As the coronavirus battered the West Coast, Bryce Olson faced an excruciating decision: He was supposed to travel from his home in rural Oregon to San Diego every three weeks to take part in a clinical trial for aggressive prostate cancer. But after his last trip in early March, he wondered whether he should drop out of the trial and stay home, at least for a few months.
He worried that if he contracted the virus during his travels, he could die before his weakened immune system could mount a counterattack. But skipping cancer treatments could unleash a disease that had menaced him for six years.
“If I let the tiger out of the cage, it may be harder to get it back in,” said Olson, 50.
Olson’s dilemma is one of many challenges confronting cancer patients and their doctors as they grapple with the twin foes of cancer and covid-19, the disease caused by the virus. Cancer will be diagnosed in estimated 1.8 million people in the United States this year, according to the American Cancer Society, and more than 600,000 will die of the disease. Now, with the virus racing through the country, cancer doctors and patients are taking sometimes drastic steps to try to deal with the crisis.
The changes range from the simple to the complex. At NYU Langone Medical Center, for example, cancer patients are directed to separate elevators to reduce their chance of being infected by the coronavirus. Nationwide, oncologists are delaying some surgeries and paring back treatments to reduce patients’ hospital time and risk of infection.
Cancer-fighting pills taken at home are being substituted for IV therapies administered at hospitals and clinics. With blood donations falling sharply, doctors are switching to regimens that require fewer transfusions. In many places, clinical trials, the last hope of many desperately ill patients, are being closed to new patients.
“I’m used to seeing patients who are afraid,” said Mark Lewis, an oncologist at Intermountain Healthcare in Utah who had pancreatic cancer three years ago. “But nowadays, they are particularly terrified. Their fear is amplified beyond the general populace.”
A World Health Organization study showed that cancer patients who develop covid-19 have a fivefold risk of dying compared with people without cancer. Researchers say cancer patients are more vulnerable because of compromised immune systems caused by their malignancies and treatments, such as chemotherapy or surgery.
With the stakes so high, oncologists sometimes struggle to figure out the right course for patients. “What’s the greater risk?” said Lynn Schuchter, an oncologist at the University of Pennsylvania’s Abramson Cancer Center. “Delaying treatment or bringing patients in from home?”
Some patients are adamant that fighting cancer should come first. A new survey by KCCure, a nonprofit organization focused on kidney cancer research, showed that a majority of patients are worried about delaying doctors’ visits, postponing IV treatments and scaling back other therapies.
“Keeping people out of hospitals makes sense, but it can be detrimental to their care at the same time,” said Dena Battle, president of the group. She said anxieties are especially high among newly diagnosed patients awaiting surgery.
Owen Wallace, a resident of Bedford Hills, N.Y., who has multiple myeloma, a blood cancer, said he was disappointed when his doctor delayed a procedure to collect his blood stem cells in mid-April in preparation for a stem-cell transplant. Like many patients with multiple myeloma nationwide, his transplant is being delayed. It’s “a letdown, 100 percent,” he said.
But Wallace, who is in remission, said his doctor assured him that he won’t be endangered by waiting for the transplant because the cancer often moves slowly, and there are other effective treatments if needed. He said he also understands that a health-care system coming under intense strain from covid-19 may not be able to provide the resource-intensive care required after transplants, including a month’s stay in isolation in a hospital.
Other patients are happy to put off surgeries and procedures, cancer doctors say.
Nancy Davidson, president and executive director of the Seattle Cancer Care Alliance, said she recently told a few older patients with early-stage breast cancer that they could safely delay their surgeries and start hormone-blocking treatments at home. Usually, the order is reversed. “They were delighted to go home and come back in a few weeks,” she said.
Doctors say treatment changes have to be weighed carefully in close consultation with patients. Some calls are relatively straightforward. For example, surgeries can be delayed for some thyroid and early-stage prostate cancers, which have high survival rates, but not for pancreatic cancer, which is much more deadly. For patients with aggressive leukemia and lymphoma, treatment usually can’t be postponed, experts say. In the Trump administration’s recent recommendation for hospitals to stop most elective procedures, most cancer treatments aren’t considered elective.
For some cancer patients, the big fear is rationing — whether they will be able to get care if they contract the virus.
“If someone starts assigning ventilators based on life expectancy, I’m in trouble,” said Stacey Simpson Duke, a 48-year-old pastor in Ann Arbor, Mich., who has advanced sarcoma, a cancer that can arise in the fat and muscles as well as the bones. “According to statistics, I should have been dead two years ago.”
Several Seattle oncologists, who have been at an epicenter of the epidemic, agree that doctors might face tough decisions. Writing in the Journal of the National Comprehensive Cancer Network, they warned that physicians could “face the heavy reality of rationing care. As the pandemic progresses, there will come a point when channeling a large amount of resources for an individual patient will be in direct conflict with the greater social good.”
Many patients are focusing on more near-term concerns. On Inspire, a health-care social network, patients raised an array of questions: Are MRI machines adequately sanitized between patients? Should they curb certain treatments? What should they do if their doctors didn’t offer telemedicine visits?
NYU Langone oncologist Michael Grossbard is one of many cancer doctors switching as many patients as possible to pills from hospital-based infusions. He said he is also cutting back on chemotherapy treatments when it’s safe to do so.
On Grossbard’s recommendation, Ron Blei, a 74-year-old retired math professor in Connecticut who has lymphoma, switched to a shorter but slightly less effective chemotherapy regimen. On weeks when Blei is scheduled for treatment, he goes to the hospital only one day, rather than five days, as he had been doing.
Blei, who is in remission, said he made the change partly because his family was worried about his frequent trips to the New York hospital during the pandemic. “It makes sense,” he said of the treatment change.
Some patients are more anxious about scaling back or postponing treatments. “This is where the physician-patient relationship is so important,” said Rafael Fonseca, head of the Mayo Clinic Cancer Center in Phoenix. “I’m calling people and telling them why we are delaying their transplant. You are cashing in your chips of trust.”
Olson, the Oregon patient with advanced prostate cancer, recently decided to stop going to the University of California at San Diego for his treatments for now. “It’s too high risk for someone like me,” he said, adding that his white blood count is low, making him vulnerable to infection.
He hasn’t given up on the trial, however. Part of the regimen — an oral medication — will be delivered to his home by FedEx. He still hasn’t figured out how to get the IV immunotherapy therapy that is the other part of the treatment. Even if the San Diego doctors arrange for him to get the infusion in an Oregon hospital, he’s not sure he’ll go.
He has concluded that it’s probably okay to miss a few immunotherapy treatments, he said. “Covid, on the other hand, could kill me.”
Coronavirus: What you need to know
Vaccines: The CDC recommends that everyone age 5 and older get an updated covid booster shot. New federal data shows adults who received the updated shots cut their risk of being hospitalized with covid-19 by 50 percent. Here’s guidance on when you should get the omicron booster and how vaccine efficacy could be affected by your prior infections.
New covid variant: The XBB.1.5 variant is a highly transmissible descendant of omicron that is now estimated to cause about half of new infections in the country. We answered some frequently asked questions about the bivalent booster shots.
Guidance: CDC guidelines have been confusing — if you get covid, here’s how to tell when you’re no longer contagious. We’ve also created a guide to help you decide when to keep wearing face coverings.
Where do things stand? See the latest coronavirus numbers in the U.S. and across the world. In the U.S., pandemic trends have shifted and now White people are more likely to die from covid than Black people. Nearly nine out of 10 covid deaths are people over the age 65.
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