COVID-19 coronavirus and cancer
Revision as of 23:53, 16 March 2020 by Jwarner (talk | contribs) (→General information relevant to cancer patients)
The intent of this page is to gather information relevant to COVID-19, the disease caused by SARS-CoV-2 virus. If you are viewing this page on a cellphone or tablet, consider loading up the desktop version of this page so that a table of contents for the page is displayed for you.
General information relevant to cancer patients
- Cancer.gov: Coronavirus: What People with Cancer Should Know (official website of the National Cancer Institute)
- Cancer.net: Coronavirus 2019: What People With Cancer Need to Know
- Fred Hutch: What cancer patients need to know
- What Cancer Patients, Survivors, and Caregivers Need to Know about the Coronavirus
- UK CLL forum guidance on COVID-19 for patients with CLL (Twitter @Ukcll, 3/12/2020)
Information for healthcare professionals
Oncology
Podcasts
Guidance for immune checkpoint inhibitors and COVID-19
Courtesy of Dr. Douglas Johnson (VUMC)
- The effects of immune checkpoint inhibitors (ICI), including anti-PD-1, anti-PD-L1, and anti-CTLA-4 agents on COVID-19 infections have not been determined.
- While these agents do not produce an immunocompromised state (in contrast to cytotoxic chemotherapy), there is theoretical concern that they could potentiate pulmonary inflammation induced by the virus.
- In patients who develop a dry cough while receiving ICI, both ICI-pneumonitis and COVID-19 infection (as well as other infectious etiologies) should be considered. Viral testing should be performed to rule out COVID-19 infection. The presence of a fever may suggest a viral (or bacterial) origin, while lack of a fever may suggest ICI-pneumonitis. However, radiographic presentations and symptoms may overlap.
- In patients diagnosed with COVID-19, we would recommend postponing resumption or initiation of ICI therapy for approximately 2 weeks after clinical resolution of symptoms or after first negative viral test.
- In critically ill patients who are receiving ICI and are diagnosed with COVID-19, steroids (e.g. prednisone 1mg/kg) could be considered although the role of steroids is highly questionable (given their potentially detrimental effects on viral clearance in other coronavirus infections). (? Role of tocilizumab -studies ongoing?)
Guidance for transplant
- American Society for Transplantation and Cellular Therapy (ASTCT) Interim guidelines for COVID-19 management in hematopoetic cell transplant and cellular therapy patients
- Mayo Clinic recommendations (Vincent Rajkumar's original Twitter thread):
- We recommend DELAY the whole transplant process (collection, & storage) for all newly diagnosed patients until the corona epidemic is over.
- If myeloma patients are already on transplant schedule, we recommend offer to delay the whole process (collection and storage) until the corona epidemic is over. If patients are already on site, collect cells but delay the transplant.
- For patients who need the transplant for progressive disease, or very high risk disease and expected early relapse and cannot wait to delay, proceed with transplant.
Critical care/ICU
- GiViTI 3/10/2020 COVID-19 meeting about intensive care patients - patient characteristics and management recommendations (Posted at: criticalcarenorthampton.com link to original document)
- Critical care resources for non-ICU clinicians (propofology.com)
- Royal London Hospital COVID Intubation SOP (Twitter @DrJEMcK, 3/14/2020; link to Powerpoint file)
Other
- AMA COVID-19 FAQ
- University of Washington COVID-19 Resource Site
- COVID-19 infographic about Italian experience by Twitter @FOAMecmo
- IDSA COVID-19 resource center
- Johns Hopkins Coronavirus COVID-19 (SARS-2-CoV) management information
- Proposed initial diagnostic and management workflow for potential COVID-19 cases given limited testing capacity (Twitter @srrezaie, 3/8/2020)
- MGH Grand Rounds Video: A Coordinated, Boston-wide Response to COVID-19 (3/12/2020)
- Coronavirus tech handbook (shared Google Doc of clinical care)
- Notes (3/8/2020) from infectious disease physician Martha L. Blum, MD, PhD from Infectious Disease Association of California (IDAC) Northern California Winter Symposium on Saturday 3/7/2020:
Infectious Disease Association of California (IDAC) Northern California Winter Symposium on Saturday 3/7/2020 (expand for more information)
- In attendance were physicians from Santa Clara, San Francisco & Orange Counties who had all seen and cared for COVID-19 patients, both returning travelers and community-acquired cases. Also present was the Chief of ID for Providence, who has 2 affected Seattle hospitals. Erin Epson, CDPH director of Hospital Acquired Infections, was also there to give updates on how CDPH and CDC are handling exposed health care workers, among other things. Below are some of the key take-aways from their experiences.
