Coronavirus and COVID-19: What People With Cancer Need to Know

 The American Society of Clinical Oncology (ASCO) is aware that people with cancer and cancer survivors, particularly those with compromised immune systems, are likely worried about the potential impact of COVID-19 on their health. Patients should talk with their oncologists and health care teams to discuss their options to protect themselves from infection.

What is COVID-19?

COVID-19, or coronavirus disease 2019, is an illness caused by a novel (or new) coronavirus that was first identified in an outbreak in Wuhan, China, in December 2019. 

Coronaviruses are a large family of viruses that can cause mild illnesses, such as the common cold, to more severe diseases, such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). Because the novel coronavirus is related to the SARS-associated coronavirus (SARS-CoV), the virus has been named SARS-CoV-2. The exact source of SARS-CoV-2, which causes COVID-19, is not certain but likely originated in bats.

The virus can spread from person to person, through small droplets from the nose or mouth that are produced when a person coughs or sneezes. Another person may catch COVID-19 by breathing in these droplets or by touching a surface that the droplets have landed on and then touching their eyes, nose, or mouth. 

Symptoms from COVID-19 can be mild to severe and may appear between 2 and 14 days after exposure to the virus. The symptoms may include fever, cough, shortness of breath, chills, headaches, sore throat, and new loss of taste or smell. Other symptoms may include aches and pains, fatigue, nasal congestion or runny nose, or diarrhea. In some people, the illness may cause severe pneumonia and heart problems, and it may lead to death. Other people who are infected may not develop any symptoms.

COVID-19 can occur in both children and adults. However, most of the known cases of the disease have occurred in adults. Symptoms in children seem to be milder than symptoms in adults. There have been recent reports of a multisystem inflammatory syndrome in children associated with COVID-19, with symptoms such as rash, fever, abdominal pain, vomiting, and diarrhea.

An analysis of 928 people with cancer and COVID-19 presented during the ASCO20 Virtual Scientific Program revealed that having active, progressing cancer was associated with a 5 times higher risk of dying within 30 days compared with patients who were in remission from cancer.

What can I do to avoid getting COVID-19?

There is not currently a vaccine to prevent COVID-19, although several clinical studies are being performed to develop an effective and safe vaccine.

The most important way to protect yourself is to avoid being exposed to COVID-19. Stay at home as much as possible and avoid areas where people gather. Avoid unnecessary travel, and follow guidance on travel restrictions issued by the U.S. Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO).

Another critical way to protect yourself is to wash your hands often with soap and water for at least 20 seconds, about the amount of time it would take to hum the Happy Birthday song from beginning to end twice. If soap and water is not available, use hand sanitizer that contains at least 60% alcohol. The best way to clean your hands, though, is through soap and water.

In addition to washing your hands frequently, it’s important to:

  • Avoid touching your eyes, nose, and mouth.
  • If you must cough or sneeze, use a tissue. Then throw the tissue away. Or, cough or sneeze into your elbow rather than your hand.
  • Avoid close contact with people who are sick.
  • Clean frequently touched objects and surfaces with household cleaning spray or wipes. These surfaces and objects include doorknobs, counters, toilets, keyboards, tablets, phones, light switches, and more.

they have the virus, or they may not have yet developed symptoms. Because of this, the CDC recommends wearing cloth face coverings when you are out in public. Cloth face coverings won’t necessarily protect you from developing COVID-19, but they can help prevent the spread of the virus in the community. The face covering should cover the nose and mouth. Surgical face masks and N95 masks should be reserved for health care workers because these masks are in limited supply. Remember that wearing a cloth face mask or face covering should not replace social or physical distancing. There is no evidence that taking vitamin C, even at high doses, can help to prevent COVID-19.

Are there special precautions that people with cancer should take?

People with cancer, people who are in active cancer treatment, older patients, and people with other serious chronic medical conditions, such as lung disease, diabetes, or heart disease, are at higher risk for the more severe form of COVID-19 that could lead to death. Recent data have shown that people with active or progressing cancer may be at higher risk than those whose cancer is in remission. The same rules apply for people with cancer as for those without cancer: Be sure to wash your hands well, and wash them frequently. Avoid touching your face, and avoid close contact with people who are sick. 

