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Cancer Care Chronicles
May 7, 2020

Cancer and Coronavirus Disease 2019 (COVID-19)—Facing the “C Words”

Author Affiliations
  • 1Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
JAMA Oncol. Published online May 7, 2020. doi:10.1001/jamaoncol.2020.1848

Until now, most people feared a diagnosis with the dreaded “C word”—cancer—owing to its associated physical, emotional, and financial hardships as well as its social stigma. However, the rapid progression of coronavirus disease 2019 (COVID-19) from a local issue to a global pandemic has quickly made it a competitor for the spot of the most feared disease, and rightly so, given the intense strain it is placing on us individually and as a society at every level. For me, having been diagnosed with both diseases 4 years apart, COVID-19 has brought back memories of being confronted with my own mortality.

Some conservative estimates suggest that if 30% of the population contracts the disease and it has a 0.5% fatality rate in the US, COVID-19 would trail only heart disease and cancer as major causes of death in the country.1 In the US, more than 16 million people currently have or have survived cancer (about 5% of the population).2 Therefore, it is inevitable that many of them will be affected by COVID-19. Published data show that patients with cancer are more likely to develop the disease, have severe symptoms, and die than the rest of the population.3,4 These data aside, patients with cancer are generally more susceptible to infections, which has led to grave concern among oncologists and patients with cancer alike about what protective measures might be taken.

I was diagnosed with Hodgkin lymphoma during my oncology fellowship training. What I had been treating a few patients for unexpectedly became my fate, too. Facing the uncertainty of a cancer diagnosis was one of the hardest times I have ever experienced personally and professionally. Being an oncologist myself, I understood the prognosis was good, with a 5-year survival rate of 94%. But while these statistics seemed reassuring to me from an oncologist’s perspective, they were not as comforting as a patient. During that time, while I received chemotherapy, I retreated and socially distanced myself to be able to come to terms with the diagnosis emotionally. Most of my close friends did not know what I was going through because I could not handle a well-intentioned but constant barrage of inquiries about my health. I planned everything meticulously; for example, I got a short haircut and then got a wig that looked like my hairstyle, so nothing would look different when I lost my own hair. I continued to see patients once a week and do research from home on other days. I was fortunate to have the best possible outcome thanks to the excellent care I received. Since then, I have recovered well and been in complete remission. And now my life has come full circle from being a patient at Memorial Sloan Kettering Cancer Center to being a faculty member there.

As COVID-19 started spreading in New York, staff at Memorial Sloan Kettering Cancer Center started working from home, moving toward telemedicine and phone visits, and rescheduling nonurgent visits. We also worked on isolating and distancing ourselves socially. However, despite this, a couple of weeks later, on a Monday in March, I tested positive for COVID-19 after having developed the symptoms of fever and body aches the day before. Given my cancer history, I could not help but wonder if my immune system had returned to its baseline and if I would be able to weather this infection without serious complications. The apprehension of what the week might bring was unnerving and scary—would I start finding it difficult to breathe? Would I need to be admitted to the hospital? Would I need to go to the intensive care unit? Would the prior chemotherapy affect my current outcomes?

I tried to work, but my head hurt. I wanted to sleep, but every little sound was amplified in my mind and kept me up. My body ached from the inside out. My fingers were cold, the pulse oximeter reading 88%. My heart rate and anxiety level went up. I rubbed my hands together to improve my circulation. Try again. This time it was 99%. Phew; I could relax until it was time to check it again.

With each passing day my anxiety dropped incrementally as my oxygen saturation remained at 99%. Although the odds were in my favor with this disease currently demonstrating greater than 99% chance of survival, I did not know going into it that I would end up on the right side of these statistics.

As an oncologist and a cancer survivor, I also worried about the patients for whom I was caring. Asking the average person to stay at home and put their life on pause for a few weeks to months can sound like a reasonable measure to take to curb this pandemic. But that is not an option for many patients with cancer receiving active life-saving therapy. So these patients must go to war every day with both cancer and COVID-19—and every patient’s trip to the chemotherapy suite to extend their life has the potential to abruptly shorten it.

As I write this, I have almost recovered from my symptoms, which were fortunately mild. My mouth feels strange and I cannot smell or taste anything. COVID-19 has this unusual complication, much like chemotherapy. No food tastes how it is supposed to, and it takes me down a memory lane I do not really miss or care to go down.

