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Cancer and COVID-19

How the novel coronavirus is affecting screening and treatment

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When Molly Cassidy dropped a measuring cup in her kitchen this summer, a broken glass shard left a deep, bleeding gash in her hand.

Although the cut clearly needed stitches, Cassidy weighed her options for nearly two hours as the wound profusely bled before she decided to go to the doctor's office — a trip that could cost her life during the coronavirus pandemic.

As more than 200,000 Americans have died from COVID-19, cancer patients — who are often immunocompromised and depend on regular treatments to prevent the progression of the disease — are particularly at risk for dying by the potentially deadly virus.

Cassidy was diagnosed with stage four squamous cell carcinoma in February 2019. She endured 35 radiation treatments, three chemotherapy sessions and underwent surgery to have part of her tongue and 34 lymph nodes in her neck removed. A week after she completed treatment, doctors found several more cancerous tumors in Cassidy's neck and collarbone.

In July 2019, she started a clinical trial where scientists mapped out the RNA of the carcinogenic tumors and created a personalized vaccine to combat them. Cassidy's tumors have minimized with each scan, and she's set to continue the treatment every three weeks until August 2021.

But if she were to contract COVID-19, not only would Cassidy's immunocompromised body struggle to fight the virus, but it could mean a delay in the treatment that prevents cancer from growing throughout her body.

"I need that treatment, it has extended and saved my life. If it were delayed, I don't know how that would affect the cancer," she said. "I'm not sure what the side effects would be from skipping a treatment, and that's obviously very dangerous."

According to a study conducted by Cancer Discovery, cancer patients who contract COVID-19 face a higher risk of dying from the virus, as well as experiencing severe outcomes like ICU admission and needing invasive mechanical ventilation.

Julie Bauman is Cassidy's oncologist for her chemotherapy treatments and the deputy director of the University of Arizona Cancer Center. As a specialist who works with cancer patients every day, she understands their unique vulnerability to COVID-19.

"Most cancers themselves put patients into immune-compromised states. That state is profoundly reinforced and worsened by the treatments that we give," Bauman explained. "Cytotoxic chemotherapy, radiation therapy and certain targeted and immune therapies increase the patient's risk of infection and serious complications from infection when it does occur."

Due to this increased risk, doctors at the UA Cancer Center noticed a decrease in patients coming in for preventitive screenings at the height of the pandemic, resulting in an increase in advanced cases arriving at the cancer center as the number of coronavirus cases declines.

"Unfortunately, the pandemic caused a lot of fear, and we did see a dip in our patient numbers for about three months," said Baldassarre Stea, who practices radiation oncology at the cancer center. "We're seeing a lot of advanced cases, they are arriving here in stage four. Usually there is a good mix, a quarter in stage one, a quarter stage two, a quarter stage three. We're seeing a shift in the number of cases that are very advanced cancer, and I think that's probably due to fear of having to come in and delaying diagnosis."

According to a survey form the American Cancer Society Cancer Action Network, 50 percent of cancer patients and survivors said the COVID-19 pandemic has impacted their health care, while 27 percent of respondents in active treatment reported a delay to their medical care.

Taylor Riall, a surgical oncologist at the UA Cancer Center, anticipated progressed cancer in her patients due to an increased apprehension to go out in public during the pandemic.

"In the beginning, patients were afraid to seek care. Even if they had something wrong, unless they were really, really sick, they didn't come out," Riall said. "As this was unfolding, I had major concern that on the other side of this...that people would have more advanced disease by the time they showed up."

Riall especially saw a decline in preventative procedures for cancer patients when Arizona Gov. Doug Ducey issued an executive order in March delaying elective surgeries in order to preserve personal protective equipment.

"I think they did us a disservice talking about elective surgery, because I would say that 95 percent of what we do is nonelective. Where this really hurt our cancer patients was probably in things like screening mammography and screening colonoscopy that were delayed, leading to delays in diagnosis," Riall said. "There was a period of time where we wouldn't see new breast cancers because nobody had a screening mammogram in that time period."

Liz Almli, a breast cancer survivor and President of Tucson Cancer Conquerors, a local nonprofit dedicated to empowering cancer survivors, said the effects of missing an important preventive cancer screening or surgery are often psychological.

"People that were scheduled to have their lumpectomy, their surgery, got delayed. Maybe it was only a couple of weeks and it shouldn't have been anything that really impacted their outcome, but psychologically, if you're scheduled for a CT scan to make sure your tumors haven't come back, and that gets canceled, your brain just runs down the rabbit hole," Almli said. "Now that everybody's had a chance to put safety precautions in place, I think people are able to get the care that they need."

As the number of national coronavirus cases began to decrease in August, physicians at the UA Cancer Center saw an influx of cancer patients and surgeries.

"Last week, we had a record number of cases in our operating room, record numbers ever. We are seeing some of that backlog coming forward," Riall said. "Some patients are still afraid to come in, but we're seeing very, very high volumes on the other side of this."

Stea has also seen a boom in patients in recent months.

"I think that the fear is over, and now we're kind of seeing a lot of patients coming through, the numbers are going up to a standard number that we've seen in the past," he said.

Keeping COVID-19 out of the cancer center

When the alarming spread of the coronavirus pandemic emerged in the United States in March, the University of Arizona Cancer Center moved quickly to implement safeguards to keep their patients and staff safe.

