Although the full impact of the COVID-19 pandemic on patients with cancer is still being evaluated, data from several studies show that in comparison with people who do not have cancer, those who do generally experience a higher risk of severe events including admittance to the intensive care unit, ventilation support, or death. Recent results from a large cohort study by the COVID-19 and Cancer Consortium and presented at the ASCO20 Virtual Scientific Program in May¹ detail how dire the health consequences can be for patients with cancer infected with the coronavirus. The study found that all-cause 30-day mortality and severe illness requiring hospitalization and/or mechanical ventilation were significantly higher in patients with cancer infected with COVID-19 than patients in the general population.¹

“I’m looking forward to seeing the data on how well patients did on reduced cancer therapies and visits to the clinic.”

— Archie Bleyer, MD

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Although data from the cohort and other studies are derived from older patients with cancer who are infected with the coronavirus, it is likely that younger patients who contract COVID-19 are also at higher risk for hospitalization and death, according to Archie Bleyer, MD, Clinical Research Professor at the Knight Cancer Institute of Oregon Health & Science University and Professor of Pediatrics at the McGovern Medical School, University of Texas.

“We don’t have enough information on how COVID-19 affects adolescents and young adults (AYAs) being treated for cancer, but if we did, I think it would show these patients have worse outcomes than AYAs without cancer infected with the coronavirus and, like older adults with cancer infected with the virus, have higher hospitalization and fatality rates,” said Dr. Bleyer. “We do know that, as of April 18, 2020, in the United States, 411 AYAs 15 to 34 years of age have died of COVID-19, and 7% of all deaths in that age group during that week were caused by COVID.² Data from China showed the incidence of COVID-19 infection increases exponentially above the age of 10.^3,4 We know that in Italy, as of May 29, 2020, 13 deaths from COVID-19 have occurred in young adults between the ages of 20 and 29 and 62 deaths in those between the ages of 30 and 39.⁵ Data from the Centers for Disease Control and Prevention also showed more children between the ages of 10 and 17 being hospitalized and receiving care in the intensive care unit than younger patients.”⁶

Overcoming Additional Feelings of Isolation and Fear

To reduce the risk of exposing immunocompromised patients to the coronavirus, many medical groups are recommending delaying or reducing cancer treatment to eliminate or minimize the amount of time patients spend in hospitals and physician offices. The result, especially for adolescents and young adults with cancer, can be increased isolation and fear that their cancer will not be cured. To provide resources for these younger patients with cancer, including emotional and financial support, as well as clinical guidance resources for oncologists managing their care, in April, a group of adolescent and young adult cancer advocacy organizations and leading oncology specialists, including Dr. Bleyer, launched CovidAYACancer.org.

Brandon Hayes-Lattin, MD, FACP

“We wanted to be pioneers in directly helping AYAs during this pandemic,” said Dr. Bleyer, a contributing physician to the website. “I understand there are a number of patient education websites from various oncology groups, including ASCO’s Cancer.Net and the American Society of Hematology’s patient education website on blood diseases (www.hematology.org/education/patients). However, ours is uniquely directed at AYAs with cancer. It is also a repository for critical clinical information, not just for patients, but for oncologists treating this population of patients as well.”

Dr. Bleyer talked with The ASCO Post about how the COVID-19 pandemic is affecting adolescents and young adults with cancer, how delays in cancer treatment could jeopardize survival outcomes for these young patients, and why he remains optimistic about how the lessons learned from the pandemic will benefit patient care.

Striking a Balance Between Providing Care and Decreasing COVID-19 Risk

Please talk about how the COVID-19 pandemic is affecting both the emotional and physical health of adolescents and young adults with cancer.

Obviously, the COVID-19 pandemic is having a huge impact, perhaps even a lifetime peak, in terms of the level of stress we are all feeling, even perfectly healthy individuals. Imagine then how stressful a time this is if you have cancer and are relying on treatment to keep you alive and potentially cure you.

“It is extraordinary how little we know about this new coronavirus.”

