Cancer During COVID-19

Cancer During COVID-19

I recently hit the gong in celebration of finishing my last cycle of chemo. As I reflect on the journey so far, it has been relatively smooth and free of complications. I am a “model patient,” per my oncologist. As if the onus was on me, the patient, to have selected this course. In truth, it is due to a variety of factors, many of which were not under my control. I’d be lying though if I said it didn’t feel a little victorious to know that as a patient I followed the textbooks in some way. Regardless, I am blessed and happy to be standing as I am today – I made it through chemo. And not just chemo–chemo during a pandemic! 

It is ironic how my breast cancer journey mirrors that of the COVID-19 pandemic. I had felt a mass in my right breast around the same time the first novel Coronavirus case was diagnosed in Wuhan, China. I was alarmed but mostly felt uncertain of the significance of both my breast mass and the new virus. Within days of receiving the results of my breast biopsy, the COVID-19 pandemic was announced. My life was officially tossed upside down… stomped on… then kicked off a cliff.

My breast center had closed shortly after I was diagnosed with breast cancer because of a COVID-19 exposure at the center. As many nonessential businesses started to close, I scrambled to find a radiology center that would perform additional imaging I needed prior to starting chemo. Fortunately, my breast center truly is comprehensive and amazing. They helped coordinate finding another nearby radiology center, sending my prior imaging to them for comparison and obtaining the final reads from them. With some mental tensity but minor delay, I was on my way.

As my ER colleagues delved head on into the pandemonium, I started chemo. As the pandemic ramped up in NYC, I was at the peak of my chemo. And as we started to gain some sense of control over the situation, the side effects of chemo started to improve. Some states started to open and Coronavirus cases surged while I underwent surgery; which, I have to mention was preceded by an unpleasant but brief nasopharyngeal swab for COVID-19 that will make me second guess every single nasopharyngeal swab I order going forward.

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Like most others, I quarantined as recommended and only left my house for 2 reasons since March 2020: 1) doctor’s appointments and 2) to get some sun on my porch. Isolation is not a new concept to people diagnosed with cancer. As immunocompromised individuals, people with cancer generally isolate themselves and/or protect themselves with face masks and frequent handwashing to reduce their risk of getting any sort of infection, not just COVID-19. So, regardless of the pandemic, I would be in quarantine.

I didn’t find it hard to stay at home. By nature–actually, by my doing–my lifestyle is active and often at odd hours of the day. School and medical training occupied about 95% of my life since graduating high school and increasingly so in the last decade as I specialized in emergency medicine and pushed my agenda of a personal life. I married my college sweetheart and had two kids during residency. 

On a given day, in no particular order, I may be working, sleeping, taking the kids to or from two different schools, grocery shopping or cooking, studying, bathing/feeding/playing with the girls, and I can usually squeeze in a shower every few days. There are stretches of days where I only see my children while they’re sleeping or only talk to my husband via text messaging. So, I welcomed being able to stay at home with them. I slept a normal circadian sleep cycle, ate meals with my family, got to put my kids to sleep and see them when they first woke in the morning (a relished rarity)… I got a brief taste of normal. 

Then chemo started and the girl’s schools closed in person sessions. Endless, uninterrupted time with my husband and two daughters was one of the unexpected silver linings of my situation. Obviously, I would have preferred to be in a better condition to be active with my kids but who says movie marathons aren’t quality time.

Seeing as I don’t know what the future holds regarding potential family planning due to the effects of chemotherapy, I would change nothing about my decision to have two kids during residency. Yes, it was crazy. Yes, I have a life-time of sleep to make up. And yes, there were many times I spent more time with my work colleagues than with my hubby and babies. But for many reasons it was the right decision for me. And my experience with breast cancer this year has reinforced that in my mind.

*Shout out to all my fellow parents in quarantine with their kids!* As unpredictable, chaotic and loud my job as an ER physician can be, it comes a close second to the challenges of being a parent. Hang in there! As parents, we do our best and our best is what we can do!

Of course, I am not alone in all of this. My village, so to speak, includes my husband, my family, my in-laws, my medicine colleagues, and friends, all of whom without my current standing is not possible. As part of a long term plan, my Mom and Dad were actually in town looking at apartments the day after I got my biopsy results. Within two weeks they were moved in. Then my Mom, who is a geriatric physician, was furloughed at her new job due to the pandemic. Suddenly, her and my Dad, who is retired, were free to help us with the kids. My Granny-in-law and Mother-in-law who developed flexibility in her job due to the pandemic also stayed with us for several weeks at a time to help. 

The timing of it all…

I am now recovered. The pathology from my tumor bed and lymph node dissection was negative – meaning no signs of cancer.

I am a survivor.

