Expert Speaks to Impact of COVID-19 in the Community Oncology Setting, Vaccine Excites Field

Michael J. Wagner, MD

The city of Seattle, Washington, was of the first in the United States to experience cases of the coronavirus disease 2019 (COVID-19), setting the stage for a number of new challenges and unknowns for both physicians and patients in the oncology setting. Without the certainty of the risk in patients with cancer, particularly rare cancers like sarcoma, a major question in the field was how to deliver appropriate treatment without compromising the risk of COVID-19.

Results from a single-center experience at a center in Seattle evaluated 10 patients diagnosed with sarcoma during the COVID-19 pandemic, with expectations to record and evaluate the management of these patients with such a rare cancer type. Study author Michael J. Wagner, MD, presented the results during the 2020 Connective Tissue Oncology Society Annual Meeting, describing that although the population was small, there appeared to be a slightly greater risk of developing severe COVID-19 among patients with sarcoma, as well as a slightly greater risk of dying from the infection. The study was able to demonstrate that receipt of chemotherapy may have been a risk factor as well, providing insight to physicians of something to bear in mind.

A large challenge in the sarcoma population in particular is that they often have to travel far for treatment at larger cancer centers with more experience in sarcomas, and when these patients need to receive treatment in the community setting as a result, community oncologists are not as familiar with the disease, nor the toxicity concerns with the chemotherapy regimens typically used to treat these patients. However, the rapid introduction of telemedicine due to the pandemic has made it easier for patients to receive treatment close to home and has provided support to the community oncologist treating these patients.

Telemedicine has played an important role in the treatment of patients with cancer during the COVID-19 pandemic, but this is something that could continue to provide support to both patients and physicians post-pandemic. However, Wagner noted that the pandemic is not over yet, despite exciting news from the FDA recently.

The first Emergency Use Authorization was granted to a vaccine, BNT162b2, for the prevention of COVID-19 on December 11, 2020, which allows for the vaccine to be distributed in the United States to individuals aged 16 years or older. This is an exciting advancement for physicians in the oncology field as this is the next step toward overcoming this pandemic and the increased risk patients face.

In an interview with Targeted Oncology, Michael J. Wagner, MD, assistant professor at University of Washington School of Medicine, assistant member of Fred Hutchinson Cancer Research Center, and physician with Seattle Cancer Care Alliance, discussed findings from a single-center experience in Seattle managing patients with sarcoma during the COVID-19 pandemic.

TARGETED ONCOLOGY: What was the rationale for this single-institution experience and what were the methods of design?

Wagner: We're based in Seattle, which was the first city to really experience COVID-19 [in the United States], so way back in March, even kind of late February, we were already starting to talk about it. At that time, nobody had any idea what was going on, so we had almost instantaneously changed the way we practice and adapted to the new and what, unfortunately, is still the current situation, but because of that, we eventually started seeing some of our own patients develop COVID-19, particularly in the spring. We didn't know what to do in terms of should we continue their chemotherapy? Should we delay treatment? In terms of patients who got particularly sick from COVID-19, should we consider the status of their cancer in terms of framing the management, even of the COVID-19? That was something that we had to grapple with, but then also the patients because again, nobody truly knew what was going on.

As we started seeing more and more patients with sarcoma specifically, we thought it would be useful to compile our own experience and let other institutions know both what we've been doing but also how our patients did in terms of [survival]. Did they get over COVID-19? Are there any trends that we saw in terms of relationship to when they last got their chemotherapy and how severe their disease got, or anything like that? That's essentially what we did. We got approval to retrospectively look back and look at the experience of our own patients who developed COVID-19 to just descriptively say, this is what we saw, this is what happened to these patients, and this information will hopefully help us, but then also other institutions adapt.

I think it's useful, especially for patients with sarcoma, because sarcomas are so generally rare, and being a mixed group of diseases, it's not very clear what patients with sarcoma should do, in particular, because they travel so far in order to get care many times because even just having a diagnosis of sarcoma will require someone to get referred to a tertiary center, so in our case, in Seattle. That alone carries the risk of COVID-19 exposure, and we wanted to help guide patient decision making as well. Could we do telemedicine to help minimize their need to travel or their chemotherapy regimens or alternative regimens completely? That would help avoid even just potential exposure to COVID-19, so bigger picture, we were interested not only in looking at what happened to our own patients who developed COVID-19, but also what's the risk of travel and the benefit of physically being at a center like ours, whether it is a risk worth taking in the current environment.

TARGETED ONCOLOGY: What were the findings from this study?

Wagner: We had identified 10 patients, and the findings were somewhat in line with other things that we've seen. There are now a number of large registries of patients with cancer who have also developed COVID-19. This is all very limited in terms of what we can actually conclude because of the small numbers, but it looked like there was perhaps a slightly greater risk of developing severe COVID-19 disease in our small subset of patients, and also, again, perhaps a slightly greater risk of dying from COVID-19. It did look like that receipt of chemotherapy, in this sort of immediate setting right before being diagnosed with COVID-19, might have been a risk factor, and then also sort of related to that, having low lymphocytes and white blood cell counts also seemed to correlate, but again, we can't conclude anything based on the small number of patients. That was at least a trend that we seem to see.

TARGETED ONCOLOGY: What the implications of these findings?

