Monday, July 6, 2020

Early Phase 1 Study Shows Promise for Platinum-Resistant Epithelial OC

Good news for women who have platinum-resistant OC and who have had 5 previous types of treatment.

The drug, STRO-002 is a combination antibody-drug conjugate, meaning it combines an antibody with chemo to deliver the medication directly to the cancer cell, hopefully eliminating some adverse side effects associated with off-targeting.

The results were presented at 2020 AACR Virtual Meeting of April 27-28.

Phase1 has been successfully completed which means that the toxic range of the medication has been established and now, Phase 2, will determine the recommended dose. OncLive conducted an interview with one of the lead investigators. Follow this link to the full article.

Friday, July 3, 2020

MGH: Part II - A Guide to Understanding Clinical Trials

Here is Part II of the MGH "A Guide to Understanding Clinical Trials".

Since the start of the SARS-COV-2 (COVID-19) outbreak, scientists have repeatedly advocated for the use of well-structured clinical trials in testing new treatments for the disease. But what does a well-structured trial look like?
In part one of this series, we discussed how clinical trials are set up. In part two, we highlight a few key components to look for when reading about the latest research and clinical trials, because they are not created equal.
Maurizio Fava, MD, Psychiatrist-in-Chief at Massachusetts General Hospital and Director of the Division of Clinical Research of the Mass General Research Institute, stresses the “importance of well-designed studies and clinical trials, as today’s clinical research will help us improve the standard of care of the future. This is absolutely critical for conditions such as COVID-19, given the need to develop ways to both prevent it and treat it.”
Here are a few things to look for to ensure that results are as accurate as possible:

Sample size: The number of patients/participants studied

The number of people involved in a clinical trial is critical because scientists are basing the success of the treatment on how it affects the participants involved. These insights that get applied to an entire population, so ensuring they are as accurate as possible is important for everyone’s safety. 
For example, a treatment that appears to work well in a sample of 20 participants may not work as well when that pool is expanded to hundreds or thousands of participants.
Keep in mind, a small sample size may also make key differences harder to spot and may not be representative of or applicable to a larger population. If a study is done on a small homogenous group with similar demographics (age, health status, ethnicity, gender, etc.), there is no telling how it could affect other demographics.

Placebo: An inactive substance given in the place of a treatment

Placebos are used when there is no existing standard of care to test a new treatment against. They are typically designed to look like the medication that is being tested but do not have a therapeutic effect. 
Testing a new treatment against a placebo gives researchers something to compare their results to and helps to eliminate bias in patient-reported outcomes.

Randomization: Assigning treatments to participants at random

Randomization is the process of randomly assigning patients to either the treatment or control group without considering underlying factors such as disease state, age, weight or medical history.
For example, if all young participants receive an experimental treatment and get better, while all older participants receive standard treatment and fare worse, it would be difficult to prove the experimental treatment was the sole cause of improvement, because age could play a role. 
However, if the experimental treatment was distributed to all participants at random and the health of the experimental group improved (regardless of age), it would be easier to draw more accurate conclusions.

Peer review: A process in which experts in the same field objectively review a scientific study before publication

Peer review is a vetting process that allows impartial subject matter experts who were not involved in the study to review research before it is published. It is critical to scientific discovery because it helps validate and improve the quality of research.
There are some cases where scientists will opt to publish their findings in a non-peer reviewed journal because it is faster and easier than going through the peer review process, but this also means there is potential for errors and findings may not be accepted by the broader scientific community.
Non-peer reviewed studies have become increasingly popular, so when reading about scientific findings or new study results, it is important to check where those results have been published.

Blinded studies: Studies that withhold treatment information from patients or researchers to reduce bias

There are two types of blinded studies: single-blind and double-blind.
  • Single-blind: Researchers know if participants are receiving the treatment or the placebo/standard of care, but participants do not. This helps reduce participant bias by limiting the “placebo effect”—a form of unconscious bias that can sometimes lead people to feel better after believing they have been given a new treatment, even if it was an inert substance or standard treatment.
  • Double-blind: Neither participants nor the researchers know who is receiving treatment. This is considered the “gold standard” in clinical trials because it helps reduce participant and researcher bias. With both groups having little information to influence their perspective, the study is likely to produce more accurate results.
One of the first high profile clinical trials for hydroxychloroquine as a potential treatment for COVID-19 received sharp criticism from the scientific community due to several issues with its structure. 
Critics were quick to point out that the sample size was small with just 42 participants, the control and treatment group participants did not appear to be randomly selected and several negative patient outcomes were excluded from the results.
Two additional studies from The Lancet and The New England Journal of Medicinewere also recently retracted. Findings gathered from The Lancet study were called into question when the scientific community noticed homogenous patient data and potential issues with the statistical analyses. Researchers leading The New England Journal of Medicine study were forced to retract their study when they could not validate their supporting research.
As we move forward and learn of new findings from researchers working to uncover the mechanisms behind disease, it is important to ask questions and critically examine the supporting research before accepting new findings as facts.

