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Cancer care during the COVID-19 pandemic
Delivering cancer treatment during the COVID-19 pandemic is challenging given the competing risks of death from cancer versus death from infection, the higher lethality of infection in immunocompromised hosts, social distancing efforts, inadequate supplies of personal protective gear, and the need to shift limited hospital resources to the sickest COVID-19 patients. We outline a general approach to cancer care in this unprecedented time, including delaying certain elective surgeries (using neoadjuvant systemic treatment approaches if possible); omitting chemotherapy where benefits are anticipated to be marginal; and utilizing virtual care visits, where possible. Our approach to cancer care during the COVID-19 pandemic relies upon guidance from the American Society of Clinical Oncology, the Centers for Disease Control and Prevention, the American Society for Radiation Oncology, the American College of Surgeons, the European Society of Medical Oncology, and other expert groups [1-5].
Relationship between diet and breast cancer risk in postmenopausal women
Data regarding the contribution of fruits and vegetables to breast cancer risk have been conflicting. In a randomized trial of almost 50,000 postmenopausal women and no prior history of breast cancer, those assigned to an 8.5-year intervention of a low-fat diet rich in vegetables, fruits, and grains experienced fewer deaths as a result of breast cancer (0.037 versus 0.047 percent), after almost 20 years of follow-up [6]. However, the absolute breast cancer risks were low in both groups. We continue to advise patients to consume a balanced diet for overall health benefits, not just breast cancer risk reduction.
Reduction in mortality with lung cancer screening
Lung cancer is the leading cause of cancer death, but there are few data evaluating the use of volume-based low-dose computed tomography (LDCT) in the reduction of lung cancer mortality. In the NELSON trial, a randomized trial including current and former male smokers in the Netherlands and Belgium, LDCT was performed at baseline and years 1, 3 and 5.5. At 10 years, lung cancer mortality was reduced by 24 percent in the screened compared with the unscreened group [7]. While the largest reduction in lung cancer mortality is likely to result from smoking cessation, we continue to recommend lung cancer screening with LDCT for individuals ages 55 to 80 years, who are in generally good health, with a 30 or more pack/year smoking history, and who currently smoke or have quit smoking within the past 15 years.
Resource-stratified guidelines for treatment of late-stage colorectal cancer
There are few data to guide the treatment strategy for metastatic colorectal cancer (mCRC) in resource-constrained settings. The American Society of Clinical Oncology (ASCO) has developed consensus-based guidelines for treatment of mCRC that stratify recommendations based on the available level of services (basic, limited, enhanced, and maximal) [8]. They include specific recommendations for initial diagnostic evaluation, systemic therapy in the first-line setting and beyond, surgical management of patients with potentially resectable disease, other liver-directed therapy options for liver metastases, issues specific to primary site radiation therapy for metastatic rectal cancer, and posttreatment surveillance.
Adjuvant chemotherapy for advanced upper tract urothelial carcinoma
Patients with urothelial carcinoma of the upper urinary tract (UTUC) with high-risk features (ie, muscle invasive and/or node-positive disease) have high relapse rates after nephroureterectomy. In an open-label, randomized, phase III trial of over 260 patients with high-risk UTUC treated with radical nephroureterectomy, the addition of adjuvant chemotherapy with gemcitabine plus a platinum improved three-year disease-free survival compared with surveillance alone (71 versus 46 percent) [9]. In fit patients with high-risk UTUC treated with nephroureterectomy, we suggest the use of adjuvant gemcitabine and platinum-based chemotherapy.
1. COVID-19 Patient Care Information, American Society of Clinical Oncology (ASCO). https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during (Accessed on April 02, 2020).
2. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.htm (Accessed on April 02, 2020).
3. https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/CO (Accessed on April 02, 2020).
4. https://www.facs.org/covid-19 (Accessed on April 02, 2020).
5. https://www.esmo.org/guidelines/cancer-patient-management-during-the-covid-19-pa (Accessed on April 16, 2020).
6. Chlebowski RT, Aragaki AK, Anderson GL, et al. Dietary Modification and Breast Cancer Mortality: Long-Term Follow-Up of the Women's Health Initiative Randomized Trial. J Clin Oncol 2020; :JCO1900435.
7. de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced Lung-Cancer Mortality with Volume CT Screening in a Randomized Trial. N Engl J Med 2020; 382:503.
8. Chiorean EG, Nandakumar G, Fadelu T, et al. Treatment of Patients With Late-Stage Colorectal Cancer: ASCO Resource-Stratified Guideline. JCO Glob Oncol 2020; 6:414.
9. Birtle A, Johnson M, Chester J, et al. Adjuvant chemotherapy in upper tract urothelial carcinoma (the POUT trial): a phase 3, open-label, randomised controlled trial. Lancet 2020; 395:1268.
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