As COVID-19 Stabilizes, Treatment of Patients With Cancer Continues With Caution

Marco Mielcarek, MD, PhD

The coronavirus disease 2019 (COVID-19) has generated many new and unexpected challenges to oncology practices around the globe. Patients with cancer, particularly those with comorbidities may be at a higher risk of developing complications related to COVID-19, and patients with hematologic malignancies, in particular, have to face more challenges with transplantation complications during the pandemic.

The state of Washington was the first in the United States to experience COVID-19, as well as the first to have a COVID-19-related death. Large cancer centers, like the University of Washington and Seattle Cancer Care Alliance, significantly reduced the number of patients coming into the hospital system and clinics to maintain patient safety and protect local health care resources at the start of the pandemic. Centers are now ramping up their cancer treatments again and seeing more patients, particularly those who must undergo a transplant, as the number of cases has begun to stabilize.

As more cancer centers across the country begin to open up again, there are several things that should be kept in mind to continue maintaining patient safety and preparing for a second wave of COVID-19. Marco Mielcarek, MD, PhD, of the Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center and University of Washington School of Medicine, says that these institutions were fortunate to have access to testing and immediate results early on. This is something, Mielcarek explains, all centers should ideally have access to so that they can have the shortest turnaround time possible for their patients.

Physicians should also bear in mind the potential complications from cancer treatments that could affect outcomes if patients acquired COVID-19, be it chemotherapy or allogeneic stem cell transplant, according to Mielcarek. Immunosuppressive treatments or those that may weaken a patient’s immune system may lead to increased mortality as well during this pandemic.

“I think the [social] distancing, mask-wearing, and hand hygiene are key components, and it should be stressed that this is important. It should be a unified message sent to our patients and to the community,” Mielcarek said. “One should avoid, as much as possible, sending mixed messages, which has happened and is irresponsible from a physician’s perspective.”

In an interview with Targeted Oncology, Mielcarek, medical director, Adult Bone Marrow Transplant Program, Seattle Cancer Care Alliance, discussed how COVID-19 has impacted the treatment of patients with blood cancers in Washington State. He highlighted the changes his transplant center is now undergoing as cases of COVID-19 continue to stabilize.

TARGETED ONCOLOGY: What has your experience been like during this pandemic while treating your patients with cancer?

Mielcarek: I'm specifically overseeing the blood and marrow transplant program, so we treat patients who have specific types of cancer, for example, patients with leukemia, multiple myeloma, and lymphoma. Among patients with different types of blood cancers who need sometimes life-saving stem cell transplants, about two thirds don't have a matched sibling and therefore receive transplants from suitable unrelated donors or other alternative donors.

In Washington State and specifically here in King County and the surrounding counties, we were the first state in the nation affected by COVID-19. We had the first case, as well as the first death from the disease back in February. In March, we began seeing rapidly increasing, newly diagnosed patients with COVID-19, so our Transplant Program, which typically transplants close to 500 patients per year, had to wind down substantially in order to make sure we were not overwhelming our local healthcare system, the hospitals and the intensive care unit beds at the University of Washington and affiliated hospitals, and secondly, to not bring patients with cancer to Seattle and exposing them to the risk of COVID-19 infection if their treatment could be delayed.

Long story short, our initial response was to wind down our program. Over the subsequent 2 months counting from early March, we decreased the number of patients arriving for transplant by approximately 50%. Our overarching goal was to decrease transplant numbers as safely as it can be done without withholding transplantation from patients in need of urgent treatment.

TARGETED ONCOLOGY: For patients requiring transplant, what should physicians do to prepare for this with their patients and what were you doing?

Mielcarek: Some patients needed a transplant urgently and one could make a strong case that if one didn't move ahead, right away, they would lose a window of opportunity. Those patients would arrive at our center and get tested for COVID-19 at the time of arrival They would also be educated in terms of how to behave to be as safe as possible, including social distancing, mask wearing after they have arrived. Patients then started the evaluation and preparation for the transplant, which takes on average 3 weeks. Even without having any suspicious symptoms, patients would get tested for COVID-19 on a weekly basis after transplant. This testing policy was in place in the interest of patients and staff. It was important to know if we may have asymptomatic patients with COVID-19 amongst us who could be spreading the virus to other patients and staff.

TARGETED ONCOLOGY: Now that we've seen or are seeing the number of cases go down, and stabilizing in many places around the country, what steps should physicians be taking as they begin moving forward again with their transplants?

Mielcarek: One should be in very close communication with the transplant center. We have an Intake Office that is staffed by very experienced senior transplant doctors who rotate on a monthly basis and by a large group of support staff. Someone should communicate with them to [consider] what's the right time for the patient to come for transplant, is it reasonable to delay, should one move forward? I think nobody will arrive just out of the blue; arrival timing must be discussed ahead of time, and those patients who really need to be transplanted urgently should be brought in.

After the peak of COVID-19 cases in Washington in early to mid-April, cases had been decreasing with a more recent upward trend though. As COVID-19 new diagnoses go down, COVID-19-related hospitalizations and mortality typically go down with some delay. We have seen that the number of COVID-19-positive patients in the University of Washington system in the ICU has dramatically decreased. This served as an indication for us that it might be safe to increase our transplant activity again, which we have done.

