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Patients with cancer often have concerns related to the COVID-19 pandemic, from which they are potentially at increased danger as a result of their cancer and/or due to immunosuppressive treatments. Mark A. Lewis, MD, Director of Gastrointestinal Oncology at Intermountain Healthcare, Murray, Utah, recently published a perspective piece in The New England Journal of Medicine contemplating the challenges of balancing the necessity of cancer care against the risks of COVID-19. A couple of weeks ago, Dr. Lewis spoke with i3 Health about strategies to effectively maintain this balance. In this second installment of his interview, Dr. Lewis shares advice for oncologists as they speak with patients about COVID-related concerns and as they themselves face the difficult task of navigating patients through this pandemic.
How do you respond to patients' concerns about COVID and cancer?
Mark A. Lewis, MD: One thing I'll point out is that it's amazing to live in the information age. I think that there is a relatively level playing field for access to information these days if you have the means to have access to the internet. A few paywalls notwithstanding, I'm amazed at how savvy my patients are in consuming really up-to-the-minute updates concerning the pandemic and specifically its impact on cancer patients.
There was a report out of China in March that showed a fivefold heightened risk of severe events for patients with cancer who were infected with the novel coronavirus. Many of my patients actually saw that report and either called me or brought it up in an in-person visit, so I am very aware of just how quickly information spreads. Unfortunately, that also means that misinformation can spread, or it can be difficult sometimes to convey all the nuances needed to dissect a clinical trial or a research article.
As it turns out, that Chinese report was accurate, but it's also important to realize that there may be some confounding variables there, such as age. The average age of a patient in my practice is actually 68. However, I have a substantial minority who are adolescent young adult cancer patients, and it's interesting to talk to them versus my older cohort. For reasons we don't entirely understand, the risk of coronavirus infection seems to go up by decade starting at age 45, and that may be somewhat irrespective of the cancer diagnosis, so I basically have a different discussion with my patients based on their demography and also based on the intensity of their treatment.
I have some people in my practice right now who are undergoing very intense chemotherapy. I know exactly when their nadirs are happening, and I'm keeping an incredibly close eye on them when they are at their low point. On the other hand, I have some other people who really have––and this is not boasting––virtually no appreciable immunodeficiency at all. So again, it really is a case-by-case situation.
I also remind them that as patients with cancer, they are already thinking about their mortality, so in a weird way, it's almost like they've been psychologically prepared for this moment––obviously no one's been completely prepared for this, but they've already grappled with life and death in a way that I think maybe the general population at large has not had to do. I think one of the things that's been so troubling for our country and the world is that for many completely healthy people, not only has this been disruptive to their lifestyle and their work, but they're now contemplating a case fatality rate that is not zero and is at least in the low single digits. I think that's been very traumatic to many people's mental health, whereas I think that patients with cancer have sort of already walked through the valley of the shadow of death. It's not a new thing for them to be thinking about mortality and even preparing things like advanced directives.
What advice can you share with oncologists as they try to chart the course of what you so aptly called in your piece in The New England Journal of Medicine the "Scylla and Charybdis" of COVID exposure and cancer?
Dr. Lewis: I would just remind my colleagues that although we're not trained for this precise scenario, we are professionally expert in risk calculation. Again, more than many other specialties, we have to confront life and death. We have to confront blunt metrics like overall survival. When we've been counseling patients in the past, we are very used to dissecting statistics, interpreting clinical trials, and individualizing care accordingly. There's certainly a new layer to that now, a new risk calculus with the novel coronavirus, but in some ways it's not that foreign to us to be having to synthesize all this different information and come up with a risk model on a case-by-case basis. As a profession, I think we're probably better poised to do that than many of our peers, and again, we are taking care of people who by and large have already thought about the possibility of death. My wife is in urgent care and was previously in primary care; largely what she was doing there prior to the pandemic was health maintenance. I think that the situation with COVID is a very different scenario for patients who have been used to going to the doctor to ensure that they remain healthy as opposed to going to see an oncologist because they're worried that their life might be threatened very soon by a malignancy, so again, our patient population is in some ways well suited to these difficult conversations.
I would just encourage my colleagues to stay strong. I know that self-care is a phrase that is often repeated––sometimes emptily––in our profession, but I think it's really important, when we can, to take care of ourselves, spend time with our families, and reach out to one another if we are in need of emotional and psychological support. As an aside, I don't think I've ever seen more sense of community online among doctors than I have right now. The internet is the best and the worst thing ever: it's great for information, and it's horrible when there's misinformation and trolling and other abusive behavior. But it's really incredible to be able to reach out to your colleagues in the US and across the world and offer each other support. I just had a message this morning from an oncologist in Zambia who was asking me for help, and I think it's an amazing world that we live in when we can have that global connectivity.
So I would just remind all of my colleagues that we're not in this alone. We're in this for our patients, and we're in this for each other.
About Dr. Lewis
Mark A. Lewis, MD, is the Director of Gastrointestinal Oncology at Intermountain Healthcare. Dr. Lewis's research interests lie in the areas of young-onset cancers and hereditary cancer syndromes, shared decision making, and patient-physician communication. He is active in the Southwest Oncology Group (SWOG), for which he chairs Adolescent & Young Adult Oncology. Dr. Lewis has also served as a reviewer for multiple peer-reviewed journals. He is the Vice President of the American Multiple Endocrine Neoplasia Support, a member of the Board of Directors for the Neuroendocrine Tumor Research Foundation, a member of the Communications Committee for the North American Neuroendocrine Tumor Society, and an active member of the American Society of Clinical Oncology.
For More Information
To learn about strategies to maintain effective cancer care during the COVID-19 pandemic, read the first part of Dr. Lewis's interview.
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of i3 Health.