- The most common presentation was 1 week prodrome of myaglias, malaise, cough, low grade fevers gradually leading to more severe trouble breathing in the 2nd week of illness. It is an average of 8 days to development of dyspnea and average 9 days to pneumonia/pneumonitis. It is not like Influenza, which has a classically sudden onset. Fever was not very prominent in several cases. The most consistently present lab finding was lymphopenia (with either leukocytosis or leukopenia). The most consistent radiographic finding was bilateral interstitial/ground glass infiltrates. Aside from that, the other markers (CRP, PCT) were not as consistent. Co-infection rate with other respiratory viruses like Influenza or RSV is <=2%, interpret that to mean if you have a positive test for another respiratory virus, then you do not test for COVID-19. This is based on large dataset from China. So far, there have been very few concurrent or subsequent bacterial infections, unlike Influenza where secondary bacterial infections are common and a large source of additional morbidity and mortality.
- Patients with underlying cardiopulmonary disease seem to progress with variable rates to ARDS and acute respiratory failure requiring BiPAP then intubation. There may be a component of cardiomyopathy from direct viral infection as Intubation is considered “source control” equal to patient wearing a mask, greatly diminishing transmission risk. BiPAP is the opposite, and is an aerosol generating procedure and would require all going into the room to wear PAPRs.
- To date, patients with severe disease are most all (excepting those whose families didn’t sign consent) getting Remdesivir from Gilead through compassionate use. However, the expectation is that avenue for getting the drug will likely close shortly. It will be expected that patients would have to enroll in either Gilead’s RCT (5 vs 10 days of Remdesivir) or the NIH’s “Adaptive” RCT (Remdesivir vs. Placebo). Others have tried Kaletra, but didn’t seem to be much benefit.
- If our local MCHD lab ran out of test kits we could use Quest labs to test. Their test is 24-48 hour turn-around-time. Both Quest and ordering physician would be required to notify Public Health immediately with any positive results. Ordering physician would be responsible for coordinating with the Health Department regarding isolation. Presumably, this would only affect inpatients though since we have decided not to collect specimens ordered by outpatient physicians.
- At facilities that had significant numbers of exposed healthcare workers they did allow those with low and moderate risk exposures to return to work well before 14 days. Only HCW with highest risk exposures were excluded for almost the full 14 days (I think 9 days). After return to work, all wore surgical masks while at work until the 14 days period expired. All had temp checks and interview with employee health prior to start of work, also only until the end of the 14 days. Obviously, only asymptomatic individuals were allowed back.
- Symptom onset is between 2-9 days post-exposure with median of 5 days. This is from a very large Chinese cohort. Patients can shed RNA from 1-4 weeks after symptom resolution, but it is unknown if the presence of RNA equals presence of infectious virus. For now, COVID-19 patients are “cleared” of isolation once they have 2 consecutive negative RNA tests collected >24 hours apart.
- All suggested ramping up alternatives to face-to-face visits, tetemedicine, “car visits”, telephone consultation hotlines. Sutter and other larger hospital systems are using a variety of alternative respiratory triage at the Emergency Departments. Health Departments (CDPH and OCHD) state the Airborne Infection Isolation Room (AIIR) is the least important of all the suggested measures to reduce exposure. Contact and droplet isolation in a regular room is likely to be just as effective. One heavily affected hospital in San Jose area is placing all “undifferentiated pneumonia” patients not meeting criteria for COVID testing in contact+droplet isolation for 2-3 days while seeing how they respond to empiric treatment and awaiting additional results.
