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.”