COVID-19’s Impact on Cancer Patients

Jai Venkat, Madhura Manjunath, Radhika Unnikrishnan, Sreya Sridhar, and Melita Devarapalli and Dr Lopamudra Das Roy

Published 2021

Since the declaration that COVID-19 is officially a pandemic by the World Health Organization, lives have been taken by storm all over the world. A deadly pandemic that has cost us millions of lives can be slowly drawn to an end with the option of a vaccine. Along with this vaccine, numerous questions for cancer patients arise as they are immunosuppressed. COVID-19 has also interfered with screening and diagnosis, particularly in developing countries.

COVID-19’s Impact on Cancer Treatment

As a result of the COVID-19 pandemic taking hold of medical faculty and hospitals, patients also experienced an interruption in cancer screening and treatment processes that have placed the brakes on early cancer detection and cancer treatments around the world. As healthcare facilities pause their services for cancer patients in order to treat the overwhelming surge of COVID-19 cases, cancer patients’ risks drastically increase due to the immunocompromised status of the cancer patients. In a study performed at the radiotherapy center of Renmin Hospital of Wuhan University, where the radiotherapy center was closed on January 24, 2020 and not reopened until March 9, 2020, researchers examined the impact that the interruption of radiotherapy treatment caused by COVID-19 had on cancer patients at the hospital.1 Out of the 140 patients that were surveyed from March 9, 2020 to June 30, 2020, 76 patients stayed at home without cancer treatment, and after 5 months of follow up, 14 patients had died of cancer and 2 had died of COVID-19 [1]. As can be seen, the closure of treatment centers in hospitals has negatively interrupted the care for cancer patients, who were not given the treatments they needed. While the COVID-19 pandemic steered hospitals’ attention towards treating COVID positive patients, cancer patients were sidelined, placing risks for their wellbeing. While this study focused on a hospital from Wuhan University, similar trends have been ongoing across the world in response to the pandemic.

COVID-19’s Impact on Screenings and Diagnoses

In addition to interruptions in cancer treatment, the COVID-19 pandemic has also caused delays in cancer screenings and diagnosis across the globe. In the UK, for example, bowel cancer screening was largely paused since the end of March 2020, which left around 1 million people in the UK without access to bowel cancer screening [2]. If this population could have had access to bowel cancer screening, approximately 675,000 people would have gotten a fecal immunochemical test (FIT) by mail [2]. This situation also applies to people who had already gotten a positive FIT test: 8,500 people who had received a positive FIT test before the COVID-19 pandemic had still not gotten a follow-up colonoscopy needed to diagnose bowel cancer, of which 10% of the people could be diagnosed early with bowel cancer, treatable by surgery [2]. While the UK partially reopened colonoscopy facilities in July, 2020, the capacity of these facilities was below 50% of that pre-COVID time, and colonoscopies at these facilities were prioritized for patients with high FIT test results and positive screening tests [3]. Thus, the COVID-19 pandemic has created a concern for the rise of preventable deaths due to delays in cancer diagnosis. A similar situation was studied in Japan, in regards to breast cancer screening interruptions due to the COVID-19 pandemic. This study examined the effects of Japan’s state of emergency declaration on breast cancer screening participation from April 2020 to May 2020 using a survey.4 From the 1874 women surveyed who had scheduled a breast cancer screening during the study’s time frame, 26.3% postponed their breast cancer screening, and postponement and cancellation was more prevalent among the prefectures of Saitama, Chiba, Tokyo, Kanagawa, Osaka, Hyogo, which were the first prefectures to declare the state of emergency on April 7, 2020 [4]. From these trends that can be seen around the world, it can be observed that the COVID-19 pandemic has greatly created a divide in adequate cancer screening, a pattern that has dangerous consequences as many people temporarily cannot have access to the resources they need for early detection of cancer.