- Feel free to share. All PUIs in Monterey Country so far have been negative. Martha L. Blum, MD, PhD
Reports of medical center experiences
Italy
- "The current situation is difficult to imagine and numbers do not explain things at all. Our hospitals are overwhelmed by Covid-19, they are running 200% capacity" (Twitter @jasonvanschoor, 3/9/2020)
- "Cases are multiplying, we arrive at a rate of 15-20 admissions per day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the E.R. is collapsing." - ICU physician in Bergamo, Dr. Daniele Macchini. (Twitter @silviast9 3/9/2020 interpreted translation from original document, Con le nostre azioni influenziamo la vita e la morte di molte persone)
- "Very aggressive disease, many young and fit people severely ill, some colleagues too. We're turning ORs into ICUs to increase positive pressure beds with respirators" (Twitter @EvaristoCroce, 3/9/2020)
- "Today, some hospitals are so overwhelmed that they simply cannot treat every patient. They are starting to do wartime triage." (Twitter @Yascha_Mounk, 3/11/2020 interpreted translation from original document, RACCOMANDAZIONI DI ETICA CLINICA PER L’AMMISSIONE A TRATTAMENTI INTENSIVI E PER LA LORO SOSPENSIONE)
- "We stop intubating people over 60. We leave them die. 30 per cent of patient are 30-60 years old. We have no more ventilators for all patients. 600 intubated in milan.... We are ready to sacrifice our lives to stop it.... There are no more surgeons or dermatologist--only doctors--all together to stop it." (Twitter @Strosterud 3/12/2020)
- "He had to let 3 people die that day, nurses crying because they see people dying in front of them and can't do anything aside from offering some oxygen." (Reddit u/goddessofthebitches 3/12/2020)
- Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy - Early Experience and Forecast During an Emergency Response, Giacomo Grasselli, MD; Antonio Pesenti, MD; Maurizio Cecconi, MD3, JAMA 3/13/2020 -- Companion 3/13/2020 JAMA Youtube video interview with Maurizio Cecconi MD "If you don't take down the transmission of the virus, then the capacity of your system will be overwhelmed." - 29:27
- “Single isolation was only for our detection period. As soon as a #COVID19 test is positive, transfer the patient to cohort isolation. At some point your negative pressure rooms are full – and you cannot isolate anyone else" “We are in a war zone here. In our 1000 bed hospital we closed up wards & programs, all outpatient clinics & built up cohort areas. Now, we have 400 #COVID19 patients. 56 intubated, 2 ECMO, 2 ECCOR, 12 on NIV, 80 CPAP on wards” (Twitter @PedsIntensiva 3/14/2020)
South Korea
- "Emphasis was placed on transparency, rapidly available and accurate information. Transparency is essential to ensure active participation from citizens." (Twitter @HannahNamMD, 3/11/2020), English Youtube video of South Korea 3/9/2020 briefing about COVID-19)
Spain
- "Spreading there very fast with young people in ICUs now and doctors getting infected" (Twitter @david raben 3/14/2020)
United States
San Francisco
- "We continue to face inadequate COVID-19 testing capacity. This is a national crisis.... At SF General Hospital, we’ve created and operationalized a quick low radiation dose chest CT that takes very little time, and has been very useful in helping us evaluate and risk stratify patients." (Twitter @VivekJainMD 3/12/2020)
Seattle
- "We are seeing pts who are young (20s), fit, no comorbidities, critically ill. It does happen.... Currently, all of ICU is for critically ill COVIDs, all of floor medsurg for stable COVIDs and EOL care, half of PCU, half of ER. New resp-sx pts in Pulmonary Clinic as offshoot" (Twitter @Chenbariatrics1 3/13/2020)
Seattle, WA 3/10/2020 (expand for more information)
- March 10,2020 “This is from a front-line ICU physician in a Seattle hospital This is his personal account:
- we have 21 pts and 11 deaths since 2/28.
- we are seeing pts who are young (20s), fit, no comorbidities, critically ill. It does happen.
- US has been past containment since January
- Currently, all of ICU is for critically ill COVIDs, all of floor medsurg for stable COVIDs and EOL care, half of PCU, half of ER. New resp-sx pts in Pulmonary Clinic as offshoot
- CDC is no longer imposing home quarantine on providers who were wearing only droplet iso PPE when intubating, suctioning, bronching, and in one case doing neurosurgery. Expect when it comes to your place you may initially have staff home-quarantined.
