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What Now? Navigating cancer treatment during a possible COVID-19 ‘second wave’

June, 2020

As business starts to re-open during the COVID-19 pandemic and we watch carefully to make sure an anticipated second wave of cases does not overwhelm our health care systems, many patients with cancer remain confused as to what to do next. Some newly diagnosed patients have been waiting for definitive surgery or systemic therapy until states open up non-essential businesses, but it is our view that during the re-opening we still need to do all we can to protect more vulnerable patients, particularly those who are undergoing cancer treatment. Acknowledging these continued concerns, and to help cancer survivors navigate the COVID-19 pandemic we at SIO wanted to highlight five key recommendations all of which are supported by the Center of Diseases Control (CDC) and/or American Society of Clinical Oncology (ASCO). For a much more comprehensive and detailed list of recommendations based on type of cancer from various professional organizations, we recommend this ASCO link.

1) Shielding (with sunshine)

The most essential recommendation is not a surprise, but still equally relevant today as it was in March 2020 when the US began its lockdown for the 1 st wave of this coronavirus. In the UK they call it “shielding” and in the US we called it “hunkering down”. “Shielding” is remaining at home as long as possible to avoid any close contacts with potential carriers. Tracking of COVID-19 spread through communities globally suggests the most dangerous places to be are enclosed places, such as a church, a restaurant, an office or clinic room. If possible, try to designate someone who is not high-risk for COVID-19 serious illness to do the higher risk tasks for you like groceries and pharmacy visits. This all becomes even more relevant with the recent protests/riots, as the increased physical proximity of hundreds to thousands of people with each other, is one of the things COVID-19 thrives on, and it is prudent for all to have again an abundance of caution. Several websites are offering interactive updates on the status of COVID-19 infections state to state which might be more helpful than the mass media which tends to focus on the worst situations in the country.

Given the quality of life enhancing effects of nature, “shielding” however should not imply staying inside the home at all times. In suburban areas, or any residence where population density is mild and there is abundant open space, gardening, going for a neighborhood walk or local trail, or just reading in the backyard has many evidence-based benefits including anxiety/stress reduction, improved energy, improved bone health, and decreased cancer risk. Some of these benefits are mediated by vitamin D which is converted into its most bio-active form when our skin cells absorb UV-B light from the sun. For those of us living in more urban, dense populations, vitamin D3 supplementation might be a safer alternative. Universal recommendations for sun exposure are difficult to make because many variables exist including geographic latitude, frequency of cloud cover or pollution, varying individual skin cancer risk, and skin pigmentation (fairer skin generally produces vitamin D with sun exposure quicker than darker skin). We recommend having your vitamin D25 levels checked so you can get a better understanding of how your body, lifestyle and your geography interact.

2) Wearing a mask and physical distancing in public of 6 ft

By now we are all familiar with this safety procedure, but to be clear – the main benefit of the mask is to reduce potential spread of virus particles if you the mask wearer are an asymptomatic carrier. This increases assurance that 6 ft distancing will be effective. Depending on the mask worn, it might have some protective properties for the wearer, but probably the most important would be making sure not to touch one’s nose or mouth with unwashed hands. Making home-made masks for virus protection is not a well-studied field, but you might find this informal study done by a company called Smart Air helpful for guidance on what materials to use. Obviously, if supplies are available, a formal surgical mask would be a more standard recommendation and some cancer centers will even supply you with one upon entering the building. Scarves, although mentioned in the CDC guidance document, perform very poorly if only worn single layer in comparison to a standard surgical mask.

Wearing gloves is not helpful. In fact, if you start using gloves as an alternative to washing hands, you could end up putting the people and things you come into contact at greater risk of COVID-19 transference, so please don’t. The virus does not cross the skin barrier. That said, some need to wear gloves to protect their hands from drug rashes or open wounds so let us not assume we know other people’s intentions.

3) Consider COVID-19 PCR testing routinely before starting immunosuppressive treatments

In the newest recommendations by ASCO, they are now recommending (if supplies are practical) to conduct a routine RT-PCR COVID-19 test even in asymptomatic patients before starting any immunosuppressive treatment such as chemotherapy. RT-PCR is the gold standard currently for detecting COVID19 virus in the nasal passages, i.e. active infection and its main shortcoming is a high rate of false negatives in the first week of infection. But detecting asymptomatic shedders (individuals with COVID-19 infection that have no symptoms) will be important to limit potential contagion in an infusion center. Also, data from the COVID-19 database registry of de-identified information from 1035 patients with cancer and COVID-19 illness was recently published in Lancet and presented at the ASCO 2020 annual conference. Overall mortality for patients with cancer and COVID-19 infection was 13%, with risk factors for mortality being older age, male, smoking, physical limitation by cancer versus no limitation, and active progressing cancer (5.2 fold risk, the highest of the factors).

