Managing Risk of COVID-19 in Geriatric Patients With Cancer

For older adult patients who have cancer, the coronavirus disease 2019 (COVID-19) is especially life-threatening. According to Centers for Disease Control and Prevention (CDC), adults aged 65 years or older are at higher risk for severe illness related to COVID-19¹, as are people with underlying medical conditions like cancer.² These individuals are instructed by the CDC to take precautions to limit their chances of infection.

William Dale, MD, PhD, believes that the overall health of geriatric oncology patients should be considered ahead of their age when caring for these patients during the COVID-19 pandemic.

“One thing I try to emphasize is that while it is true that older people are at higher risk for severe illness from COVID-19, it is as much about their health as it is about their age. If a patient has other diseases, that patient is at higher risk than people who don’t have them,” Dale said. “Physicians should try to be active about protecting patients with diabetes, heart disease, and other diseases. Also, patients should make sure to have a reasonable supply of the medications they need and should practice self-care at home.”

In an interview with Targeted Oncology, Dale, physician and geriatrician, Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope, discussed his experience with caring for geriatric oncology patients during the COVID-19 pandemic. He also shared best practices for using telemedicine.

TARGETED ONCOLOGY: We know that cancer patients are immunocompromised, and that risk is amplified when patients are elderly. With that in mind, how are you advising your patients during the pandemic?

Dale: The advice is primarily that they need to be more diligent at protecting themselves from contracting the virus than those who are at lower risk. We should be giving older patients the same sort of advice that we're giving everyone – but ask them to be extra careful about following those recommendations and making certain their family members do, too. Like everyone, they should wash hands regularly for at least 20 seconds, wear masks when in public, not touch their face, make sure that they are wiping down high-touch surfaces to sterilize things, and maintain physical distancing (what is often called “social distancing”) of at least 6 feet from others.

A note on the term “social distancing”:I'm a social scientist, so I don't like using the term “social distancing” because it can easily lead to social isolation, which is very dangerous for older adults. We have to do physical distancing, but it is equally important to maintain emotional connections. I continue to remind patients that physical distancing is important, but they need to have their support network in place. Their support system is the counterbalance to all the infection risk precautions that we're telling people to take, which can lead to isolation. Their vulnerability is an important reminder to younger individuals who may be asymptomatic carriers that they should take steps, such as physical distancing and mask wearing, to not pass COVID-19 to older family members and friends. It is up to all of us to do this on their behalf, and they need to do even more to protect themselves.

A lot of my patients find physical distancing hard because they like to be around other people, so giving them options is important. Some have solved their feelings of isolation by connecting via video calls or talking with family on a phone while the family member is standing outside the house, sitting in a car or standing at the curb.

TARGETED ONCOLOGY: What are the key challenges with treating geriatric oncology patients during this time?

Dale: The biggest challenges is that they like to come into the office! In many cases, they see coming to see the physician as part of their social lives and they count on being able to do that. I won't say they’re skeptical, but they just are unhappy about not coming into the office, and they are looking forward to doing that.

The second piece that makes it complicated to treat older patients right now is that they're not necessarily the happiest about doing a video conference visit or they don't have the equipment to do it. Most of my elderly patients would rather just talk on the phone because they're used to the phone. That distancing is challenging for me as a physician because I’m someone who likes to have eye contact. Physical contact during a visit is also important for patient care. Overcoming those natural distances has been one of the bigger challenges during this time.

Another challenge on the medical front is prescribing medications and monitoring patients on those medications. Because our patients are on a lot of other medicines, we have to come up with strategies for them to get their medicines in time and to anticipate that bill if they are trying to stock up on their medicines in preparation for the worst. Worth mentioning – some of my patients are on pain medication, and it may be difficult for them to get get a few months’ worth of pain medication because of the societal fear that the opioids will be abused. Making sure that patients get the medicines they need when they need them is also of high concern and trying to help patients anticipate that has been a big focus.

TARGETED ONCOLOGY: Many practices have switched to telehealth to limit or eliminate visits to the clinic. For elderly patients, what has been your experience with using telehealth? Are there any difficulties with introducing some of the more modern technologies to this population of patients?

Dale: I do think that you have to first figure out what their comfort level is going to be with technology and then make sure it all works. There's a little bit of more upfront time than I think we all imagined when we made this conversion. I won't say I'm perfect, either. We all have our challenges with technology, but elderly patients, especially, will say ‘I'm just not comfortable.’

