Immunotherapy – Evolving cancer care during COVID 19 pandemic

Author : Dr. N Aditya Murali, Consultant – Medical & Haemato Oncology, Aster CMI Hospital

India

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New Delhi, June 19, 2020 :

Dr. N Aditya Murali

The COVID 19 pandemic has touched every aspect of human life including healthcare delivery for other chronic diseases. With the explosion of medical information on this pandemic, medical care for diseases like cancer is also evolving every day. Gone are the days when patients used to schedule day care chemotherapy appointments like any other regular appointments.

The challenges for a cancer patient are manifold. Most patients worry about exposure to the COVID 19 virus when they visit the hospital. Another worry is whether chemotherapy will lower their immunity making them more susceptible to COVID 19 infection. And patients on chemotherapy may require repeated hospitalizations making them more susceptible to contracting COVID 19 infection. There is always a lingering doubt in the patient’s mind whether to delay cancer treatment or not. Another question being asked is whether the interval between each cycle can be increased or whether intravenous therapy can be converted to oral therapy to reduce the risk of exposure. Many are even unsure as to which is more dangerous and difficult to treat – Cancer or COVID 19.

LANCET Oncology, a premier medical journal published a study on Cancer and COVID 19 infection on May 28^th with some startling hypothesis which may lead to a radical change in cancer care during COVID 19. First, patients with cancer appear to be at an increased risk of mortality and severe illness due to SARS-CoV-2 infection, regardless of whether they have active cancer, are on anticancer treatment, or both. The absence of an association between 30-day all-cause mortality and recent surgery, recent non-cytotoxic therapy, or recent cytotoxic systemic therapy suggests that curative surgical resections, adjuvant chemotherapy i.e. chemotherapy given with a curative intent, and maintenance chemotherapy could continue during the SARS-CoV-2 pandemic with extreme caution, although this finding should not be interpreted as a recommendation.

In elderly patients or patients with co-morbidities who are at a high risk of contracting the COVID 19 infection, non-chemotherapy options like targeted agents and immunotherapy can be explored. Especially in selected cancers like early stage breast cancer which express the oestrogen receptor and without overexpression of a high risk receptor like HER2, targeted agents like hormonal therapy can be used as an option for effective disease control, thereby mitigating the risks of immune suppressive chemotherapy. Advances in treatment have meant certain subset of patients with lung cancer can be treated with a chemotherapy free option like targeted therapy or immunotherapy. Patient suffering from advanced stage lung cancer with particular driver mutations can be treated with oral agents effectively as a first line treatment option. Some patients of stage 4 lung cancer can be treated with single agent immunotherapy with even superior results as compared to chemotherapy, at the same time reducing the immune suppression associated with chemotherapy and the attendant side effects. In fact, immunotherapy alone has now been approved as first line therapy in certain types of cancers like metastatic lung cancer, metastatic kidney cancer, metastatic liver cancer, and metastatic genito-urinary cancers. With a view of reducing hospital visits during the COVID 19 pandemic, extended intervals (6 weekly vs the traditional 3 weekly) between each immunotherapy session of a drug called Pembrolizumab, has been extensively studied and approved by the USFDA.

History has taught us that the only way to overcome an adversity by innovating and evolving. Like all other facets of society, health care delivery has also risen up to the challenge and is striving to maintain optimum outcomes for patients suffering from cancer during this COVID 19 pandemic.

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