Thursday, June 25, 2020

MGH: A Guide to Understanding Clinical Trials" Part 1

Although this article is not specific to ovarian cancer, "A Guide to Understanding Clinical Trials" is important info for all of us.

Published on the MassGeneral website, I am including the full text below. This is part 1.

When a new disease such as COVID-19 is discovered, it is up to doctors and scientists to investigate how the disease behaves so treatments can be developed and tested.
There are numerous clinical trials for COVID-19 therapeutics across the globe, and results from these trials (often uncontrolled and published in non-peer reviewed journals) are being released on a regular basis.
With all of the new information coming out so rapidly, it can be confusing to understand what these results mean. The Mass General Research Institute is providing a resource to explain how clinical trials work and share what makes for a strong clinical trial with clear and promising results.

What are clinical trials and why are they important?

Clinical trials are scientific studies designed to test the safety and usefulness of new medical interventions such as treatments, devices, preventative care, screening or diagnostic procedures, and more.
They are crucial to the advancement of strong science and patient care because, if well-designed, they can validate the performance of an intervention under controlled circumstances to ensure it is safe, effective and provides measurable benefits to patients.

How do they work?

Scientists typically conduct research on a disease or potential treatment for several years to lay a foundation for a clinical trial. During this time, they are gathering as much information as possible to learn about how a disease behaves, what it does to the body, which populations are at risk for it and what may be potential targets for treatment. Research can move into the next phase, called preclinical or translational research, once enough promising and validated reproducible data have been generated to justify further testing.
Preclinical trials are the first opportunity to see how a treatment may work in specific non-human models. In this stage, scientists must follow strict guidelines to test their interventions in vitro (in a petri dish or test tube) or in vivo (in a living organism such as an animal model) before moving on to human trials. If the findings are promising, investigators must fill out the necessary paperwork and get approval so the study can move onto a Phase I clinical trial.

What happens in the four phases of clinical trials?

According to the Federal Drug Administration (FDA), there are four phases of clinical trials that each inform decisions made in the next phase:
  • Focus: Establishing the safety and correct dosage of a treatment
  • Time frame: Typically lasts several months
  • Sample size: 20-100 participants who are either healthy or have the targeted condition
  • Bottom line: Designed to understand how the treatment and dosage are tolerated within the human body

Tuesday, June 23, 2020

Ovarian Cancer National Conference, Oct. 2020

The Ovarian Cancer Research Alliance (OCRA) will be holding its national conference from Sept 29 - Oct 2.

In their own words:
Join us (virtually) September 29 – October 2!
The global pandemic may have upended our original plans but it can’t stop us from uniting the ovarian cancer community from all over the world.  The format may be different (no in-person hugs) but we promise to provide the same eye-opening, educational content from the country’s top researchers and doctors about every aspect of ovarian cancer, including treatment, wellness, advocacy and survivorship, as we always have but this time with a few surprises. 
While we’re undeniably disappointed that we won’t be able to see everyone in person, there is a significant up-side to moving our conference online: Now anyone who wants to attend will have the chance, no travel necessary! We’re excited to expand our strong and welcoming community to reach even more people with important updates in the ovarian cancer field and OCRA’s patient support programs.
Past attendees have said that this conference is a can’t miss event for the ovarian cancer community:  a gathering of hope, inspiration, new found knowledge and sisterhood.
We are excited for you to join us!
To register, follow this link.

Monday, June 22, 2020

Nirapamib Wins FDA Approval for Front-Line Treatment of OC

Nirapamib a PARP inhibitor, is now available for maintenance treatment in all women with advanced epithelial, primary peritoneal or fallopian cancer regardless of BRCA mutation status who have responded to platinum based chemo.

Olaparib (Lynparza) is only approved for women with germline BRCA mutations.

PARP inhibitors work by preventing cancer cells from repairing their DNA damage caused by previous anticancer medications.

Despite FDA approval for front-line therapy after platinum based chemo, the side effects may make the drug intolerable for some women. These include anemia, neutropenia, GI toxicity and fatigue.

To read more about Nirapamib's approval, follow this link.