4) Consider COVID-19 serology testing

COVID-19 serology testing (i.e. testing for virus antibodies in the blood) is more readily available than ever although none of the available tests are FDA-approved. The federal mandate in the US is that all insurance providers must cover the cost of COVID-19 antibody testing. The FDA has a website listing serology tests given Emergency Use Authorization (EUA) which means given the circumstances, it is reasonable to use without official FDA approval. Generally, you want a test done with high sensitivity and particularly high specificity, and the Abbott test is preferred/ available at some cancer centers. This test tells you whether you may have been exposed to COVID-19 already, and typically the test is not positive until weeks after infection so it is not used to diagnose acute infection (the RT-PCR test is for that). The assumption is that a test being positive will confer some degree of immunity but how complete that immunity would be is not very clear. Hence this is not a strong recommendation, but something that health care workers and patients might like to know. The problem is the false positive rate of testing, which increases if you do the test when there is no clinical history suspicious for COVID- 19 (i.e. you are asymptomatic, you shielded religiously, are in remission and not immunocompromised and had no known exposure to a COVID-19 infected person). One consequence could be false reassurance, possible inappropriate abandonment of protective behaviors, and increased risk of COVID-19. Thus, these are important issues to discuss with your health care provider before just doing the test.

5) Never a better time to engage with a preferred mind-body practice!

The COVID-19 pandemic has changed our society in ways we had never imagined possible. With every major crisis, humanity has adapted and evolved, and our long view is that we will emerge better than before. But with record rates of unemployment and suddenly millions of people with more free time to feel, and now forced to be present with their emotions, it is not unexpected that the “essential businesses” of adult-coping such as alcohol, nicotine, cannabis, and narcotics use are going stronger than ever, and rates of inappropriate use and abuse are escalating. However, with telemedicine increasingly available (thanks to the urgency of relaxing laws during COVID-19) and the availability of a cornucopia of evidence-based mind-body practices, there never has been a better time to dive into these increasingly appreciated wellness practices. The practices that have the most evidence for breast cancer survivors (where the bulk of the mind-body research has been conducted) involve several practices, which have been reviewed in the SIO clinical practice guidelines for integrative oncology treatments in breast cancer.

Cognitive behavioral stress management (CBSM), which combines standard Cognitive Behavioral Therapy techniques such as relaxation, imagery, cognitive coping, assertiveness and communication training has been shown to promote better adherence with full dose planned treatment, better overall survival, and benefit finding (meaning a greater likelihood that an individual will believe their crisis was a blessing in disguise to acquire a new benefit or ability. CBT for insomnia (or CBT-I) is also recognized as the gold standard treatment for insomnia in both cancer patients and the general public, and it is more effective than sleep medications and non-specific CBT. One of the central premises of CBT-based interventions is that feelings and emotions are dictated by automatic thoughts, beliefs and stories or interpretations we make (rather than actual life events) which often occur rapidly without conscious choice. Through CBT with a trained therapist, those beliefs can be brought to awareness and reframed to something more realistic and compatible with wellness and resiliency. Finding a skilled provider can
be a challenge, but this website might be of help.

Other practices well studied and shown to be safe and effective in the enhancement of quality of life for patients with cancer include Mindfulness-Based Stress Reduction (MBSR as popularized by Jon Kabat Zinn in Full Catastrophe Living), or similar adaptations specific to cancer patients and survivors such as Mindfulness-Based Cancer Recovery (MBCR). One advantage of mindfulness-based interventions is that they can be taught by a certified MBSR teacher and due to their popularity, courses are available online including MBCR specifically for people with cancer. Mindfulness-based interventions involve direct experiential training in individual mindfulness practices and skills, through techniques such as the body scan, mindful awareness of breathing and eating, and are designed to help cultivate the ability to develop and maintain present-focused awareness allowing you to “become an observer of your own mind, emotions and thoughts.” When this skill is developed through ongoing practice then the potential exists for personal insights which lead to increased adaptability to stress.

Online interactive MBCR program

MBCR self sytudy

MBSR program online course

Last but not least, movement based meditation practices such as tai-chi, qi-gong and various types of yoga have also been shown to have a multitude of benefits including reduced joint pains from antihormonal therapies for women with breast cancer and reduced stress, anxiety and depressive symptoms. Perhaps just as importantly, they also require a level of mindfulness and being present, which means less time watching mass media and social media which are intentionally designed to trigger strong emotions and a desire to keep watching/reading more.

Given many of these mind-body practices lend themselves well to teaching online, the Society for Integrative Oncology is proud to host Wellness Wednesdays starting June 10 th where each week a wellness short of 20 minutes will be presented so one can explore a mind-body practice for free. These wellness shorts were developed by a team led by our Yoga Special Interest Group, chaired by Leigh Leibel, a global health activist for increasing awareness of evidence-based wellness practices. She is also an SIO board member and serves as Director of Integrative Oncology at Columbia University Irving Medical Center designing evidence-based mind-body protocols for cancer patients and survivors.

Promo video for Wellness Wednesdays
Follow @integrativeonc for further announcements