The COVID-19 pandemic, although tragic and destructive, has brought the world together in many ways and made us all part of a bigger community where differences seem insignificant and we have a deeper appreciation of others. As oncologists, we are doing our best to protect our small cancer community from COVID-19 such that one demographic intersects the other minimally or, ideally, not at all. It is wonderful to see oncologists come together to build a registry on these patients with an intent to rapidly share these data to help guide management.5-9

When I had cancer, I felt very supported by and connected with family and loved ones, but I also felt very isolated at the same time. It felt like I was the only one with that “C word” diagnosis, alone on that journey, and they were helpless bystanders, given that I had chosen to distance myself from extended friends and family. This time, with COVID-19, although I needed to physically distance myself and have minimal human contact, I somehow did not feel as alone or socially disconnected knowing that we, as a society, country, and world, are united in our fight against this disease. Although my family and friends live all over the world, we are all dealing with the same issues of life being at a standstill due to COVID-19. May we emerge on the other side with minimal damage from the combined effect of both the “C words.”

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Article Information

Corresponding Author: Urvi A. Shah, MD, Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY, 10021 (shahu@mskcc.org).

Published Online: May 7, 2020. doi:10.1001/jamaoncol.2020.1848

Conflict of Interest Disclosures: Dr Shah reported grants from Celgene and the Parker Institute of Cancer Immunotherapy and personal fees from the Physicians Education Resource.

References
1.
Katz  J, Sanger-Katz  M, Quealy  K.  Could coronavirus cause as many deaths as cancer in the US? Putting estimates in context.  New York Times. March 16, 2020. Accessed April 27, 2020. https://www.nytimes.com/interactive/2020/03/16/upshot/coronavirus-best-worst-death-toll-scenario.html
2.
Miller  KD, Nogueira  L, Mariotto  AB,  et al.  Cancer treatment and survivorship statistics, 2019.   CA Cancer J Clin. 2019;69(5):363-385.PubMedGoogle ScholarCrossref
3.
Liang  W, Guan  W, Chen  R,  et al.  Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.   Lancet Oncol. 2020;21(3):335-337.PubMedGoogle ScholarCrossref
4.
Onder  G, Rezza  G, Brusaferro  S.  Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy.   JAMA. Published online March 23, 2020. doi:10.1001/jama.2020.4683PubMedGoogle Scholar
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The COVID-19 and Cancer Consortium. Accessed April 27, 2020. https://ccc19.org/
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ASH Research Collaborative. ASH RC COVID-19 Registry for Hematologic Malignancy. Accessed April 27, 2020. https://www.ashresearchcollaborative.org/covid-19-registry
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American Society of Clinical Oncology. ASCO Survey on COVID-19 in Oncology (ASCO) Registry. Accessed April 27, 2020. https://www.asco.org/asco-coronavirus-information/coronavirus-registry
8.
Center for International Blood & Marrow Transplant Research COVID-19 data collection form. Accessed April 30, 2020. https://www.cibmtr.org/Covid19/Pages/default.aspx
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    2 Comments for this article
    EXPAND ALL
    Between fear and work commitment, COVID-19 and hematological cancer
    Humberto Martinez Cordero, Hematologist - Internist | Instituto Nacional de Cancerología. Colombia
    Between fear and work commitment, COVID-19 and hematological cancer.

    I am a hematologist and I was diagnosed with early stage classic Hodgkin lymphoma just under two years ago, I received chemotherapy and radiation therapy. The interim PET-CT was negative, as well as the one at the end of the treatment. My cancer prognosis is excellent (1). While receiving the treatment, I had to be absent from work for a few months. At the end of chemotherapy and during radiotherapy, I decided to go through the hospital wards with the strict use of personal protection elements and hand washing. Finally
    I had no infection and everything went well. A couple of months later I was appointed head of the Hematology and Bone Marrow Transplant unit at the National Cancer Institute of Colombia.