- Plan for this NOW. Consider wearing airborne iso PPE for aerosol-generating procedures in ANY pt in whom you suspect COVID, just to prevent the mass quarantines.
- we ran out of N95s (please stop hoarding!) and are bleaching and re-using PAPRs, which is not the manufacturer's recommendation. Not surprised on N95s as we use mostly CAPRs anyway, but still.
- terminal cleans (inc UV light) for ER COVID rooms are taking forever Enviro Services is overwhelmed. Bad as pts are stuck coughing in the waiting room. Rec planning now for Enviro upstaffing, or having a plan for sick pts to wait in their cars (that is not legal here, sadly)
- CLINICAL INFO based on our cases and info from CDC conf call today with other COVID providers in US:
- the Chinese data on 80% mildly ill, 14% hospital-ill, 6-8% critically ill are generally on the mark.
- Data very skewed by late and very limited testing, and the number of our elderly pts going to comfort care.
- being young & healthy (zero medical problems) does not rule out becoming vented or dead
- prob the time course to developing significant lower resp sx is a Wk longer which also fits with timing of sick cases we started seeing here, after we all assumed it was endemic as of late Jan/early Feb).
- based on our hospitalized cases (including the not formally diagnosed ones who are obviously COVID it is quite clinically unique) about 1/3 have mild lower resp sx, need 1-5L NC. 1/3 are sicker, FM or NRB. 1/3 tubed with ARDS.
- Thus far, everyone is seeing: nl WBC. Almost always lymphopenic, occasionally poly-predominant but with nl total WBC. Doesn't change, even 10days in. BAL lymphocytic despite blood lymphopenic (try not to bronch these pts; this data is from pre-testing time when several idiopathic ARDS cases) fevers, often high, poss intermittent; persistently febrile, often for >10d. It isn't the dexmed, it's the SARS2. low ProCalc; may be useful to check initially for later trend if concern for VAP etc. up AST/ALT, sometimes alk phos. 70-100 range. No fulminant hepatitis. Notably, in our small sample, higher transaminitis at admit (150-200) correlates with clinical deterioration and progression to ARDS. LFTs typically begin to bump in 2nd week of clinical course. mild AKI (Cr <2). Uncertain if direct viral effect, but notably SARS2 RNA fragments have been identified in liver, kidneys, heart, and blood.
- characteristic CXR always bilateral patchy or reticular infiltrates, sometimes perihilar despite nl EF and volume down at presentation. At time of presentation may be subtle, but always present, even in our pts on chronic high dose steroids. NO effusions.
- CT is as expected, rarely mild mediastinal LAD, occ small effusions late in course which might be related to volume status/cap leak. Not more helpful than CXR.
- when resp failure occurs, it is RAPID (likely 7-10d out from sx onset, but rapid progression from hospital admit). Common scenario for our pts is, admit 1L NC. Next 12hrs -> NPPV. Next 12-24hrs -> vent/proned/Flolan 18/ interestingly, despite some needing Flolan, the hypoxia is not as refractory as with H1N1. Quite different, and quite unique. Odd enough that you'd notice and say hmmm.
- thus far many are dying of cardiac arrest rather than inability to ventilate/oxygenate given the inevitable rapid progression to ETT once resp decompensation begins, we and other hosps, including Wuhan, are doing early intubation. Facemask is fine, but if needing HFNC or NPPV just tube them. will need a tube anyway, & no point risking the aerosols. no MOSF.
- cardiomyopathy. multiple pts here have had nl EF on formal Echo or POCUS at time of admit (or in a couple of cases EF 40ish, chronically). Also nl Tpn from ED. Then they get the horrible resp failure, sans sepsis or shock. Then they turn the corner, off Flolan, supined, vent weaning, looking good, never any pressor requirement. Then over 12hrs, newly cold, clamped, multiple-pressor shock that looks cardiogenic, EF 10% or less, then either VT->VF-> dead or PEA-> asystole in less than a day.