People who are at higher risk of getting very sick from COVID-19 should avoid any non-essential travel during this time of COVID-19 outbreak. In most parts of the United States, a “shelter in place” or “stay at home” order has recently been in effect or may still be in effect. For people with cancer who live in these areas, avoid leaving your home unless it is necessary. For people who live in areas where a “shelter in place” restriction issued by the government has been lifted or is in the process of being lifted, it is best to live as if there is such an order still in effect. Stay at home to reduce exposure to other people. Avoid any social gatherings. If you must leave your home, keep a distance of at least 6 feet between yourself and other people. Only leave your home for essential reasons, such as buying groceries, going to the doctor, or picking up medication from the pharmacy. Wear a cloth face covering or mask, and make your trip out as brief as possible. Another alternative is to have your food and medications delivered, so you do not have to leave the home.

Walking or exercising outdoors is fine as long as the area is not crowded and you are able to keep a distance of at least 6 feet from other people.

Be sure to keep enough essential medications, both prescription and over-the-counter, to last for at least 1 month. Create or update an emergency contact list that includes family, friends, neighbors, and community or neighborhood resources who may be able to provide information or assistance to you if you need it.

In order to stay connected to your support system, connect with your family and friends virtually, through video chats or phone calls. Some examples of technology that can be used for video or other live chats are FaceTime, Zoom, Google Hangouts, and social media platforms, such as Instagram and Facebook.

If you are scheduled for cancer treatments, have a discussion with your oncologist about the benefits and risks of continuing or delaying treatment. If you are not scheduled for cancer treatment but are scheduled for an appointment with your oncologist, it may be possible for the doctor to conduct the visit using videoconferencing or telemedicine. Be sure to check with your cancer care team to see if this is recommended for you.

Finally, it is always important to have your health care wishes in writing, in case you are too sick to make decisions for yourself. This way, your family and your medical team will know what is important to you and what your wishes are. If you have not yet done this, now is a good time. Cancer.Net has valuable information on this topic. Because some hospitals and clinics are limiting visitors, and some are allowing no visitors, having your health care wishes in writing is more important than ever. Here are some examples of important questions to ask yourself, to discuss with your loved ones, and to write down:

  • What level of quality of life would be unacceptable to me?
  • What are my most important goals if my health situation worsens?
  • If I am unable to speak for myself, who is the person in my life who I would want to speak for me?
  • Who should not be involved in making decisions for me?
  • If my heart stops, do I want to have CPR (cardiopulmonary resuscitation) done?

Will anything change with my cancer-related medical visits?

Due to the COVID-19 pandemic and the increased risk of exposure to the virus by going out in public, most hospitals and clinics have changed their visitation policies. Some may allow 1 visitor per patient, and others may allow no visitors. Before heading to your medical appointment, check with the clinic or hospital for their current visitor policy.

Your cancer care team may switch some of your appointments to telemedicine. During a telemedicine appointment, you are able to stay at home and visit with your doctor or other health care team member through video conferencing using your phone or computer. Your doctor’s office will let you know what system they are using for telemedicine appointments, and they will give you instructions on how to have your visit this way. If you are interested in having a visit by telemedicine rather than in person, ask your doctor’s office staff if this is possible. 

Your doctor may recommend delaying some treatments for supportive care, such as bone-strengthening treatments, for example, denosumab (Xgeva) or zoledronic acid (Zometa), or intravenous iron supplementation. They will only recommend delaying treatments if they feel it is in your best interest to do so. Cancer screening tests, such as mammograms or colonoscopies, and other tests, such as bone density tests, may also be delayed to reduce your risk of exposure to the virus.

Oncologists may recommend stretching out the length of time between cancer treatments using medications, such as chemotherapy or immunotherapy. Or they may recommend delaying starting these treatments, based on your cancer diagnosis and the treatment goals. It’s important to remember that your oncologist will only do this after weighing the risks and benefits for your situation.

For people who don’t have a cancer diagnosis but are at high risk of cancer, such as those with a hereditary cancer syndrome like Lynch Syndrome or a BRCA mutation, your doctor may recommend delaying some screening tests or cancer risk-reducing procedures. In general, it is safe to have these delayed for some amount of time. If you have concerns about your particular risk, have a discussion with your doctor about the risks and benefits of delaying procedures.

What should I do if I think I may have COVID-19?

