COVID-19 coronavirus and cancer

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Revision as of 12:36, 13 March 2020 by PeterYang (talk | contribs) (added Seattle experience, collapsible elements)
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The intent of this page is to gather cancer-specific information relevant to COVID-19, the disease caused by SARS-CoV-2 virus.

General information relevant to cancer patients

Information for healthcare professionals

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

South Korea

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.

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

Testing

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) - CANCELLED
  • SGO (Society of Gynecologic Oncology) 2020 Annual Meeting on Women’s Cancer, (3/28/2020 to 3/31/2020, Toronto, Canada) - CANCELLED (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) - CANCELLED

Postponed

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

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