We had a very measured way of reopening our center. We have incrementally increased the number of patients we have brought back into our system. I think as of June 1, we got back to the typical number of patients arriving for transplant per week. Most recently, we have been arriving 16 new transplant patients per week, who then get started on the evaluation that gets them ready for the transplant. A few months ago, when we had to wind down, we would only arrive a handful of patients per week, so we are up to full arrival capacity right now. Having said that, we all watch the news and know that COVID-19 is not over; we see lots of waves in other parts of the country. Even within a given state, if you look at different counties, activities of COVID-19 vary substantially. In Washington State, for example, King County and Snohomish and Pierce County, the adjacent counties here to the north and to the south, are stable in terms of COVID-19 activity. Yakima County, for example, back over to the east, has seen a lot of COVID-19 activity recently. There are lots of pockets within one state where the activity varies dramatically. Therefore, all these factors have to be taken into account when one makes the decision to re-open the transplant program.

Immunotherapy activity here at our center during the peak of COVID-19 had also significantly decreased for the same reasons, like to protect the healthcare system and not to add additional patients to the ICU beds than necessary. Because some patients will get immunotherapy treatment, they do get quite sick and need intensive care for a while. We didn't want to add to the COVID-19 patients in the ICU, and then of course, patients have to travel to us to get immunotherapy. We are one of the larger immunotherapy centers, and again, if there's any possibility the treatment could be delayed until COVID-19 comes under better control, we try to delay for the same reasons that I just outlined for the transplant program. Immunotherapy activity is also ramping up now.

TARGETED ONCOLOGY: How can physicians develop a more robust infrastructure for patient and staff COVID-19 testing?

Mielcarek: Here in Seattle, we have been quite lucky in terms of testing, specifically for our cancer patients and for the patients in the University of Washington system in general because we had early access to in-house antigen testing by PCR for COVID-19. We did not have to rely on other laboratories that still had ways to go in terms of developing the testing, including its efficiency and reliability. We had access here, through our infectious disease colleagues, to very good PCR testing so that we could, from early on, test all patients who arrived. As I mentioned earlier, we didn't only test them upon arrival, we kept testing the transplant patients every week to monitor them, even asymptomatic patients.

In Seattle, we did not have a problem, but the cancer doctors themselves don't develop the tests, right? They have to collaborate with laboratories and with infectious disease experts to basically make these tests available, and ideally, not only make them available but make them broadly available, so they are easy to access for patients.

If you get a patient admitted to the hospital and the patient has COVID-19-suspicious symptoms, you want to determine if that patient has COVID-19, so you want that test to be turned around ideally within a few hours and not within a few days. If it takes days to get the patient ruled out, you use a lot of personal protective equipment (PPE) even if the patient turns out to be COVID-19 negative. Broad availability, reliable tests, and quick turnaround times are very important; ss far as I see it, this is not directly under the oncologist’s control though. Development of testing infrastructure is driven by laboratory medicine, infectious disease experts, and the health infrastructure in general, which needs financial support from local governments because this testing is very expensive. It should be made available at no cost to the patient for the society to be able to screen effectively and then to isolate patients who test positive for COVID-19.

TARGETED ONCOLOGY: Oncology practices have changed substantially now during the pandemic, and I think we'll continue to see more changes in the treatment of blood cancers as states begin opening up and the disease begins stabilizing. What do you think the biggest unmet needs are that should be addressed during this shift?

Mielcarek: It remains to be seen. I think we have learned a lot now from our first exposure to COVID-19, and I don't know whether I want to call it first wave. I don't think the first wave is necessarily over. People talk about it all the time. I think there's 2 kinds [of waves]. The first wave, that's kind of petering out a little bit, and the activity is highly variable across the state and across the country. We have learned what's required in terms of dealing with COVID-19 in the community. I think the distancing, mask-wearing, and hand hygiene are key components, and it should be stressed that this is important. It should be a unified message sent to our patients and to the community. One should avoid, as much as possible, sending mixed messages, which has happened and which is highly irresponsible from a physician’s perspective. I think the science is pretty clear at this juncture, and what's sending mixed messages is the urge to confuse science with political interests, which I think is very counter-productive to the interest of human health in this country and on a global scale.

With testing, there's a lot of room for improvement. Even though it's available here in the metropolitan areas of Seattle, which has some very large hospital systems, in some rural areas, it's not necessarily available. I was reading that in some rural areas, it can take up to a week or so to get COVID-19 test result back. That's not acceptable if you want to respond appropriately. A patient who is COVID-19-positive can have exposed many, many other individuals who then become positive. A great focus needs to be on more effective testing across the country, and then, I think, there's limited experience in terms of what it means for cancer patients who are actively undergoing cancer treatment, and specifically bone marrow transplant patients. This experience is still evolving, and there have only been a few reports that start answer some of many questions. It appears though that if you have a cancer patient who gets chemotherapy, it's not an inevitable death sentence if they contract COVID-19. I think it certainly increases the risk of mortality, but that depends also on how sick the cancer patient is overall, what type of chemotherapy the patient is getting, and what's the underlying diagnosis. For bone marrow transplant patients who get allogeneic transplants, we're still learning how big of a problem it is if the patient contracts COVID-19. Is a COVID-19 infection in these patients creating insurmountable problems or can they deal with it? It certainly increases the risk of dying from COVID-19, but it's not an inevitable death sentence. I think we’re learning, and we have learned a lot in the last few months.

TARGETED ONCOLOGY: Do you have any key messages you would like to share?

Mielcarek: I think people should pay attention to recommendations from scientists. We're all in this together, and we have to be thoughtful in terms of how and when we treat our cancer patients during COVID-19. We want to treat those who urgently need treatment right away, but we don't want to rush into treatment. We also understand, of course, that delaying cancer treatment too much can cause significant problems that can lead to losing the opportunity to get effective treatment. Therefore, I think it's a very intricate balance between delaying and not delaying treatment in these challenging times. We have learned how to approach it, and it will help us when the next wave arrives.