Thursday, June 18, 2020

Going Through Divorce While Undergoing Treatment

This story appeared on SurvivorNet.com and it's about one woman's journey through ovarian cancer while undergoing a divorce.

I've know several women (of all types of cancer) go through divorce while undergoing treatment. It's something that's not talked about much but certainly crosses some women's minds.

You can read the article by following this link.

Monday, June 15, 2020

Nirapamib Plus Bevacizumab: a Winning Combo

Recent findings presented at the 2020 ASCO Virtual Scientific Program confirmed that combination nirapamib (Zejula) plus bevacizumab (Avastin) showed a 66% reduction in the risk of disease progression or death.

The results from this phase II study confirms earlier findings that showed improved clinical outcomes in the AVANOVA trial that were clinically significant.

Patients with recurrent platinum-sensitive epithelial, fallopian tube or peritoneal cancer and high-grade serous or endometrioid histology participated in the study. Additionally, patients with any number of prior therapies were allowed to participate.

The results of the study led by a group from Denmark is now set to move into phase III. If this continues to be successful, it will likely change treatment protocols for recurrent OC.

To read more about the study, follow this link.

Monday, June 8, 2020

DF Doctors Present Findings

Drs. Liu, Brady and Matulonis from Dana Farber, recently presented their findings on a phase III study looking at recurrent, platinum-sensitive ovarian cancer (OC) at this year's ASCO Virtual Scientific Program.

The study looked at treating recurrent OC with three different treatment options: platinum based chemo, treatment with olaparib (PARP inhibitor) or olaparib plus cediranib (anti-angiogenic).

The study did not meet its primary endpoint of progression-free survival but the authors felt that the results showed a comparable effect to the more traditional platinum based chemo. Of note however, the combination of olaparib and cediranib were more successful in patients with germ-line BRCA mutations.

To read more about the study, follow this link.

Wednesday, June 3, 2020

Scientists identify factors for predicting which patients with ovarian cancer won’t benefit from immunotherapy-PARP inhibitor combination - Dana-Farber Cancer Institute | Boston, MA

Scientists identify factors for predicting which patients with ovarian cancer won’t benefit from immunotherapy-PARP inhibitor combination - Dana-Farber Cancer Institute | Boston, MA: In patients with advanced ovarian cancer, a combination of drugs known as immune checkpoint inhibitors and PARP inhibitors can produce powerful remissions, clinical trials have shown, but up until now investigators haven’t been able to predict which patients won’t benefit from the treatment and should explore other options.

Monday, May 18, 2020

Atul Gawande, M.D. writes articles for The New Yorker and has some excellent advice for all of us about how to re-enter the world after our weeks in seclusion.

The New Yorker reports and analysis on Covid-19 are free to all to read.

Here is the beginning of this article with the link attached below. As usual, Dr. Gawande offers a thoughtful analysis on the strategies that healthcare workers have undertaken that can be applied to all of us sitting at home wondering how safe it will be to venture outside to resume semi-normal activities as more non-essential services are added. I hope you'll read on...

Amid the Coronavirus Crisis, a Regimen for Reëntry

In places around the world, lockdowns are lifting to various degrees—often prematurely. Experts have identified a few indicators that must be met to begin opening nonessential businesses safely: rates of new cases should be low and falling for at least two weeks; hospitals should be able to treat all coronaviruspatients in need; and there should be a capacity to test everyone with symptoms. But then what? What are the rules for reëntry? Is there any place that has figured out a way to open and have employees work safely, with each other and with their customers?

Well, yes: in health care. The Boston area has been a covid-19 hotspot. Yet the staff members of my hospital system here, Mass General Brigham, have been at work throughout the pandemic. We have seventy-five thousand employees—more people than in seventy-five per cent of U.S. counties. In April, two-thirds of us were working on site. Yet we’ve had few workplace transmissions. Not zero: we’ve been on a learning curve, to be sure, and we have no way to stop our health-care workers from getting infected in the community. But, in the face of enormous risks, American hospitals have learned how to avoid becoming sites of spread. When the time is right to lighten up on the lockdown and bring people back to work, there are wider lessons to be learned from places that never locked down in the first place.

These lessons point toward an approach that we might think of as a combination therapy—like a drug cocktail. Its elements are all familiar: hygiene measures, screening, distancing, and masks. Each has flaws. Skip one, and the treatment won’t work. But, when taken together, and taken seriously, they shut down the virus. We need to understand these elements properly—what their strengths and limitations are—if we’re going to make them work outside health care.

To read the article, follow this link.