Fear Among Cancer Patients

While the COVID-19 pandemic has greatly impacted the risks that cancer patients experience in terms of delayed cancer detection and treatment and increased risk of COVID-19 infection, another area of impact the pandemic has had on such patients is the emotional aspect. As members of the cancer patient population are living through a dangerous pandemic situation and lockdowns across the world, they are met with fear and apprehension and their state of mental health and how this relates to their care is important to consider. One study found the trends in cancer patient community thoughts through analyzing large sets of social media data [5 ]. This study analyzed over 2 million tweets and over 20,000 discussion posts by cancer patients from the time period of April 1, 2020 to April 30, 2020 [5]. Through the analysis process, it was determined that the overall positive attitude in online cancer support groups decreased from February 1 to April 30 while the emotion of fear was consistently expressed during this period (although the emotion of joy was expressed occasionally corresponding to announcements of possible treatments for COVID-19) [5]. The study also found that some of the common patterns in discussion among the two data sets included treatment and diagnosis delays, cancellation of consults, missed scans, and risks of chemotherapy [5]. This study demonstrates the common pattern of mental stress that is common among cancer patients during the COVID-19 situation that the world is currently undergoing. Additionally, the fear that such patients have may interfere with the access to treatment and medical care they get. From a study that analyzed patients at the Breast Unit of the Tor Vergata University Hospital, out of the 78 patients that were analyzed in the breast cancer category, 4.87% of the patients in the pre-COVID group refused surgery, while 77.8% of patients (7 out of 9 patients) in the post-COVID group refused surgery, while also noting COVID-19 as their reason for refusal [6]. As can be seen, many cancer patients are refusing treatment for their cancer due to fear caused by COVID-19- a risk that can put patients at heightened risks. As cancer patients refuse treatment due to COVID-19 and the fear surrounding it, more danger for cancer complications ensues. However, there is a light at the end of the tunnel: recent extraordinary developments in vaccines for COVID-19 can help to greatly alleviate the pandemic situation and bring about hope for cancer patients.

Vaccine Information

After almost over a year with the COVID-19 pandemic, scientists have finally developed vaccines in an effort to prevent the spread of this virus. The 3 most prominent vaccine brands are Pfizer-BioNTech, Moderna, and Johnson & Johnson’s Jansssen. These three vaccine brands each have their own descriptions and conditions. Pfizer-BioNTech is an mRNA Vaccine that can be given to people 12 years and older in a series of 2 shots, 21 days apart [7]. Moderna is also an mRNA vaccine but it can only be given to people 18 years or older in a series of 2 shots, 28 days apart [8]. Johnson & Johnson’s Janssen is a viral vector vaccine (vaccine that inserts a modified version of the virus in your body) that can be given to people 18 years or older in just 1 shot [9]. Common symptoms of the COVID-19 vaccine include fever, fatigue, pain/redness/swelling where the shot was administered, headache, chills, nausea, muscle pain, and swollen lymph nodes [10]. These side effects are more fearsome for patients with cancer. Regardless of the cancer type, cancer patients might perceive taking the vaccine as an action of risk because of their immunosuppressed status. Their immunosuppressed bodies have a high risk of infection which can interfere in their treatment procedures [11].

Common Vaccine Questions

Many cancer patients are hesitant to take the vaccine in fear of messing up with their clinical trials or treatments. Patients have various questions about the vaccine and its side effects on their cancer and whether they should take it or not. Oncologists at Mayo Clinic recommend cancer patients to get the vaccine as soon as they can because they are at a higher risk of getting infected by the virus. It is advisable for cancer patients to get the vaccine because COVID-19 is more of a danger to them compared to the side effects of the vaccine. Clinical trials to approve these vaccines indicate that cancer patients did not notice any severe side effects [12]. The Pfizer-BioNTech vaccine and the Moderna vaccine are mRNA vaccines that provide our bodies with instructions to make the proteins that fight the virus instead of inserting a modified live virus to fight the virus. This reduces the risk of infection in immunosuppressed cancer patients. It is recommended to ask a healthcare provider if a cancer patient should get vaccinated. The cancer type and treatment type are two main factors to consider when making this decision. Timing the vaccine between cancer treatments is very important. Patients undergoing chemotherapy should take the vaccine during chemotherapy when their while blood cell count is higher. This way if they experience fevers as a side effect, they have white blood cells to fight off the fever eliminating the need of hospitalization. Sometimes, however, it is best to wait after any kind of intensive chemotherapy is completed to get the vaccine. Patients receiving immunotherapy can take the vaccine during their treatment. The vaccine will not affect their treatment. Patients who are receiving therapies like rituximab, blinatumomab, anti-thymocyte, globulin, alemtuzumab, or other lymphocyte-depleting therapies should wait 3 months after completing their treatment to get the vaccine as these treatments affect the lymphocytes which are important immune responders [13]. Patients who have recently undergone stem cell transplant or who have received the CAR T-cell therapy or immunosuppressive therapy should wait 3 months after the completion of their treatment to get the vaccine [14]. Regardless of these different treatments, if cancer patients happen to live COVID-19 intensive areas, they should talk to their healthcare provider about taking the vaccine during treatments even if they receive partial protection against COVID-19.