I am fortunate to have had an uncomplicated medical course, abundant support from friends and family, and a silver lined journey.

Although the pandemic has not yet recovered, the world is learning how to handle life with COVID-19. And I believe that we shall overcome this as well. Of course, as with any disease process – prevention is key! Maximize the factors that you can control to reduce transmission of COVID-19: wash your hands frequently, social distance and wear a mask. After feeling a total loss of control over my life this year, I think it’s easy to act in accordance with the guidelines to reduce transmission of COVID-19 to myself and others. I’m not saying it’s not inconvenient. I am saying I believe it’s the right thing to do.

I know you’ve heard about herd immunity and high risk populations during the pandemic. The “others” your actions are trying to protect, is me. I am 32 years old. I am a daughter, sister, wife, mom, cousin and friend. I didn’t choose to have breast cancer and I don’t want to die because of others actions (or inactions). 

It’s okay if you don’t care about me like that. I could be your Mom or Dad, brother or sister, best friend, significant other, or neighbor. I could be someone you care about a lot that you may not even know is immunocompromised. Maybe it’s not cancer; it’s their long-term steroids, or HIV, or diabetes, or their age causing their immune system to be more susceptible to infection. I didn’t have many choices this year but I do choose to take steps to reduce transmission and protect those around me. 

For people with cancer during this pandemic, the medical field’s objectives include maintaining beneficial anticancer therapies as well as protecting the providers that care for us (1). About 50,000 new patients are diagnosed with cancer each day that require treatment (2) and the pandemic doesn’t change this. Earlier diagnosis and urgent therapy is associated with significant benefits in terms of morbidity and mortality (3), so it is crucial for cancer patients to have access to appropriate medical evaluation and therapies in a timely manner. I anticipate people are experiencing delays in diagnosis during the pandemic because of limited access to healthcare for routine screening for cancer, like, mammograms and colonoscopies, and for evaluation of suspicious symptoms, like, breast masses or pain, or painless rectal bleeding. The pandemic is not a reason to sit back. As patients, I urge you to advocate for yourself and reach out to your primary care doctor, virtually, to discuss any concerns. 

Diagnosing COVID-19 in the general population can be challenging based on its vague and broad symptomology and imperfect tests. COVID-19 is even more challenging to diagnose in patients with cancer as its symptoms, such as, fever, fatigue, myalgias, anorexia, and loss of smell (anosmia) or taste (ageusia), and lab abnormalities, including, low white blood cell count (leukopenia), high white blood cell count (leukocytosis), high lymphocyte count (lymphocytosis), elevated liver enzymes, elevated inflammatory markers and elevated creatinine can also be due to cancer or cancer therapies. Combine this with several testing options which have limitations in their specificity and higher than ideal false negative rates and it can become messy figuring out if someone has COVID-19 or not.

The data regarding COVID-19 and patients with cancer is limited given how recently the virus emerged and it is primarily from Asia. Patients with cancer make up about 1% of all patients diagnosed with COVID-19 (4). It doesn’t sound like a large amount, however, cancer patients who are also infected with COVID-19 have TRIPLE the mortality rates than non-cancer patients infected with COVID-19 (5). Newer data from the same researchers shows that further out from diagnosis (after 30 days) mortality rates in patients with cancer actually increases (5). Even cancer patients diagnosed with COVID-19 that are otherwise in good health and don’t have other comorbidities–like me–have higher mortality than the general population.

As a new “survivor,”  I am at an increased but unquantified risk of contracting COVID-19 as my immune system recovers over the next several months and accordingly will follow the guidelines for a little longer than most. But hey, I made it to the other side! Could it have been better? Uh, yeah, obviously, by not having happened in the first place!! It also could have been worse in so so many ways and I am thankful for the course of my journey and all of the individuals who were a part of it in any way.

Kavita Jackson, MD

References

  1. Raymond E, Thieblemont C, Alran S, Faivre S. Impact of the COVID-19 Outbreak on the Management of Patients with Cancer. Target Oncol. 2020;15(3):249-259. doi:10.1007/s11523-020-00721-1
  2. Bray F, Ferlay J, Soerjomataram I, et al.. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer J Clin. 2018;68:394–424.
  3. Hansen RP, Vedsted P, Sokolowski I, et al. Time intervals from first symptom to treatment of cancer: a cohort study of 2,212 newly diagnosed cancer patients. BMC Health Serv Res. 2011;25(11):284.
  4. Zhang L, Zhu F, Xie L, et al. Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China. Ann Oncol. 2020.
  5. Kuderer N, Choueiri T, Shah D, et al. Clinical impact of COVID-19 on patients with cancer. Lancet. 2020;395(10241):1907-1918.

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