- Needless to say this is awful for families who had started to have hope. We have actually had more asystole than VT, other facilities report more VT/VF, but same time course, a few days or a week after admit, around the time they're turning the corner.
- Treatment - *Remdesivir might work, some hosps have seen improvement with it quite rapidly, marked improvement in 1-3 days. ARDS trajectory is impressive with it, pts improve much more rapidly than expected in usual ARDS. Recommended course is 10d, but due to scarcity all hosps have stopped it when pt clinically out of the woods - none have cont >5d. May cause LFT bump, but interestingly (200s-ish) for a day or 2 then rapidly back to normal suggests not a primary toxic hepatitis.
- unfortunately, the Gilead compassionate use and trial programs require AST/ALT <5x normal, which is pretty much almost no actual COVID pts. Also CrCl>30, which is fine. CDC is working with Gilead to get LFT reqs changed now that we know this is a mild viral hepatitis. currently the Gilead trial is wrapping up, NIH trial still enrolling, some new trial soon to begin can't remember where.
- steroids are up in the air. In China usual clinical practice for all ARDS is high dose methylpred. Thus, ALL of their pts have had high dose methylpred. Some question whether this practice increases mortality.
- it is likely that it increases seconday VAP/HAP. China had a high rate of drug resistant GNR HAP/VAP and fungal pna in these pts, with resulting increases mortality. We have seen none, even in the earlier pts who were vented for >10d before being bronched (don’t do now) 29/ - unclear whether VAP-prevention strategies are also different, but wouldn't think so? Hong Kong is currently running an uncontrolled trial of HC 100IV Q8. general consensus here (in US among docs who have cared for COVID pts) is that steroids will do more harm than good, unless needed for other indications. - many of our pts have COPD on ICS. After some observation & some clinical judgment, is to stop ICS if able, based on known data with other viral pneumonias and increased susceptibility to HAP. Thus far pts are tolerating that, no major issues with ventilating them that can't be managed with vent changes. We also have quite a few on AE-COPD/asthma doses of methylpred, so will be interesting to see how they do.
- "None are sleeping more than a couple hrs a night. Everyone is utterly exhausted. My colleague has seen so many people die as to have become totally numb.... there were no IV pumps available. So the nurse had given some of it, left the syringe attached, and planned to come by to give more a little later, and then finish it.... In short, this is a nightmare, teetering on the precipice of even worse destruction. The goal of every American city should be to avoid becoming the next Seattle." (Twitter @scott_mintzer, 3/15/2020)
New Jersey
- "So far I've treated 5 confirmed COVID-19 patients reqiring hospitalization, and currently have 14 suspected cases... and I can tell you that in 18 years of medical practice I've never seen anything like this" "It's a severe viral pneumonia. The problem is there is a flood of COVID-19 suspected cases coming to the ER, and we are quickly filling the hospital with them" (Twitter @BioBreakout, 3/14/2020)
- "NJ ER/ICU doc here. We are already overrun. And without appropriate cleaning/protective equipment." (Twitter @CHRISTO37877949, 3/14/2020)
- "What we’ve seen in the patients who ultimately are positive is that things can turn very rapidly. We had a patient that we were thinking about releasing — he seemingly was recovering — and then, two days later, he was put in the ICU. The flu isn’t like that.... Holy Name’s 11 positives are all males — and all between the ages of 28 and 48." (roi-nj, Life at the epicenter of N.J.’s coronavirus outbreak by Tom Bergeron 3/14/2020)
Indiana
- "We're seeing some patients present to the ED with diarrhea, #COVID19 unsuspected but later confirmed" (Twitter @suzchongmd, 3/15/2020)
Patient/community experiences
China
- "A thread about what I observed in Chinese society, and what you should be mentally prepared for" (Twitter @tony_zy, 3/6/2020)
- "A regular person’s journey on Douban. In the past few weeks I’ve witnessed hundreds if not thousands of tragedies unfolding before my eyes" (Twitter @tony_zy, 2/8/2020)
United States
- "My boyfriend and I have self-quarantined ourselves in our apartment since Feb. 23rd." (Twitter @microbeminded2, 3/9/2020)
- "The last one week, it has been hell." (Twitter @pulte, 3/8/2020)
Testing
- University of Washington Virology "Licensed medical practitioners from anywhere in the US can order #SARSCoV2 #CoronavirusUSA testing from @UWVirology. We continue to add capacity and can test hundreds more people daily." (Twitter @UWVirology 3/9/2020)
- FDA FAQs on Diagnostic Testing for SARS-CoV-2 - lists acceptable swab/media, that single swab may be adequate
- % of detection of SARS-CoV-2 in Different Types of Clinical Specimens, JAMA 3/11/2020
- Guidelines and patient criteria for COVID-19 testing by MA state public health vs. commercial laboratories 3/13/2020
Hematology/Oncology meetings
An extensive list is available at The Cancer Letter website.