Friday, May 15, 2020

So Just How Effective Are Those Masks?

This article from The Annals of Internal Medicine appeared in my inbox this morning after being picked up by the National Center for Biotechnology Information/National Institutes of Health.

The question the authors wanted to answer was simple: Do surgical and cotton masks block the transmission of Covid-19?

The conclusion I found stunning - not only was the answer no (that didn't surprise me) but the outside of masks were more contaminated that the inside of face masks - counterintuitive right?

The study size was small: 4 patients and the study did not compare the use of these masks to N95 masks. Given that N95 masks are in short supply and a previous study showed that surgical masks were effective in preventing the dissemination of the influenza virus, the researchers wanted to know if surgical masks would also prevent the spread of Covid-19.

They had each of the patients cough 5 times on a petri dish that was 20 cm (approx 10 inches) away from their mouth. They coughed in this sequence: without a mask, a surgical mask, a cotton mask and then again without a mask.

The masks were swabbed in this order: the outside of the mask first then the inside side of each of the masks.

Here were the results: all surfaces on the outside of the masks were positive for Covid-19 whereas only one patient contaminated the inner and the outer surfaces of the surgical and the cotton masks.

So how is it that more virus was found on the outside of the mask - not the inside as one would suspect? Here's the reason postulated: Since the masks are not tight fitting, a turbulent jet of air is created at the edges of masks where the particles escape and essentially contaminate the outside of the surface. I think of it as a similar effect to how our glasses get fogged up and our breath rises up when we cover our nose and mouth.

But it doesn't explain the lack of virus on the inside of 3 out of 4 of the masks. As the authors noted, the velocity of the cough may have forced the particles straight through to the outer surface, but it doesn't account for larger particles coughed that would have been unable to penetrate.

Here's what the authors' say: "We do not know whether masks shorten the travel distance of droplets during coughing. Further study is needed to recommend whether face masks decrease transmission of virus from asymptomatic individuals or those with suspected COVID-19 who are not coughing.
In conclusion, both surgical and cotton masks seem to be ineffective in preventing the dissemination of SARS–CoV-2 from the coughs of patients with COVID-19 to the environment and external mask surface." 
Keep in mind that the authors were careful to point out that the study:
1. Did not include N95 masks.
2. Does not reflect the actual transmission of infection from patients with Covid-19 wearing different types of masks.
3. The study did not test whether masks shorten the travel distance of droplets during coughing. 
4. The study did not test if face masks decrease transmission of virus from asymptomatic individuals or those with suspected COVID-19 who are not coughing.
So there is still a lot more that would be helpful to know but for me, the takeaway is clear. Presuming my family and I don't have Covid-19, it still behooves us to:
  • thoroughly wash our hands after removing a mask, 
  • throw away disposable masks after single use or rewash the mask if it's reusable 
  • continue to maintain social distancing

To read the full study, follow this link.

Sunday, May 10, 2020

Who to Treat and When During Covid-19

The challenge for gyn/oncs during Covid-19 is deciding who should get surgery now, who can wait, which patient should start chemo and how to treat the patient who actually has Covid.

There is no road-map to follow and what is guiding these clinicians is the answer to this question: Is the treatment curative or not?

In addition, there is no evidence-based medical guidelines to follow during this time. Because of that, the Society for Gynecological Oncology has put together the SGO Covid-19 Task Force. The goal of the task force is to, "gather and disperse important resources regarding surgery, infusion clinical trials, resident and fellow education, patient communications and wellness during the pandemic." You can read more about this by following this link.

Wednesday, May 6, 2020

Answering Questions on Cancer and Covid-19

Thanks again to Betsy for alerting me to this website and the articles devoted to cancer survivorship.

The American Society of Clinical Oncologists and the National Coalition for Cancer Survivorship worked together to provide this information about Covid-19 and cancer. The article first appeared in March and was updated on May 3, 2020 and will hopefully be of interest to all.

Q1: Can you briefly describe what it means to be 'immune compromised'?

The term ‘immune compromised’ refers to individuals whose immune system is considered weaker, more impaired, or less robust than that of the average healthy adult. The primary role of the immune system is to help fight off infection. Individuals with compromised immune systems are at a higher risk of getting infections, including viral infections such as COVID-19. There are many reasons that a person might be immune compromised: health conditions such as cancer, diabetes, or heart disease, older age, or lifestyle choices such as smoking can all contribute to weakened immune systems. Patients with cancer may be at greater risk of being immune compromised depending on the type of cancer they have, the type of treatment they receive, other health conditions, and their age. The risk of being immune compromised is typically highest during the time of active cancer treatment, such as during treatment with chemotherapy. There is no specific test to determine if a person is immune compromised, although findings such as low white blood cell counts or low levels of antibodies (also called immunoglobulins) in the blood likely indicate an immune compromised state.