Wagner: One thing is that there probably is at least some level of increased risk for patients with cancer in the environment where COVID-19 is prevalent, and I think the changes that we've made to our practice, such things as increased use of telemedicine, can hopefully minimize that risk. That's actually 1 nice thing that's come out of this whole fiasco of a year, where we can actually provide expert sarcoma care to patients, in theory, anywhere in the world. Legally, we can't do that, but it minimizes just the financial impact of having to travel, the hassle of needing to travel all the way across the state or sometimes even across state lines, but then also in the current setting, minimizes the risk of COVID-19 exposure, which is really the main reason that we've implemented that.

In some cases, especially if we know that someone is positive, or is at high risk for COVID-19, say having a family member known to be positive, then we at least consider and discuss with the patient if we should delay chemotherapy a little bit. It's not ideal for the sarcoma, but depending on the specific situation, that might actually be a wise choice.

TARGETED ONCOLOGY: What are the biggest challenges physicians are facing now treating patients with sarcoma during this COVID-19 era?

Wagner: The challenge is the physical act of getting to our center, so either for the consultation, although like I said we've been able to get around that to a large degree just by telemedicine, but then also even just for treatment. A lot of the chemotherapy regimens for many different sarcomas are pretty complicated. They're not terribly common, so even though sometimes they're used in the community setting, they're used very rarely. Community oncologists have less experience treating Ewing sarcoma, for example, just because there's not very much Ewing sarcoma relative to other cancers. However, those chemotherapy regimens are very important because it's, in many cases, curative-intent treatment. We don't want to delay it. We want to make sure that it's done safely, so we try to do as much as we can in Seattle, but sometimes we just can't do that, especially because of the risk of COVID-19 exposure.

We've been trying to work with community oncologists, and in many cases, we can do that. The patients can actually get the same chemotherapy regimen they would get here in Seattle and other centers, but again, they're not chemotherapy regimens that [community oncologists] are typically used to giving. They can come with a fair bit of toxicity and side effects, so I think that has been a challenge.

Another challenge is for patients who have COVID-19, and this was actually the case for several of the patients who were in our cohort. Just having a larger discussion in terms of what are the goals, what are your goals of care, especially surrounding the specific circumstance of your sort coma, plus the uncertainty with COVID-19, especially back when we were seeing it early in the spring, when we truly didn't understand what some of the risk factors are, and what expected outcomes were for COVID-19 alone, let alone in the setting of metastatic sarcoma. It's been difficult to have those conversations, both because of the uncertainty in terms of outcomes but also because those conversations, I would argue, are better had in person. When someone has COVID-19, the visitor restrictions are such that many times the family can't go in. We also are not necessarily allowed to actually physically be in the room with the patient, and that just adds a layer of complexity to what, in many cases, is an end of life discussion. It's just hard for everyone.

TARGETED ONCOLOGY: What advice would you like to share with community oncologists at this time?

Wagner: A lot of states have relaxed the telemedicine rules in terms of licensing. I think access to tertiary expert sarcoma care is actually probably higher than it used to be before the pandemic, and I hope that that's a change that actually stays. We can, in many cases, do telemedicine visits for patients who are either too sick or just unable for other reasons, like financially or just because they're not wanting to travel 8 hours to get to our clinic. Telemedicine is a good [option] and I would say an excellent possibility as something that we can offer to patients, depending on state rules, almost anywhere.

We're always available. If there's a question, we can help guide treatment again, even if the patient is unable to travel, in our case all the way into Seattle, but we like working with community oncologists because that way, the patient can stay at home or at least close to home and be with family while they're undergoing the whole cancer experience and getting chemotherapy, while at the same time getting the expert sarcoma input.

TARGETED ONCOLOGY: Following the news of the first Emergency Use Authorization from the FDA for a preventative COVID-19 vaccine, how do you see this impacting your practice?

Wagner: I'm very excited that there's now a vaccine that seems to be effective and is getting rolled out. First, I would say everyone should get the vaccine this year, if nothing else has demonstrated that, but also, I hope moving forward, especially once a vaccine is implemented, which I think is many months if not a year plus into the future, I don't think telemedicine is going away. I think that's something that we'll still be able to offer, to a large degree, to patients, and I think it's really going to revolutionize not only the way sarcoma care is delivered but all cancer care, even just medicine in general.

If we have to find a positive in all of this, I think that's 1 of them. Hopefully, COVID-19 won't be a big issue well into the future because of widespread adoption of the vaccines, but if it is, at least now we have a better understanding of what the virus is and what the course of it is. We can make some modifications to either how we deliver care, especially in terms of when to give chemotherapy, and if we have to wait a little bit. If there are some hotspots that come up, then at least now we're a bit more aware. We can triage patients too in terms of scheduling their appointments, and we're more cognizant that if people were exposed, delaying a week and making sure that we can adequately determine they actually don't have COVID-19, not only to protect the patient specifically but also ourselves and our other patients. With no more widespread use of testing, which again was an issue back in the spring when just the number of available tests was extremely [bad], so we've overcome already many challenges, and I think we're going to continue doing that.

Moving forward, we're going to see continued telemedicine and just increased awareness of COVID-19 as a potential risk, just along with all the other viruses that anyone can get things like the flu and the cold, not that I'm comparing COVID-19 to the flu, but hopefully, at least in terms of prevalence and risk, that's all just going to be lumped together.

TARGETED ONCOLOGY: What are your key takeaways?

Wagner: Telemedicine is going to be a thing that we're all going to be using a lot more in the future, and it's going to minimize both the financial impact on patients plus the time that it takes to travel. By increasing our use of telemedicine, we'll be able to provide expert sarcoma care to patients in a much broader setting, ultimately and hopefully improving the care for everyone.