    The arrival of COVID19 this year in our country has given me back the feeling of living the imminent risk of infections, complications and death, with the latent fear of being absent in my home, to my wife and my two young children. A high percentage of the population is expected to become infected and it is clear that oncohematological patients are among the highest risk population. (2). Now I am concerned about myself and my patients and good things have happened in this regard, such as having led 2 consensuses in Latin America for patients with lymphomas and multiple myeloma, in addition to having participated in the national consensus for the treatment of patients with COVID-19 (3,4,5). Adverse situations have also occurred to me, such as the appearance of anxiety, insomnia and a mental dilemma that moves between the fear of getting covid-19 and the commitment to patients who depend on my care, this has already been studied in studies qualitative in health workers. (6). As I said, my cancer prognosis is excellent, but now the uncertainty is around the concept that acquiring COVID-19 infection means, in my case, a high risk of death.



    References

    1. Gallamini A, Kostakoglu L. Interim FDG-PET in Hodgkin lymphoma: a compass for a safe navigation in clinical trials? Blood. 2012;120(25):4913-20.

    2. Williamson E, Walker AJ, Bhaskaran KJ, Bacon S, Bates C, Morton CE, et al. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. medRxiv. 2020:2020.05.06.20092999.

    3. [Internet]. 2020 [cited 10 May 2020]. Available from: https://www.researchgate.net/publication/340543700_Consenso_del_Grupo_de_Estudio_Latinoamericano_de_Linfoproliferativos_GELL_para_el_manejo_de_Linfomas_en_estado_de_Pandemia_SARS_CoV-2_COVID_19

    4. [Internet]. 2020 [cited 10 May 2020]. Available from: https://www.researchgate.net/publication/340543700_Consenso_del_Grupo_de_Estudio_Latinoamericano_de_Linfoproliferativos_GELL_para_el_manejo_de_Linfomas_en_estado_de_Pandemia_SARS_CoV-2_COVID_19

    5. [Internet]. 2020 [cited 10 May 2020]. Available from: https://www.researchgate.net/publication/340543700_Consenso_del_Grupo_de_Estudio_Latinoamericano_de_Linfoproliferativos_GELL_para_el_manejo_de_Linfomas_en_estado_de_Pandemia_SARS_CoV-2_COVID_19

    6. Sun N, Wei L, Shi S, Jiao D, Song R, Ma L, et al. A qualitative study on the psychological experience of caregivers of COVID-19 patients. Am J Infect Control. 2020:S0196-6553(20)30201-7.
    CONFLICT OF INTEREST: None Reported
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    Cancer Patients and COVID-19
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    The oncologist author of the contribution to Cancer Care Chronicles has presented a sensitive and detailed account of a hazardous journey that deals with cancer, a disease in which abnormal cells multiply uncontrollably and leads to the destruction of body tissue.  

    Only those who have personally experienced a life-threatening cancer diagnosis, such as the author of the chronicle, who has fortunately recovered from both cancer and coronavirus, as well as their close family members, friends, and healthcare providers, including oncologists and nursing staff who administer chemotherapy and radiotherapy treatments, would have the capacity to appreciate fully the significant
    impact of any type of cancer on the quality of life, and on the preservation of life itself.

    A common side effect from chemo and radio therapies is the loss of (all) bodily hair in a short period of time, which can lead to many confronting issues for patients.

    Some patients don wigs, which can be appealing, but yours truly embraced the Yul Brynner / Bruce Willis follicly/follically-challenged sartorial look as economical and expedient.

    Unlike cancer, where members of the general public free of the disease are seemingly not concerned about possible infection, the SARS-CoV-2 virus that causes the COVID-19 disease would almost certainly be on the minds of every human being, especially as the chances of infection and transmission are far from negligible.

    Cancer patients have diminished immune systems, and so are more susceptible to contracting COVID-19, and suffering severely from such an infection.

    Whether cancer patients with COVID-19 are more likely to transmit the disease to healthy humans does not yet seem to have undergone serious clinical trials.

    A simple fact that every cancer patient understands presciently is that it is impossible to survive and enjoy quality of life without the continuous and selfless support of family, friends, oncologists, and nursing staff, especially with triweekly chemotherapy sessions lasting for more than six years, and counting.

    Acknowledgement of gratitude does not come close to expressing just how much cancer patients, as well as patients infected with COVID-19 or any other disease, truly appreciate the comforting support of family, friends, oncologists, and nursing staff, when their selfless help is needed the most.
    CONFLICT OF INTEREST: None Reported
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