Q2: Does a history of cancer raise your risk for health complications from COVID-19 (SARS-CoV-2)?

It appears that patients with cancer and survivors of cancer may be at higher risk of health complications from COVID-19. This is not surprising given that this group of individuals is often immune compromised. There is also evidence from one study (Liang et al, Lancet Oncol, http://dx.doiorg/10.1016/S1470- 2045(20)30096-6) that reported patients with a history of cancer had a higher incidence of severe complications, including needing intensive care unit care, mechanical ventilation (being on a breathing machine) or death, compared with other patients who did not have cancer. This is just one study though, and the small number of cancer patients in that study (18 patients) cannot necessarily be generalized to all patients with cancer.

Q3: Does having received chemotherapy or radiation in the past raise your risk for getting COVID-19 or having a more serious course of illness?

Monday, April 13, 2020

VB-111 Hits Milestone in Phase III Platinum-Resistant Ovarian Cancer Trial

There has been little progress made in the treatment of platinum resistant ovarian cancer until recently. An international, double-blind study has received the go-ahead to continue with its Phase III study because of very encouraging results to date.

Platinum-resistant OC is defined as a recurrence within 6 months of ending first-line treatment with platinum-based chemo. The definition has also been extended to include cancer progression within 6 months of any subsequent treatment for recurrence.


The study of VB-111 with paclitaxel vs paclitaxel alone, began in December of 2017 and is expected to end in 2023. VB-111 works in two ways to destroy ovarian cancer cells. "VB-111 is a first-in-class anticancer agent that targets tumors through a dual mechanism. In addition to delivering a gene therapy that eliminates a tumor’s blood supply, the viral vector where the gene is inserted induces specific immune responses that lead to cancer cell death."

Richard Penson, M.D., MRCP, is a principal investigator in the OVAL study. He said that the Phase II study results showed a high response rate and better survival. The encouraging results of the Phase III study means that the trial will now continue without changes. 

You can also read more about the study by following this link to OncLive. OncLive requires a sign-up (free) but you get GREAT links to ovarian cancer research videos.


Friday, April 10, 2020

Chemo & Covid: Q & A

Covid 19 has cancer patients worried and rightly so. To that end, the American Cancer Society put together some questions and answers for those who are receiving treatment.

You can access this by following this link.

Wednesday, April 8, 2020

MIT’s Koch Institute wins STAT Madness with technology to see tiny ovarian tumors

When I attended a symposium in Boston on Ovarian Cancer several years ago, I was struck by potential ways to help surgeons recognize microscopic oc cells that involved using florescent materials that would, under infared, light up. WOW!

Well thank you Betsy for sending me this article about just this thing. "These probes find ovarian cancer cells by piggybacking on bacteriophages genetically engineered to latch onto a specific protein found in abundance on these invasive cancer cells. Their fluorescence in low wavelengths is boosted by infrared light to show the anatomy — organs and tissues where the tumors are lurking. And a third light source illuminates it all for the surgeon, who is guided by a software-enabled display on a monitor."

The MIT team is in talks w/the FDA for a small, phase I trial in women. To read more about this amazing research, follow this link.

Tuesday, March 17, 2020

Emergency Room Doctor: How We Treat Cancer Patients With Coronavirus Symptoms

This article appeared on the SurvivorNet.com website today. I'm reprinting it here. I hope that this information is helpful.

So what happens when a person undergoing cancer treatment goes to the emergency room worried they might have coronavirus? As many people in the SurvivorNet community are concerned, the editors thought it could be helpful for me to explain how we take care of these patients. Hopefully, knowing the specific medical protocol can help demystify the process, and maybe lessen the anxiety.

Most Emergency Departments, which is where I work as a doctor, have protocols on what to do with a feverish person undergoing chemo.