— Archie Bleyer, MD

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One of the obvious stressors for patients who feel their therapy is the only reason they are surviving is the fact that they can’t get to the clinic for their chemotherapy infusion because of stay-at-home orders, or their surgery or radiation therapy has been canceled or delayed to keep patients out of the hospital to reduce their risk of contracting the coronavirus. We have to strike an incredibly delicate balance between ensuring that patients receive their treatment in a timely manner and not allowing that treatment to create an increased risk of becoming infected with the virus and having a worse outcome, including death.

It is a difficult dilemma for us and for our patients. For our CovidAYACancer.org site, we consulted with dozens of experts in AYA oncology, specifically in the treatment of leukemia and germ cell tumors, to come to a consensus about treatment strategies, taking into consideration the COVID-19 pandemic.

The Impact of COVID-19 on AYAs With Cancer

Early reports from China indicated that older adults and those with underlying medical conditions were most susceptible to contracting COVID-19 and having worse outcomes than younger adults. What are you learning about the vulnerability of AYAs with cancer if they become infected with COVID-19?

We have incomplete data on how seriously COVID-19 affects AYAs with cancer. We have been informed of two younger patients with acute lymphoblastic leukemia who, at 14 and 31 years of age, did not survive after contracting COVID-19. The patients were neutropenic from their chemotherapy regimen the week before developing COVID symptoms, which may have increased the risk of infection and death.

Improving Oncology Care by Doing Less

What will be the long-term consequences of COVID-19 on AYA patients with cancer?

It is extraordinary how little we know about this new coronavirus. It is going to take months to reach a sense of clarity on what the long-term effects of the virus might be on the healthiest members of the population. For patients with cancer, determining the long-term ill effects from the virus is even more problematic.

Unfortunately, I do expect an increase in the death rate of patients with cancer, certainly among older adults who have received less treatment because of the pandemic and often have other underlying health conditions. The same may happen to AYAs with cancer who are on immunosuppressive cancer therapy or have comorbidities such as obesity or pulmonary dysfunction. We still try to provide aggressive oncology care to our youngest patients who are generally healthier and do not have the added complication of comorbidities.

However, I also think there will be a lot of good that comes out of this experience with COVID-19 and how we treat patients with cancer. I’m looking forward to learning how we might improve oncology care by doing less, since a lot of what we do in cancer therapy may not be necessary, and we could find that out by virtue of the pandemic. I’m looking forward to seeing the data on how well patients did on reduced cancer therapies and visits to the clinic. I’m especially looking forward to learning how we can keep patients at home more through telemedicine, as well as with therapy and supportive care delivery at home.

There is a huge array of possibilities that might be available to us to make treatment not only easier to deliver and less psychosocially stressful, but also more effective. I anticipate a lot of benefit coming out of this crisis. 

DISCLOSURE: Since January 2017, Dr. Bleyer’s only conflict of financial interest is intellectual property in F3 Platform Biologics and expert testimony he provided on behalf of Neptune Generics.

REFERENCES

1. Warner JL, Rubinstein SM, Grivas P, et al: Clinical impact of COVID-19 on patients with cancer: Data from the COVID-19 and Cancer Consortium (CCC19). ASCO20 Virtual Scientific Program. Abstract LBA110.

2. Centers for Disease Control and Prevention: Provisional COVID-19 death counts by sex, age, and week. Available at https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Sex-Age-and-W/vsak-wrfu. Accessed June 15, 2020.

3. Adolescent and Young Adult Cancer Coalition COVID-19: General treatment suggestions, Figures 1 and 2. Available at https://www.covidaPan yacancer.org/figure1-2. Accessed June 15, 2020.

4. Pan A, Liu L, Wang C, et al: Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China. JAMA 323:1-9, 2020.

5. Palmieri L, Andrianou X, Barbariol P, et al: Characteristics of COVID-19 patients dying in Italy: Report on the characteristics of deaths. Available at www.epicentro.iss.it/en/coronavirus/sars-cov-2-analysis-of-deaths. Accessed June 15, 2020.

6. Centers for Disease Control and Prevention: Coronavirus disease 2019 in Children—United States, February 12–April 2, 2020. Available at www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htm. Accessed June 15, 2020.