In Greek mythology, legend has it, ships passing through a narrow strait were forced between a terrible duo: Scylla, a six-headed monster, on one side, and Charybdis, a whirlpool that would suck in sailors who came too close, on the other.
The myth is a fitting metaphor for navigating safely between cancer and COVID-19, Charu Aggarwal, MD, MPH, an associate professor of Hematology-Oncology, noted during the Abramson Cancer Center’s “Cancer and COVID-19” virtual conference last week, which brought together about 1,900 health professionals.
Aggarwal credited a recent editorial in the New England Journal of Medicine by Mark Lewis, MD, for the metaphor and added, “It’s like being between a rock and hard place for us, as well as for our patients.”
Indeed, it has been a tough seven months filled with difficult decisions and obstacles.
Hospitals had to quickly adapt to a rapidly changing environment and enforce protocols to deliver care safely and effectively. Many individuals are choosing to skip cancer screenings or delay treatments. And those battling both COVID-19 and cancer are facing a higher risk of worse outcomes and more complicated care.
Thankfully, though, as the cases grew around the world, so did the understanding of the impact the SARS-CoV-2 virus has had on oncology. Clinicians, nurses, hospital support staff, and researchers have continued to chart a course ahead during these times.
Many of them came together for the conference to hear Penn Medicine physicians and a notable guest share that knowledge. “The agenda tonight is power packed,” said Robert H. Vonderheide, MD, DPhil, director of the Abramson Cancer Center and chair of the conference.
Anthony S. Fauci, MD, one of the most well-respected infectious disease experts who is helping lead the national COVID-19 response effort, presented the keynote address. The director of the National Institute of Allergy and Infectious Diseases took the opportunity to offer up everything from updates on the vaccine trials and rising rates to advice for the oncology field.
“The numbers are striking,” Fauci said. “We passed a mark just a couple of days ago with 200,000 deaths…and essentially, [there is] no particular end in sight.”
COVID-19 Vaccine: A Race for Answers — and Prevention
In the face of the ongoing epidemic, anti-viral drugs like remdesivir have been showing promise in COVID patients both with and without cancer. Monoclonal antibodies, Fauci said, will be a “giant step forward in the treatment of early disease,” once challenges around scaling up can be resolved.
While hydroxychloroquine (HCQ) has put up a good fight against cancer, science continues to show it is not effective at preventing or treating COVID-19. The co-leader of a randomized prophylactic HCQ trial at Penn and program co-leader of Cancer Therapeutics at the Abramson Cancer Center, Ravi Amaravadi, MD, shared results published that same day. The team found no difference in infection rates between health care workers taking HCQ compared to those who weren’t.
“We believe that our efforts should be focused on other preventative modalities,” Amaravadi said. That includes mainly, he added, the vaccines in the pipeline.
Widespread public vaccination against COVID-19 could not only eventually stem the spread of the disease, but also better protect cancer patients who are at elevated risk due to treatments that compromise their immune system.
The sprint to find a safe and effective vaccine continues, with six government-backed trials currently in progress, including nucleic acid, viral vector, and protein approaches. The big question posed to Fauci was on timing: “We need to wait for the results of the phase III trials, which I believe will be available by the time we get to November or December,” he said — though he said sooner could be possible. “I think that’s unlikely, but it’s not impossible.”
Whether people will need to get revaccinated against COVID, as they do with the annual flu vaccine, still remains a question mark. If so, it’s not necessarily because the virus will mutate year after year like the flu, Fauci suggested, but because of the durability of people’s immunity. After a certain amount of time vaccinated people may lose the ability to fight off SARS-CoV-2. Studies at Penn, led by E. John Wherry, PhD, director of Penn’s Institute for Immunology, have helped draw a clearer picture of how immune system responds to this novel coronavirus, but there’s still so much to learn.
What is clear is that people respond to the virus in very different ways. Some produce T cells and other immune cells to attack the virus; while others show no T cell activation and in some cases no B cells either.
“The bottom line is we are still searching for what a typical immune response to SARS-CoV-2 virus is in COVID-19 patients,” Wherry said at the conference. That hunt continues under a Translational Immunology Profiling Pipeline — modeled after their work in cancer immunotherapy — where patients’ responses are analyzed and studied. Mapping those out can help inform how to best treat different patients.
Adam C. Cuker, MD, an associate professor of Hematology Oncology, also spoke about venous thromboembolism (VTE), a type of blood clot experienced by some COVID-19 patients, including those with cancer who face a higher risk of VTE. Anticoagulation drugs remain the recommended treatment, he said, but more clinical data is needed to better understand VTE in patients, along with outcomes and potential other treatments.
“There’s one clear risk factor that trumps the rest. And that is the severity of illness,” Cuker said. “The sicker the patient is, the higher the risk of venous thromboembolism.”
The Impact of COVID-19 on Cancer Patients and to Cancer Care
When the pandemic started, clinical operations were greatly impacted at health care facilities everywhere, including Penn Medicine. Care continued, but much of it looked very different, as the majority of visits moved to telehealth and some treatments were delivered safely at home. Screening stopped altogether for weeks, which means cancers weren’t being caught and therefore treated; it’s a pause that could take many lives over the next decade.
“From a 40,000-foot look, you should try to get back to the normal type of screening that you have done as quickly as you possibly can…,” Fauci said. “I would use [COVID-19] testing to get back to where you want to be.”
Today, Penn’s clinics look closer to what they resembled before the pandemic, albeit with new safety protocols in place, including appropriate COVID-19 testing. And it’s constantly evolving, said Lynn M. Schuchter, MD, chief of Hematology-Oncology and conference chair.
“Our goal is to optimize patient and staff safety,” she said. Because of education that reinforces the importance of social distancing and mask wearing for patients to protect themselves in their daily lives, Penn has experienced a relatively low incidence of COVID-19 in cancer patients, less than two percent. Nationally, it’s between one and four percent.
While that number remains low, the risks for those patients are high. One study put the mortality rate at 13 percent for patients with cancer versus less than three percent in the general population. They’re also more likely to be sicker and less likely to receive critical care.
Multidisciplinary virtual meetings are helping physicians navigate these risks with treatment plans that ensure both the infection is treated and the necessary cancer treatments are delivered appropriately.
“We are now in a phase where we are providing cancer care and really co-existing with COVID,” Schuchter said.
When the issue of racial disparities in cancer and COVID-19 infections came up, Fauci suggested a short-term plan: concentrate testing capabilities and care access for underserved communities.
“In the long range, and it sounds very idealistic,” he said, “is that maybe we can use this horrible experience…to finally get us to do something about the decades and decades of long problems of the social determinants of health that allow minorities to be in the vulnerable positions that they are in. It’s not something we are going to cure overnight, but we need to make sure we address that in the coming decades.”
During the event, Kathleen Murphy, MD, an associate hospital epidemiologist and assistant professor of Medicine, echoed those comments, pointing to the disproportionate impact on people in the black, Hispanic, and Native American communities, which are up to three times more likely to contract COVID-19. It has highlighted the urgent efforts needed, she said, to address longstanding system health and social inequities.
Moving forward, hospitals need to stay diligent and show patients that it is safe to come back, as the pandemic presses on and the possibility of a second wave looms large over flu season.
“We don’t know what’s in our future,” Lawrence N. Shulman, MD, deputy director for Clinical Services at the Abramson Cancer Center, said in his talk on national efforts around COVID-19 and cancer care. “We need to learn from this experience to carry us forward better next time, and we can confront something like this by working together.”
Watch the full Penn Medicine Cancer and COVID-19 virtual conference on YouTube.