The other thing that I'm learning now is that many of my visits are very social in the sense that somebody comes with my patients, like a caregiver, a spouse, another family member, or friend. On telehealth, you can still do that, but it may violate social distancing. Figuring out how to fit everybody in on the call is a difficulty.

My last point on the use of telemedicine is specific to my older patients. Some of them have cognition issues, whether it's a memory problem or they're having some trouble with executive function. Communicating with these patients requires a lot more repetition and to count on technology is fraught with danger. We have to be extra careful.

TARGETED ONCOLOGY: Many clinical trials have been halted or terminated due to the COVID-19 outbreak. Although many clinical trials exclude elderly patients, some do include this patient population. What is your solution for any patients who were being treated in a clinical trial and can no longer receive that investigational treatment?

Dale: When it comes to older adults in clinical trials, we’re mostly concerned that they have been historically excluded for a variety of reasons, like age, comorbidities, and concern about worse organ function. Other problems, like being frail or having cognitive problems, excludes them from some trials. City of Hope has been among the best in enrolling patients in trials, and we’ve led the charge to do that. Our constant mantra has been to put as many appropriate patients as possible on trials so that we could help them, learn and improve treatments for similar patients.

I don’t want to tell any patient we have to stop treatment in a trial that they just got on. But because of the pandemic, some trials are on hold, with delays to restarting rather than stopped. As long as the older patients aren’t being treated any differently than younger people, that’s appropriate. COVID-19 has required us to adapt ourselves to a new situation.

TARGETED ONCOLOGY: In the clinic, what processes have you put in place to aid in the prevention of COVID-19?

Dale: The most important process is being scrupulous about physical distancing, avoiding unnecessarily exposing yourself to disease risk and scrupulously washing your hands. City of Hope has a screening process in place prior to allowing entrance into our clinical areas to protect the health of our patients, caregivers, staff and visitors.

Another thing that has been interesting is understanding the symptoms for COVID-19 and making sure people are fully aware of them. They’re more aware of symptoms like cough, shortness of breath, and fever, but we are finding out that few patients own a thermometer or have access to one because of the shortage.

One of the unique features of this disease, and the most dangerous, is how quickly people can get in trouble. They go from having mild symptoms to severe symptoms rather quickly. Having a plan thought out for if patients start to show these mild symptoms is important. We have to figure out where they should go and what the plan is for making sure they’re seen sooner rather than later.

The other key point is to be completely clear about what their care plans are and that their advanced directive are all in place. Knowing that a patient does not want to be intubated, for example, is important information to have on record. This is vital because in some cases, patients don’t have time in the moment to rethink that choice.

TARGETED ONCOLOGY: What advice can you give to community oncologists on prevention?

Dale: My heart goes out to them. I’m especially lucky that I work in a center where we have the ability to do a lot of these things described above. The small community practices are already incredibly busy with patients, and COVID-19 just adds another layer of challenge for them.

If they can, community practices should set up as many of their conversations and visits with their patients via telemedicine as possible. One of the more dangerous places is the doctor's office, where one is exposed to other sick patients. People have to be careful about waiting rooms, and doctors have to stretch out appointments to reduce the number of people in the clinic at once. Putting practices in place to maintain physical distancing and ensure exam rooms are appropriately cleaned are essential.

Community practices that have older patients should consider scheduling them on certain days so that older patients are not exposed to younger patients who could be asymptomatic carriers.

The only other big thing with these practices is how they are going to do testing if they need to. It’s important for the groups to know what the options are for their patients.

TARGETED ONCOLOGY: As this issue continues to evolve, what is important for community oncologists to understand about elderly cancer patients?

Dale: One thing I try to emphasize is that while it is true that older people are at higher risk for severe illness from COVID-19, it is as much about their health as it is about their age. If a patient has other diseases, that patient is at higher risk than people who don’t, regardless of age. Physicians should try to be active about protecting patients with diabetes, heart disease, and other diseases. Also, patients should make sure to have a reasonable supply of the medications they need and should practice self-care at home.

_References:

_{1. COVID-19 guidance for older adults. CDC website. https://bit.ly/354it5N. Accessed April 24, 2020.}

_{2. People who are at higher risk for severe illness. CDC website. https://bit.ly/2W03jKz. Accessed April 24, 2020.}