By Dan Veljovich, MD
Dr. Dan Veljovich is a Gynecological Oncologist with Swedish Cancer Institute. Dr. Veljovich is also a member of the Rivkin Center Board of Directors. Questions were submitted by members of the Rivkin Center patient and survivor community.
The ongoing COVID-19 pandemic has created a lot of worry and questions from our cancer patient and survivor community. Below I have addressed some frequently asked questions on how to best manage cancer care during the outbreak. Please note that these are general guidelines and you should consult your personal healthcare provider for questions specific to you.
What are some tips for managing exposure and risks for going into busy medical facilities for regular chemotherapy treatments and appointments?
In general, the most important strategy to avoid exposure to COVID-19 for patients either in cancer surveillance or active cancer treatment is to AVOID HEALTH CARE FACILITIES. Unless absolutely necessary, cancer patients should minimize contact points with the health care system as much as possible, including not going into their physicians’ offices unless a physical exam is needed. In our practice, a few guidelines are as follows:
- TELEHEALTH visits are being utilized for ALL standard pre-chemotherapy visits, with laboratory results and imaging study results reviewed with the patient on a virtual visit using FaceTime, Google Duo, or Zoom so as to avoid the patient making any contact with an outpatient office. This minimizes exposure both to the patient and provider.
- Liberal hand washing as often as possible, minimization of any hand-to-face contact, and maintaining appropriate social distancing even in the doctor’s office to the extent possible.
- NO PHYSICAL EXAMINATION unless imperative to do so, as this is yet another contact point in the system.
- Ensuring that white blood cell, absolute neutrophil, and lymphocyte counts are appropriate before proceeding with chemotherapy or immunotherapy or biological therapy.
- Avoiding doctor visits for surveillance until after the pandemic has blown through Seattle/King County, with emphasis on tumor markers and imaging as needed, but again avoiding doctor visits.
- Avoiding contact with ANY health care facility to the extent possible during the surge of coronavirus, which is difficult to predict at this time.
What do patients who have low white cell/neutrophils need to watch for to monitor for infection?
The most important symptoms to report immediately are FEVER, SHORTNESS OF BREATH, or COUGH. In an immunocompromised patient with a low absolute neutrophil count, these symptoms should be reported immediately to their physician and currently the most common course of action would be to NOT go to the oncologist’s office so as to avoid potential spread to other oncology patients, but to contact her primary care physician and have testing done at one of the mobile testing centers. The idea is to keep patients who have COVID-19 out of the hospital and office setting and remain quarantined at home if not ill, but a primary care physician should make the final decision about whether the patient should be seen in a medical facility for evaluation.
Do patients who are currently in chemotherapy treatment but have normal white counts and neutrophils need to take special precautions beyond the current guidelines in place for the general population?
Patients undergoing any form of anti-cancer therapy are by definition more immunocompromised relative to the general population and therefore should be ultra-vigilant regarding the usual precautions utilized by the general population, including frequent hand washing with soap and hot water for 20 seconds at a time, minimizing contact with others (avoiding any public store or setting to the extent possible), practicing the 6 foot rule, and immediately reporting any symptoms consistent with coronavirus. LYMPHOCYTES typically fight viral infections and patients with normal absolute neutrophil counts can have lymphopenia which put them at increased risk of viral infection. Again, only having touch points in the medical system for infusion appointments and pre-chemotherapy labs is advisable (i.e. NOT seeing your doctor in an outpatient setting and using telehealth visits instead).
How should patients in remission handle regular oncology checkups and/or their oncology health in general if their oncologist’s office is not seeing low risk patients and/or the labs are not taking low risk people because of COVID-19?
Delay surveillance visits until AFTER the pandemic as cited above. The risk of a surveillance visit at this time is higher than any benefit and unless patients have symptoms that are worrisome for recurrence I would recommend avoiding the doctor’s office. Most labs are still operational so tumor marker studies can still be done.
Are the risks for someone in remission any greater than they were before they had cancer?
Typically patients who have completed therapy more than 3 months ago with normal lab counts and have no significant increased risk. However, the most significant risk factors for COVID-19 infection in the general population are increasing age (generally greater than 65 years old), multiple co-morbidities (i.e. hypertension, diabetes, cardiac disease), and any underlying pulmonary disease, including a history of asthma, smoking or COPD. Given that many cancer patients are older and have multiple co-morbid medical conditions, these factors generally put cancer patients at higher risk even in those women who have completed therapy and are not classically immunocompromised secondary to low white blood cell counts.