Global Impact

This pandemic put immense stress on the medical system, with healthcare in the most affected areas running short on staff and medical supplies. Patients with cancer were one of the most affected groups of patients, as they frequently needed access to the hospital [15]. More recent studies have positive results in the effects of Cancer and Covid-19 . A study from a New York cancer facility with 423 patients with symptomatic COVID-19, found that recent chemotherapy, surgery, or having metastatic disease, was not linked to increased risk of problems [16]. Because both conditions share many risk factors, such as advanced age, a history of smoking, and obesity, determining the impact of COVID-19 in cancer patients is complex. This means that trials and studies with long-term follow-ups are needed to further understand the effects of COVID-19 in cancer patients. Organizations are currently looking into the more long term effects of Covid-19 and cancer and will know more information in the coming years. However, studies already show that there is a significant decline in cancer screenings, visits, therapy, and surgery in the US from before the pandemic [17].

Not only were cancer patients affected by Covid-19 in the US, but also in other countries as well. Developing countries, such as China and India, have had difficulty controlling the virus. The greatest risk for cancer patients during the COVID-19 outbreak is restricted access to critical health care and incapacity to receive necessary medical services promptly, particularly in developing nations and locations such as China. At the beginning of the pandemic, the number of affected Covid - 19 patients skyrocketed in Wuhan Hospitals, because of a lack of awareness about personal protection, limited understanding about the new virus, and insufficient availability of Covid-19 tests at the start of the outbreak. This caused extreme cross-infection in Wuhan hospitals, especially with cancer patients, who are often in an immunocompromised state from both their cancer and their treatment. To reduce exposure for some patients with cancer, doctors in China would often hold off on chemotherapy until after the pandemic was over [18]. All of this caused many cancer patients to be infected with Covid-19, compromising their immune system, and causing more complications. However, now China is able to control the spread of Covid with the vaccine allowing for patients with cancer to be treated normally.

At the beginning of the pandemic, one of the countries hardest hit by Covid was Spain. Cancer, a very serious public health issue in Spain, was estimated by the Spanish Cancer Registry Network (REDECAN) to reach 277,394 cases and of that 160,198 were predicted to be men [19]. While no official studies have been carried out in Spain to assess Covid-19’s impact on Cancer, a similar answer can be ascertained by compiling data on cancer in Spain during the pandemic and comparing it to data of previous years. A retrospective, multicenter nationwide study collected information from 78 oncology departments of 36 different hospitals and analyzed that data [20]. Of these 78 departments, 44 implemented adapted covid protocols in March 2020. Of these 44 departments 86.4% (38/44) carried out Covid-19 triage (14 days quarantine etc.), while 59.1% (26/44) of the 44 carried out on site PCR tests for any cancer patient that was clinically suspected of having Covid-19. A shift from in-person to virtual meetings was seen in 97.7% (43/44) of these departments. Despite all of these precautions there was still a significant dip in all cancer related statistics (May-June 2019 v. May-June 2020). The average number of new cancer patients decreased by 20.8% (160.2 in 2019 to 126.4 in 2020) . The mean of total cancer cases in these 78 departments reduced from 2858.2 in 2019 to 1686.1 in 2020 and the amount of cancer biopsies reduced from 465.5 in 2019 to 367.2 in 2020. Thanks to the Covid-19 vaccine the COVID situation in Spain is much more under control now, but the impact it had on cancer patients is not yet fully known [20].

While the toll that Covid took on healthcare systems in western countries was great, the toll it took on developing nations such as India is immeasurable. An ambidirectional cohort study taken at 41 cancer centers across India (all were members of the National Cancer Grid of India) compared data from the time period of March 1- May 31 in 2019 and 2020 [21]. The data collected was very broad as it observed new patient registrations, number of patients visiting outpatient clinics, hospital admissions, day care admissions for chemotherapy, minor and major surgeries, patients accessing radiotherapy, diagnostic tests done (pathology reports, CT scans, MRI scans), and palliative care referrals. The data showed that there was a 54% reduction of new registered cancer patients in the March -May time period (112,270 in 2019 and 51,760 in 2020). Patients who had follow up visits decreased by 46% (634,745 in 2019 to 340,984 in 2020). At 70% of these facilities Cancer screening was either stopped completely or was functioning at 25% capacity [21]. The graphs below (Figure X) shows the regions in India where cervical cancer is most present and (Figure Y) the areas in India where Covid-19 was most prevalent. By cross-referencing these charts it can be observed that there is a correlation between cancer patients and covid infection rates (though this was already known as cancer patients have been listed as high risk). While vaccination efforts are still ongoing in India, due to the immense population size, there is much more difficulty controlling the spread than in other countries.

In conclusion, cancer patients have experienced extreme ups and downs throughout the last year and half when it comes to treatment and screenings. With the option of a vaccine it has been debated whether or not cancer patients should receive it, and in the interest of their health, it is best to do so. Developing countries and developed countries both had to adapt and overcome major challenges.

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BCHDev DevelopOctober 14, 2021