New safety protocols included a comprehensive screening process for everyone who enters the center, a drive-through testing system for those who fail the screening, implementation of telemedicine when appropriate and a rotating staff system where members switch between teams working at the center and at home for 14-day periods.

"On multiple occasions, we were one to several weeks ahead of where Arizona or Pima County's policy was. By taking those actions before there was significant community spread in Pima County, I think we were really able to keep COVID out of the cancer center," Bauman said.

Cassidy, who receives treatment at the UA Cancer Center, says she feels "very safe" at the center and receives a COVID-19 screening call before every appointment.

"We're required to wear masks and there's social distancing within the cancer center. The implementation of all the safety measures they have put in place has helped me feel very safe as a cancer patient," Cassidy said.

However, one of the most difficult safety measures the cancer center implemented was a no-visitor policy.

"The hardest part is navigating the visitor policy," Bauman said. "That was incredibly difficult for patients, for caregivers, and honestly, for physicians and nurses. Taking care of patients, we know how important that therapeutic alliance is, and having a caregiver present for every step of the journey is definitely the best care for a cancer patient."

Cassidy said although she has missed her husband's presence at her treatments, the no-visitor policy has made her feel safe. However, long chemotherapy sessions take a heavy toll on cancer patients and can be very difficult to experience alone.

"Sometimes you'll see someone who's quite sad or quite emotional, because it might be their first chemo treatment. It's really hard to be going through cancer and have to go into the cancer center alone without your support group," Cassidy said.

According to Bauman, the cancer center began allowing visitors with "new patient consultations" in late August, a policy she says will soon be implemented across all Banner facilities.

"At the initial establishing of that therapeutic alliance, we were able to preserve good social distancing and screening processes, and start allowing caregivers with all new patient consults," Bauman said. "In the next week, we're actually moving towards this across Banner, including outpatient oncology, so all patients can have one caregiver with them for all events, including follow up appointments."

The importance of socialization for cancer patients

Aware of most hospitals' no-visitor policy and the trialsome implications this would have on cancer patients, Liz Almli of Tucson Cancer Conquerors moved quickly to find a way to reach patients without phsycially being with them.

"People are going by themselves to their first chemotherapy infusion alone, and that's really scary. So we've created chemo bags to send trying to make sure that people go with everything they need to keep them entertained," Almli said. "Keep them hydrated, you know, lip balm because your lips crack when you get chemo, and just the whole goodie bag full of chemotherapy supplies because we can't go with people, which has been really difficult."

In 2014, the Tucson Cancer Conquerors formed as a small nonprofit group for cancer patients and survivors to exercise together. Now, the group has 90 active members that socialize through group workouts, gardening, meditation and other activities aimed at connecting survivors.

When the coronavirus pandemic struck, the group moved activities to online Zoom classes and YouTube videos. The group's board members also identified the most high-risk members to check up on weekly.

Almli says one the hardest parts of being physically separated from group members is the lack of socialization. In fact, breast cancer patients are more likely to survive if they have larger social networks, according to a 2016 study published by the American Cancer Society.

"Many people count on meeting twice a week for their socialization. Cancer patients tend to be very isolated, and I think that not having that place to go twice a week was really difficult," Almli said. "There's a lot of research that says people who are socially isolated tend to do more poorly during treatment and tend to have higher recurrence rates, so there's something about having that support and that connection that's really important."

The Tucson Cancer Conquerors began meeting in person again in socially distanced, masked groups on Sept. 26 in an outdoor exercise group divided into pods of 10 people.

"People were so elated to be able to see each other. And to be exercising, because it's so important for their health, and for their mood and their sleep," Almli said.

Overall, Almli believes it's important to protect vulnerable populations, but the implications of socialization on cancer survival also make it important to avoid isolation.

"We're all hopeful this will not go on too much longer, but we all are learning to move forward," Almli said. "But right now, you just can't stay locked in your house for the next year. So we've got to figure out a way to protect our people who are most vulnerable and move forward in a way that's most healthy for everyone."

The future of cancer care: 'It changes everything we do in the future"

Although U.S. coronavirus case numbers have dropped compared to previous months, the pandemic's lasting impact is sure to leave its mark on the future of cancer care.

Dr. Riall at the UA Cancer Center has moved many cancer surveillance-based appointments that don't require hands-on care to virtual telehealth visits.

"[Coronavirus] changes everything that we do in the future," Riall said. "I think in the long term, we're going to have a hybrid model of telehealth visits and in-person visits."

As a cancer patient, Molly Cassidy foresees the pandemic affecting the difficult decisions those with cancer must make.

"When you're faced with what types of decisions you need to make, COVID can impact those decisions because some people might not want to receive a treatment that makes them go to the cancer center on a daily basis. Those types of questions could weigh heavily on the treatment plan decisions that patients would make," Cassidy said.

While cancer patients may face varying forms of care and even harder decisions to make in the future, Riall believes in reflecting on the challenges of coronavirus in order to build a clear path for moving forward.

"On a personal level, I think it's really needed that everybody kind of step back, and evaluate what's really important as we do mourn the loss of our normal," Riall said. "I think every day: What do I need to do to be resilient? How do I support my patients and help them be resilient? How do I want my life to look moving forward, as everything has changed? I think it's been a year of a great reflection of great opportunities. But it's not all bad."

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