuvant regimens).
What About Patients Who Develop COVID-19 While on Immune Checkpoint Inhibitor Therapy?
This scenario probably raises more questions than answers. As noted previously, there can be “crossover” toxicity between ICI agents and COVID-19, especially respiratory toxicities (e.g., pneumonitis). Recently, there was an article from Dr. Melissa Bersanelli out of Italy on this exact subject (Bersanelli, 2020). Some have suggested that patients delay treatment with ICI in the face of COVID. However, since we don’t know how long this pandemic will last, oncology APs are faced with this decision daily on whether to treat patients with potentially curative agents or delay initiating treatment in the hopes that we can “wait it out.”
Managing Active Treatment Patients in the Face of a Pandemic
Practices must have a systematic plan in place for assessing and treating these patients. Hold therapy in patients with fever and test for COVID-19 early and often. Our triage nurses are invaluable in these circumstances. Make sure to educate your patients on the warning signs of neutropenic fever, side effects from immunotherapy, and symptoms of COVID-19. Encourage them to call at the first sign of any side effects. Encourage them to stay home, wash their hands, avoid sick people, wear a mask when they do have to go out, and keep their distance from others.
Unfortunately, cancer will not take a back seat to COVID-19, and our patients need us now more than ever. With careful planning and early assessment and interventions, we can get our patients through this and continue to provide
the top notch cancer care that we as oncology APs are accustomed to giving. And, I’m pretty sure we’ll learn a little along the way.
References
Bersanelli, M. (2020). Controversies about COVID-19 and anticancer treatment with immune checkpoint inhibitors. Future Medicine, 12(5). https://doi.org/10.2217/imt-2020-0067
Haslam, A., & Prasad, V. (2019). Estimation of the percentage of US patients with cancer who are eligible for and respond to checkpoint inhibitor immunotherapy drugs. JAMA Network Open, 2(5), e192535. https://doi.org/10.1001/jamanetworkopen.2019.2535
Nishino, M., Giobbie-Hurder, A., Hatabu, H., Ramaiya, N., & Hodi, S. (2016). Incidence of Programmed Cell Death 1 Inhibitor-Related Pneumonitis in Patients with Advanced Cancer: A Systemic Review and Meta-Analysis. JAMA Oncology, 2(12), 1607–1616. https://doi.org/10.1001/jamaoncol.2016.2453
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