First Step On Arriving At The ER

When you arrive in the ER, you’ll likely be screened with questions first. If the staff is concerned you might have Coronavirus, you’ll likely be given a  mask and hand sanitizer.
Your vital signs will checked: the temperature, heart rate, blood pressure and how much the oxygen saturation is. Vital signs offer a clue if something is off in the body. After a physical exam, a series of tests are ordered: a chest x-ray to see if there is a pneumonia, a urine test to see if there is a urinary tract infection. Blood work, like the following, is also ordered:
  • CBC ( complete blood count) with differential: this tells the white blood cell count ( is there leukopenia or neutropenia?), if the person is anemic (does the person need a blood transfusion?) and if the ability to clot blood is ok ( is the person bleeding easily?).
  • Complete Metabolic Panel (CMP): this checks all the electrolytes (like sodium, potassium, kidney function and blood sugar) as well as liver function.
  • Blood and urine cultures: Bottles and vials of blood and urine are sent to the lab to see if any bacteria are growing in them that might be responsible for an infection. If bacteria is found, tests are run on it to see what specific antibiotics works against it. Cultures can take a few days to grow; it is not a same day test.
  • Other tests can be added on like a flu swab, stool tests, etc. COVID-19 cultures are sent based on whether a person meets testing criteria by the CDC. The purpose of this work up is to find the fever source. Sometimes, the answer is not immediate. So, many protocols include giving a dose of broad-spectrum, intravenous (IV) antibiotics. Broad-spectrum antibiotics cover a broad range of bacteria to treat everything that it could be. The antibiotics can be narrowed down or stopped once the culture results are known.
We understand a hospital is the last place a person dealing with cancer wants to be. Between frequent hospital visits, the desire to spend time with loved ones and simply missing home, people do not want to stay in the hospital.

Admission vs Discharge?

The decision of admission versus discharge depends on certain factors:
  • If the person is sick ( very weak, dehydrated, can’t keep down medications because he or she will vomit so IV treatment is needed) or unstable     (vital signs are abnormal, or a person’s mental status is off, or not breathing properly) the concern is, if sent home, the person can deteriorate. People meeting these criteria should be admitted. People who have normal vital signs and are otherwise well, may be admitted until the cultures come back negative, or sent home after a discussion with the oncologist. In cases of discharging home, it is essential that the oncologist is following the culture results. If a person is going home, it is helpful to obtain a copy of the test results for home records and to share with other health providers. It is important to also know what to return to the hospital for.
  • The whole goal, from the ED, is to make sure that the person is safe, monitored and treated appropriately so that he or she can either go home or continue the treatment process upon admission. There should always be discussion between you and your healthcare providers and, please, ask questions freely. That said, we might not have all the answers right then and there. This is especially true in the ED where tests are still running, there is a limited amount of time to talk, or the environment is hectic.  However, remember, this is an ongoing and dynamic process involving a lot of discussions, fighting and hope- and we as your health care providers want to support you through all of that.

What We Worry About With Cancer Patients & Coronavirus

Chemotherapy continues to be a typical treatment for many cancers.  However, “living life” while on chemo can be anything but typical. Mundane tasks such as running errands, preparing meals and self-care can be challenged by chemo’s side effects, such as fatigue, nausea, vomiting and a weakened immune system.
  • Weakened immune systems due to chemo can present itself in blood work through leukopenia. Leukopenia is a low white blood cell count- the cells that help the body fight infection. Sometimes, white blood cell numbers can go so low that it can shift to neutropenia- which is when then main white blood cell that fights infection, the neutrophil, is super low.
  • The weakened immune system complicates what were formerly simple issues. A fever that could have just been treated with medicine and some rest becomes an event. What does fever while on chemo and/or a low white blood cell count mean? To medical professionals, it can mean different things.
  • It can mean it’s a reaction to the treatment. It can also mean there is an underlying infection that is taking advantage of the body’s compromised defenses and is causing the fever. The infection can be viral like a cold, or bacterial like a urinary tract infection. It could be simple and go away with medications or it can get complicated and require further in-hospital treatment. Either way, healthcare providers are conservative with treating fevers in people undergoing chemo because a person can get sicker quicker and, sometimes, in a bigger way.


Friday, March 13, 2020

CoVid 19 and Cancer

This is reprinted from an article sent by Diane Riche, New England Coordinator for the Ovarian Cancer National Alliance's Program, "Survivors Teaching Students". 

From Fred Hutch Cancer Research Center…

The spread of COVID-19 across the U.S. is looking increasingly likely, even as researchers and public health officials work to distribute information, ramp up testing and enact measures to slow and eventually stop this new coronavirus.

Not everyone will get sick. But like the flu virus, there are definitely people who are more at risk.

With COVID-19, people who are older (particularly over 70) and people with underlying health conditions, such as chronic lung disease (think COPD), cardiovascular disease, diabetes, chronic kidney disease and cancer appear to be at higher risk for major complications. That includes admission to intensive care and even death.