Call ahead before visiting your health care professional or the emergency department if you have a fever and other symptoms of a respiratory illness, such as cough and shortness of breath. Let them know if you think you may have COVID-19. They will ask you questions about your symptoms, travel history, exposure, and medical risk factors to find out if you should be tested for COVID-19. They will then give you instructions on how to get tested in your community. 

A common question I hear from patients is about which doctor to call. I recommend calling the doctor who you have the most contact with. If you have been off cancer treatment for more than a year and are seeing your primary care provider regularly, you may call your primary care provider. However, if you are seeing your oncologist more regularly or are on active cancer treatment, call your oncologist.

If you are receiving cancer treatment that suppresses the immune system and you develop a fever and respiratory symptoms, call your oncologist as you usually would if you develop a fever while on treatment. Be sure to follow their guidance on when to come into the office or hospital and when it’s safer to stay home.

Severe symptoms could be a medical emergency, and you may need to call 911. If you or your loved one has symptoms, such as trouble breathing, persistent pain or pressure in your chest, new confusion, or bluish lips, you should seek medical attention immediately.

Testing for COVID-19 involves inserting a 6-inch-long swab, similar to a Q-tip, deep into the nasal cavity for at least 15 seconds. The swab is inserted into a special container and send to a laboratory for testing. There is 1 U.S. Food and Drug Administration (FDA)-approved at-home self-collection kit for this virus, approved under an emergency-use authorization. This self-collection kit is currently only available to health care workers and first responders who have been exposed to the virus or who have symptoms of COVID-19.

If it is possible that you have COVID-19, you should stay at home and isolate yourself while you are tested and waiting for your test results. Staying home when you are sick is the best way to prevent transmitting the novel coronavirus and other respiratory viruses, such as the flu, to other people. If you live with someone, you should quarantine yourself in one part of the home, if possible, to lower the risk of spreading the virus to the rest of the people who live with you. And again, be sure to wash your hands often.

If you are concerned that you’ve been exposed to someone with COVID-19, closely watch for developing symptoms. Check your temperature regularly for fevers. If you have active cancer or are currently in cancer treatment, let your medical team know about your possible exposure. On June 3, 2020, a study was published in the New England Journal of Medicine that included 821 people with no symptoms of COVID-19 who had a household or work exposure to COVID-19. This study showed that treatment with hydroxychloroquine after an exposure to someone with COVID-19 did not provide any benefit.

Is there a way to find out if I have already had COVID-19?

Antibody tests, also known as serologic tests, are being developed. These may be able to find out if you have already had a COVID-19 infection. These tests look for antibodies in the blood. Antibodies are specific proteins made by the body in response to an infection.

Antibody tests will not necessarily tell you if you are immune to COVID-19 or if you might be immune to a second COVID-19 infection. Some people who get COVID-19 may not make antibodies. Or they may make very low levels of antibodies. Some people may have a “false positive” antibody test, meaning the test finds antibodies, but the antibodies are related to a different coronavirus and not COVID-19. Antibody tests are not widely available yet, and you can’t yet do these tests at home.

If I have had COVID-19, will I be able to continue cancer treatment?

If you have tested positive for COVID-19, you should have a discussion with your oncologist about the impact of this on your cancer treatment. At many centers, a negative COVID-19 test is recommended before chemotherapy or other cancer treatment starts again. However, some patients with COVID-19 continue to test positive even after recovering from their symptoms. In this situation, your health care team will consider the risks and benefits of restarting cancer treatment despite the positive test.

When your cancer treatment resumes, it is important to wear a mask when coming to the infusion clinic or cancer treatment center and to practice good hand hygiene by using hand sanitizer or handwashing before and after visits.

Are there any treatments available for COVID-19?

Scientists are working hard to develop and test treatments for COVID-19. Clinical trials are research studies that involve people. Working very quickly, researchers and physicians have developed clinical trials to find effective treatments for this disease. Clinical trials for potential COVID-19 treatments are now open in many locations in the United States and in other countries. If you have been diagnosed with the coronavirus disease and you join a clinical trial for patients with COVID-19, you may be able to receive these medications. Also, by joining a clinical trial, your participation will help scientists find the most effective and safe treatment for the illness. The Beat19 study, the NCI COVID-19 in Cancer Patients Study (NCCAPS), and a study at Stanford, for example, are designed to collect symptoms from people who may have COVID-19 to help researchers learn the course of the disease and help find a treatment. 