Canceled
- AMIA Informatics Summit (3/23/2020 to 3/26/2020, Houston, TX) - CANCELED
- SGO (Society of Gynecologic Oncology) 2020 Annual Meeting on Women’s Cancer, (3/28/2020 to 3/31/2020, Toronto, Canada) - CANCELED (may be rescheduled for in-person or virtual meeting)
- European Haemophilia Consortium (EHC) Youth Leadership Workshop (4/3/2020 to 4/5/2020, Amsterdam, Netherlands) and World Haemophilia Day (4/24/2020, Brussels, Belgium) - CANCELED
Postponed
- 1st Translational Research Conference: Chronic Lymphocytic Leukaemia (3/20/2020 to 3/22/2020, Paris, France) - POSTPONED until November 17-19, 2020
- NCCN Annual Conference (3/20/2020 to 3/22/2020, Orlando, FL) - POSTPONED until TBA
- Summit on National and Global Cancer Health Disparity (4/3/2020 to 4/4/200, Seattle, WA) - POSTPONED until Fall 2020
- AACR Annual Meeting (4/24/2020 to 4/29/2020, San Diego, CA) - POSTPONED until TBA
Rescheduled as virtual meeting
- ENETS Conference for the Diagnosis and Treatment of Neuroendocrine Tumor Disease - VIRTUAL MEETING
Still happening as planned
- ASCO Annual Meeting (5/29/2020 to 6/2/2020, Chicago, IL) - STILL PLANNED
General information
Trackers
- COVID-19 Coronavirus tracker for United States and Canada, with case-by-case descriptions (1point3acres.com)
- Johns Hopkins CSSE Worldwide Coronavirus Tracker
- Australia COVID-19 tracker (covid19data.com.au)
Number of cases/epidemiology
- ArcGIS charts and maps about COVID-19 cases, with multiple options to break down by country
- Animated bar chart race of COVID-19 cases outside China from 1/27/2020 to 3/11/2020 (gohkokhan.com)
- COVID-19 cases per 10 million people
- Clusters of disease spread in South Korea, "Patient 31" (Reuters, 3/3/2020)
- Cases per country as of 3/12/2020
- Italy vs. United States number of cases offset graph through 3/13/2020
Misc information
- John Campbell Youtube Coronavirus videos
- CDC.gov COVID-19 Coronavirus information
- Estimate of mortality rate by age (Twitter @DorsaAmir, 3/7/2020)
- Influenza vs. COVID-19 mortality rate by age (Twitter @AshokKumarSheo8, 3/7/2020)
- Ars Technica summary of COVID-19 information (Arstechnica.com, 3/8/2020)
- Response to COVID-19 in Taiwan Big Data Analytics, New Technology, and Proactive Testing (JAMA 3/3/2020)
- Coronavirus: Why You Must Act Now (Medium, Tomas Pueyo, 3/10/2020)
- COVID-19 Update; 3/14/2020. A Message From Concerned Physicians by Howard Luks MD (Medium 3/14/2020)
- UCSF Expert panel discussion 3/10/2020, notes by Jordan Schlain MD
- Dermatologist's guide to COVID-19 handwashing (Twitter @RoxanaDaneshjou, 3/15/2020)
- COVID-19 presentation slides by Michael Lin MD/PhD PDF 3/13/2020 (Twitter @michaelzlin 3/14/2020)
- Fei Zhou et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020 Mar 11. PubMed link to original article