“The early data from China, and reports from the ground in Italy and other sites of local transmission is that our cancer patients are going to be at increased risk,” said Dr. Steve Pergam, a clinical and infectious disease researcher at Fred Hutchinson Cancer Research Center.

Who’s most at risk?

“Patients with hematologic [blood] malignancies we believe will have the biggest risk,” he said. “Also, patients who are in active chemotherapy and bone marrow transplant patients. Those are the ones with the most profound immune deficits.”

What else should cancer patients and survivors keep in mind as they navigate yet another new normal, in this case the introduction of a completely novel viral pandemic to the human race?

We turned to our cancer and infectious disease experts for answers. Wash your hands and read on.

Are all cancer patients at risk? Or just those currently getting treatment?
Pergam, the medical director of infection prevention at Seattle Cancer Care Alliance, said patients with blood malignancies such as non-Hodgkin lymphoma, chronic lymphocytic leukemia, acute myeloid leukemia, acute lymphoblastic leukemia and multiple myeloma are most at risk.

Also at risk: those in active treatment for any type of cancer and those who’ve undergone bone marrow transplants. (Active treatment is usually defined as surgery, radiation, chemotherapy and other treatments such as immunotherapies.)

Dr. Gary Lyman, an oncologist and health policy expert at the Hutch, added that even those out of treatment may want to be extra cautious.

“The risk extends beyond the period of active treatment,” he said. “The after-effects of treatment don’t end when people finish their last course of therapy or leave the hospital after surgery. The after-effects of cancer and the immunosuppressive effects of treatment can be long term.”

Can patients and survivors get tested to see if they’re immunosuppressed?
Pergam said there’s no easy blood test to check someone’s level of immune suppression, but being in active chemotherapy, having low white-cell or low lymphocyte counts and/or taking immune-suppressive agents (such as prednisone) are all associated with immune suppression and increased risk of infection.

“We don’t know all the details on this yet but if you’ve been told you’re immunosuppressed by your provider, then you should be extra cautious,” he said.

Can patients and survivors get tested to see if they’re immunosuppressed?
Pergam said there’s no easy blood test to check someone’s level of immune suppression, but being in active chemotherapy, having low white-cell or low lymphocyte counts and/or taking immune-suppressive agents (such as prednisone) are all associated with immune suppression and increased risk of infection.

“We don’t know all the details on this yet but if you’ve been told you’re immunosuppressed by your provider, then you should be extra cautious,” he said.

What data do we have on how the coronavirus affects cancer patients?
Not a lot, Lyman said.

“But there was an early study from China published in a major medical journal, The Lancet, that shows both current and former cancer patients are at greater risk from COVID-19.”

Published mid-February, the study looked at 2,007 cases of hospitalized COVID-19 patients from 575 hospitals in China. Out of that group, they found 18 patients with a history of cancer they could track — some currently in treatment, some years out. Nearly half of those patients had a higher risk of “severe events” (defined as admission to the ICU, the need for ventilation or death).

“We found that patients with cancer might have a higher risk of COVID-19 than individuals without cancer,” the study authors wrote. “Additionally, we showed that patients with cancer had poorer outcomes from COVID-19, providing a timely reminder to physicians that more intensive attention should be paid to patients with cancer, in case of rapid deterioration.”

Pergam acknowledged the study, but said it was hard to make assumptions based on just 18 patients. Also, it was a mixed group of survivors and current patients with different cancers and a variety of therapies. Some of them smoked and/or had other health issues like high blood pressure, diabetes or COPD, all of which make people more susceptible to infection.

“The message that’s very clear,” Pergam said, “is that those who have comorbidities are at an increased risk from this infection. We have a lot of concerns both from this paper and another one that suggest there are increased rates of major complications, including the need for ICU, intubation and death in cancer patients — as many are double and triple hits. They not only have cancer but respiratory, cardiac or other organ dysfunction, as well.”

People over the age of 70 also face more of a risk. The fatality rate is nearly 15% for people 80 and over (more here on who exactly is getting sick). Pergam said that when elderly people don’t do well with a virus, it’s often “a litmus test of sorts” for infections that might cause more complications in immunosuppressed patients. 

“Immunosuppressed and cancer patients should be extra cautious and treat this like a really bad flu season,” he said.

Should I cancel my treatment or follow-up appointments?  
Experts at SCCA, Fred Hutch’s clinical care partner, said cancer patients with scheduled appointments should keep them, unless they’re experiencing coronavirus symptoms.

The facility is currently screening everyone for respiratory symptoms. Those with symptoms are asked to wear a mask, which decreases the spread of viruses and bacteria.  

