Working from home, using telehealth, shielding patients from the virus and adjusting treatments: in this article, lung cancer specialist Associate Professor Nick Pavlakis talks to the limbic about the profound impacts that the COVID-19 pandemic has had on medical oncology daily practice
Lung cancer patients are especially vulnerable to higher risk of severe infection from COVID-19 and as the relaxation of coronavirus restrictions across the country begins, screening and social distancing within cancer wards will become more important than ever, argues Dr Nick Pavlakis, who is Head, Department of Medical Oncology, Royal North Shore Hospital, Sydney.
“We all know that elderly patients, number one, are high risk, people with chronic respiratory illness are high risk people on immunosuppression are high risk. Generally any cancer patient who has chronic illness especially when they’ve got asthma, COPD, a history of recurrent bronchitis or recurrent chest infection are our most vulnerable group and when you look at the lung cancer population as a whole they fit into most of those categories,” says Dr Pavlakis.
The lung cancer specialist says the risk-benefit equation for certain lung therapies has changed in the era of COVID-19.
“We have to be cognisant of a new risk-benefit ratio when we chose a treatment and discuss it with a patient. Yes, we want maximal survival from treatment but what’s the risk of a serious complication? That risk-benefit ratio has changed in the context of COVID-19 because you have the potential for exposure to another life threatening situation.”
He says ‘rational discussions’ about trying to minimise immunotherapies – if not warranted – are continuing. However, so far it seems the therapy has not been associated with a negative signal for more severe COVID-19 infection.
“We had a plan to cease or suspend immunotherapy in patients who were doing well in that plateau period, but the overseas experience with [the therapy] seems to be more positive than negative in terms of [COVID-19] risk. Some of the immune therapies that we give – and we don’t know that they’re immunosuppressive they may in fact improve immune reactions to coronavirus – minimise hospital exposure to patients, which means they only have to come in once every three or four weeks into the clinic so we’ve been lucky with that.”
Cautionary approach in complex patients
But Dr Pavlakis remains cautious about lung cancer patients in the setting of COVID-19.
“Often these patients have COPD, chronic bronchitis, they’re often older they have obstructive lung disease that could lead to post obstructive pneumonitis; they get a lot of changes in their lung so there are a lot of confounders – they’re a complex patient.”
The combination of chemotherapy and corticosteroids, which is still widely used in lung cancer, does predispose patients to more serious infections, particularly viruses, exposing patients to risk of bacterial pneumonia and doubling chances of a life-threatening event, he adds.
“Many of our paradigms in lung cancer in Australia have shifted to combination chemotherapy upfront rather than sequential therapy, although we do use monotherapy in patients who are selected to do well. And that poses two issues – you’re causing granulocytopenia with chemotherapy and you have the risk of pneumonitis and other complications. So the medications that we give in lung cancer do put people at risk – but it has always done,” he points out, adding that winter has always been a challenge for lung cancer patients.
What’s changed this year is you have far more illness in the community for which you can’t vaccinate against, so all of a sudden the risk ratio for chemotherapy has changed as vulnerability has increased.”
Measures such as isolation within chemotherapy clinics, staggered appointment times along with allocating staff to teams to avoid cross exposures will continue to ensure minimum exposure for patients, he adds.
Testing for COVID-19
As for whether patients starting attending a chemotherapy clinic require testing for COVID-19, Dr Pavlakis says no
“Social isolation has been going on in the community for six to eight weeks – if we were just two weeks in we’d say: ‘yes, it’s possible you’ve had exposure that you don’t know about’ but we’ve had a long time now for people to declare their hand,” he said, noting that patients attending clinic do undergo questionnaire screening and temperature screen.
“If they’ve been isolating, they’ve been perfectly well and have had nothing to hint that they’ve been at risk then we don’t test”
It’s a reflection too of the limitations of the test.
“If the testing was completely available to the degree we all want it then you’d just test everyone. But it doesn’t prevent having had an exposure, having too a early test and having a problem two weeks later. So a good history, temperature screen and a risk assessment based on how they’ve been isolating is still very important.”
Telehealth pros and cons
Meanwhile Dr Pavlakis says telehealth has been ‘fantastic’ for a quick review of patients before chemotherapy the next day.
“Telehealth has created opportunities and has got us to look at the way we’ve been practicing we can reduce the frequency of face-to-face follow-ups and patient contact time. And while it’s not suitable for clinical observation, it does at least allow you to capture what’s going on and triage if you need to look at that person or find other means of catching up with them or delay treatment.”
But a telehealth consult can be ‘deceptive’ in terms of judging accurately how well a patient appears, he warns.
“There’s a strong value for face-to-face consulting that cannot be replaced. The clinical observation of watching someone walk to your rooms is so valuable for judging that patient’s performance for how fit they are, you can’t get that on a teleconference. ”
“People can present a brave persona on the phone and even by video but when you actually get them in next time you realise they’re not as fit as they portray so there are some risks.”
“You hope that you can gain some information in other ways – for example nurses can convey observations to you as patients attend nurse-led clinics as well as basic clinical observations in terms of blood pressure and pulse oxygen.”
Surgery
In terms of surgery, Dr Pavlakis says there may be a need to fall back on therapies normally reserved for more high-risk surgical patients.
“In early stage lung cancer usually if someone has a tumour to cut out we cut it out in an otherwise not so well patient an alternative would be stereotactic radiotherapy, for instance. Normally you’d consider that for someone who isn’t well enough for surgery but what defines not well enough for surgery in the context of COVID?”
For Dr Pavlakis, COVID-19 has swung the balance of decision making towards less invasive approaches in some patients who may otherwise have been good candidates for surgery.
A patient may potentially be more vulnerable through the process of hospitalisation and a procedure than they otherwise would have been – COVID has swung the balance of decision making to say, well maybe in this patient we should think of this radiotherapy technique, which has shown short term results of disease control to be excellent at three years, as an alternative to surgery. That’s the kind of example of a techniques that’s been around but how we can apply it more widely in clinical circumstances that lend themselves more suitably for it now.”