Remdesivir, an antiviral medication, may be potentially helpful in treating COVID-19 infections. This is just one of many medications that is being studied in clinical trials as a possible treatment for infections from this virus. Remdesivir received an Emergency Use Authorization from the FDA on May 1. This authorization allows this intravenous medication to be given to hospitalized patients with severe COVID-19 infections.

Convalescent plasma is the liquid portion of blood that can be collected from people who have recovered from COVID-19. This plasma may have antibodies to SARS-CoV-2. Convalescent plasma is not yet an approved treatment for COVID-19, but it is being studied in clinical trials as a possible treatment. If you have fully recovered from a COVID-19 infection, you may be able to donate your plasma at a blood bank in your area in order to potentially help others. Learn more about donating convalescent plasma at the websites of the Red Cross and AABB (formerly known as the American Association of Blood Banks).

Hydroxychloroquine(Plaquenil) and chloroquine (Aralen) are also being studied as a treatment for or as a way of preventing COVID-19 after a small French study involving 20 patients showed possible activity of these medications in treating people with COVID-19. Other studies have shown increases in deaths related to these drugs. On April 24, the FDA issued a warning that these drugs should not be used outside of a clinical trial or hospital because of potentially fatal heart rhythms that can occur as a side effect of this combination of medications. On May 25, 2020, the WHO temporarily stopped clinical trials using hydroxychloroquine after a study was published in the Lancet journal that found an increased rate of death in patients with COVID-19 who took hydroxychloroquine compared with those who did not take the drug. However, the study authors were unable to perform an independent audit of the data and retracted it from the journal. As a result, the WHO resumed study of hydroxychloroquine on June 3. A study presented at the ASCO20 Virtual Scientific Program found that patients with cancer who used a combination of hydroxychloroquine and azithromycin, an antibiotic, as treatment for COVID-19 had a nearly 3 times greater risk of dying within 30 days compared with patients who didn’t receive either drug. On June 15, the FDA revoked its emergency use authorization for hydroxychloroquine and chloroquine due to their findings that these drugs are not helpful in treating COVID-19 and that the risks outweigh the potential benefits of taking these drugs.

A version of chloroquine (chloroquine phosphate) is used as an additive to clean fish aquariums. Consuming this fish tank additive has led to at least 1 death and other overdoses. Do not consume this product—it can kill you.

Drinking bleach or injecting bleach or other household disinfectants is very dangerous and can kill you. These are not treatments for COVID-19, and they will not help prevent it. 

When will things return to normal?

Public health experts haved worked with the local and federal governments to help answer this question. In many parts of the United States, shelter-in-place or stay-at-home restrictions have been lifted or may be lifted in the coming days or weeks. However, we know that the coronavirus continues to circulate in the community and in some communities more than others. As nonessential businesses reopen and as more people begin to leave their homes regularly, it is possible that we will see another surge in COVID-19 cases and deaths.

If your local community, county, or state has allowed nonessential businesses to reopen, the best way to stay safe is to continue to stay at home and avoid being in public as much as possible. Wear cloth face masks or face coverings when you must leave your home. Continue to wash your hands thoroughly and frequently and stay at least 6 feet away from other people if you need to go to the grocery store or pharmacy or other areas where other people may be.

If you decide to eat at a restaurant that has reopened, it’s safest to eat outside. The restaurant should have social distancing measures in place. Avoid buffets. Try not to handle a menu unless you’ve seen it cleaned first, or read the restaurant’s menu online on your phone. Always wash your hands or use hand sanitizer after touching anything.

The safest approach, especially if you are considered high risk, is to continue living as if the stay-at-home restrictions are still in place. If you have questions about your personal risk due to your cancer or cancer treatment, be sure to speak with your doctor for their guidance.

Where can I get the latest information about COVID-19?

Staying up to date on the latest information on the COVID-19 outbreak is important. The CDC and your local and state health departments will have ongoing information about whether the disease has been diagnosed in your community.

Editors Note: Merry Jennifer Markham, MD, FACP, FASCO, is the Interim Chief of the University of Florida (UF) Division of Hematology & Oncology, an Associate Professor in the UF College of Medicine, and the Associate Director for Medical Affairs at the UF Health Cancer Center. Dr. Markham is the past chair of ASCO’s Cancer Communications Committee. Reprinted with permission. © 2020 American Society of 

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