More advice for SCCA cancer patients can be found here. The American Cancer Society offers this guidance for cancer  patients with questions about COVID-19.

What should I do if I have symptoms?
If you develop symptoms of coronavirus (such as high fever, a deep dry cough, fatigue and shortness of breath), call your provider.

“What’s really important is if you get sick, let someone know,” Pergam said. “Call your provider and tell them if you have respiratory symptoms. Sometimes, they may advise you to stay home. If you’re feeling that you need to go to an ER because you’re feeling very ill, call ahead and let them know you have respiratory symptoms. They can provide guidelines and protect you when you walk in the door.”

And if the symptoms are minor, Pergam said, just stay home. Remember, it’s still flu and cold season.

“We don’t want to overburden the health care system with the worried well,” he said. “It’s a balance. We want to be prepared but also make sure people don’t panic. If we panic, there will be a run on the health care system.”

Testing for COVID-19 in Seattle has been greatly aided by the UW Medicine Clinical Virology Lab, which started testing people immediately after the U.S. Food and Drug Administration gave its OK. The lab anticipates it will soon be able to test more than 1,000 samples a day; researchers said eventually they will be able to test 4,000 and perhaps even 5,000 samples a day.

Currently, a doctor’s recommendation is the only requirement for the COVID-19 test.

What if a family member develops symptoms?  
“Your family is important and you don’t want to avoid them, but if someone in your household gets sick, use some social distancing,” Pergam said. “Wear gloves, have them sleep in a different room if you can, make sure you wipe down areas with some sort of bleach wipes and keep washing your hands regularly. That’s really important.”  

It’s also crucial not to bring a sick family member into your cancer treatment center.

“We need less people who are ill, not more,” Pergam said. “You don’t want someone going in with you even if they only have minor symptoms.”

Finally, he said it’s important to bring just one caregiver with you to treatment, not your entire family.

Should cancer patients (and survivors) avoid public transportation and events?
Pergam said people currently in treatment, if at all possible, should avoid taking public buses or trains. But he also acknowledged not every patient can afford Lyft or Uber or some other rideshare service.

“Talk to your care team about what options exist to support you getting there without taking public transportation,” Pergam said. “Some hospital systems have services set up for patients.”

If you have no choice but to use the bus or a train, take precautions and distance yourself from others.

“Protect yourself,” Pergam said. “Sit in the back of the bus or other areas with less exposures and if you see someone who seems ill, coughing, move away.”

Pergam said cancer patients a few years out of treatment “should be OK,” but whenever possible should also avoid crowded buses or trains.

“If you have to get on a bus, practice distancing,” he said. “Or stay home if you can. It increases your risk when you are in public spaces.”

As for other public gathering places, Pergam again advised caution. Instead of going out to a movie, watch something at home instead, he said. Get take-out or delivery from your favorite restaurant instead of showing up in person. Or cook at home. Many grocery stores offer delivery service. You can even ask your pastor if they can set up a computer so you can go to “virtual church.”

“This doesn’t mean you have to be a hermit, just limit close interactions, particularly in public spaces,” he said.

Are there ways to keep your immune system strong?
Both Lyman and Pergam stressed the importance of sleep in recharging the immune system.

“Sleep deprivation is one of the most potent ways of suppressing the immune system,” Lyman said. “Everybody has a different threshold but if you’re not getting a minimum of six or seven or, ideally, eight hours of sleep a night, there’s demonstrable scientific evidence that the immune system may be compromised.”

Also helpful: exercise, preferably something aerobic, like walking or jogging, that will get the heart pumping.

“Take a walk outside in the fresh air; that’s really good for you,” said Pergam, who’s also at risk as a kidney transplant recipient and cancer survivor. “Right now, that’s better than going to the gym.”

Another step to staying strong and healthy through the COVID-19 crisis: getting good nutrition.

“It appears that 70%-80% of our immune system is in the gastrointestinal tract,” Lyman said. “And [it is] directly impacted by the food we eat and the microbes that thrive in our gut. A balanced diet, eating fruits and vegetables, is very important.”

As is staying up to date on vaccinations, including the flu vaccine; avoiding smoke or smoking (cancer patients can get smoking-cessation help here) and making sure you have any and all other medical conditions (high blood pressure, lung disease, diabetes, etc.) under control, he said.

Stress also appears to be bad for the immune system. Although both researchers admitted it’s not easy to stay relaxed at a time like this.  

“Some things we cannot control,” said Lyman, whose age and health issues put him at risk, as well. “But you can control what you eat, whether you exercise and how much you sleep. These are definitely the things I’m doing.”