Cancer and COVID19 - what's the risk?

I've been back in the clinical world for just over a week, and it's been really good to be back with my clinical colleagues.  It feels fully unreasonable that we are being hailed as heroes when we get to leave the house, be busy and engage with other people face-to-face (a safe distance apart).  Everyone is motivated, there is a sense of being 'extra kind' and I think many of us feel lucky that we have employment at this time of immense financial and social uncertainty for so many people.  Yes, it's a bit scary, but aren't we all a bit scared?

I think we can all agree that one reason that COVID19 is so stressful is how uncertain everything this.  This is no less true for cancer patients.  Oncologists and their patients are having to make really tough decisions together about how to proceed based on unknown risk.  Some authors have discussed the process of prioritising treatments - but the idea of stopping or delaying cancer treatment is, of course, every bit as frightening as COVID19 itself.  Cancer IS uncertainty, as everyone who lives with, or works in the area of, cancer will know.

Uncertainty begins even with committing to an anti-cancer treament.  You might have seen my earlier post about cancer clinical trials - for the most part, anti-cancer treatments are approved on the basis of phase 3 clinical trials - that is, big trials involving hundreds or thousands of patients, where the new drug/therapy/treatment is compared with the existing 'gold standard'.  That allows cancer doctors to discuss with patients the likely benefit of any new cancer treatment.  For example, say Wonderdrug works in 20% of patients - that's 20 in every 100 people who received the drug.  What was it about the 20 people that meant they responded to the drug, and the other 80 people didn't?  Maybe (ideally) it's something measurable like a certain marker in the cancer or blood that you can check in advance?  But often we just don't know.  We discuss with patients what we think the benefit might be to them, and discuss the risks of a given therapy.  The issue of side effects, while often known and manageable in general, are also impossible to say with certainty how significant they will be until you start - it's the same problem.  We might know from studies or experience that 20 out of every 100 people get really nauseated from Wonderdrug, but how do we know which 20 people that will be, for example?  So cancer patients live with uncertainty from the moment they get their diagnosis - I'm acutely aware of how this must be one of the toughest, if not THE toughest, thing(s) about cancer.

This isn't just true for oncology, I should say.  This is true for all of medicine and surgery - indeed all of life!  It's all probabilities and likelihoods, balancing risks and benefits.

So then comes COVID19.  Everyone's terrified.  Everyone's scared.  We see the huge number of people worldwide who are suffering from COVID19 infection, and in severe cases ending up in intensive care and/or dying.  Cancer is scary enough, but now this?

The evidence for COVID19 plus cancer right now is limited.  Big analyses of who was worst affected in China and Italy have suggested patients with cancer are more vulnerable with regards to COVID19, but that requires serious context - cancer means many things (advanced or curable? on or off treament? what kind of treatment? other health conditions? etc etc etc).  We need to understand more about about these previous patients so we can make decisions with, and for, future cancer patients.  Clinicians are sharing their experience of COVID19 as quickly as they can, but when you really look closely, the studies of patients who have cancer AND had COVID19 are actually very small.  For example, a study of 1524 cancer patients found 12 patients who developed COVID19, and looked at these more closely.  Another study looked at 1572 patients with COVID19, of whom only 18 had cancer, and another looked at 28 patients with cancer who also had COVID19.  It's a big thing to conclude anything at all from such a small number of cases.

For example, take the study with 12 patients.  Two patients sadly died of COVID19 - that makes a mortality rate of 16.7%.  But what if just one more patient had died, or survived - that would change your mortality rate to 25%, or 8.3% - a huge difference.  And in that particular study, the authors say that one patient actually died of non-COVID19 causes, and only five were having treatment when they got COVID19 (none of whom died). 

So whilst the studies suggest people with cancer are at an increased risk, we need to know more.  Oncologists, like the whole healthcare service, are working incredibly hard to learn, fast, about the risk from having cancer, from anti-cancer treatment, and the mere fact that having anti-cancer treatment means leaving the house and coming into contact with other people.

But the take home message here is: people living with cancer, we've got your back.  It's scary but oncologists are massive evidence nerds. The evidence is coming and we're with you all the way. Stay home, stay safe.



Disclaimer - I would be DELIGHTED if anyone wants to update me with any important references I've missed.  

Roofs and Redeployment

At the time of writing, nearly 30,000 people have been diagnosed with COVID19, and just over 2,300 people have died in the UK.  The NHS has done the biggest reshuffle in its history and my card has been dealt - redeployment is finally here. 

I'm shortly going back to the cancer department, 8 months after I paused my clinical work to start a PhD.  The overarching emotion is relief.  There's also decent dollops of guilt (at the worry it causes my family, and at the time I've been out of the clinical game), anxiety (will I know what to do?) and a general sense of overwhelmedness. 

As discussed, Mr KP works as a doctor in the Emergency Department, so we've already started a system of minimising the risk at home as best we can.  We've established a COVID19 decontamination area in our house, and a system of cleaning our clothes and ourselves when we get home.  We've dug out old pairs of scrubs which we've previously debated throwing away - thank goodness we didn't! - so that I have something to wear when I'm on call (oncologists generally just wear office clothes... until now!).   Like a hospital, we now have COVID zones, just within our own house! 

So much of this feels like mental preparation - personally, that means avoiding the news. Apart from the fact it doesn't change my management plan (I'm still going to be socially distancing... I'm still going to go back to the hospital...), often it's hard to watch the hype.  For example, the hype around escalation and resuscitation decisions.  I think this speaks more to the fact we need to talk about this more in non-COVID times if its headline news that intensivists have to make reasoned decisions about who will benefit from intensive care.  This is no more true now than it was before, although admittedly we all worry about these decisions becoming more challenging.  Perhaps we, as a medical profession, need to learn how best to convey that in times of peace as well as times of war. 

I'm stumbling over the kind messages of support from everyone at the university.  It's quite overwhelming when people keep saying they are proud of you when you haven't even done anything yet.  I certainly don't deserve any praise; it's my clinical colleagues who have been managing the daily changes in policy, rotas and ward movements.  My only positive contribution has been towards a UK-wide coronavirus cancer monitoring project - an attempt to learn as efficiently as possible from cases of covid affecting patients with cancer.  It's been amazing to see a project like this, one that would normally take reams of paperwork and months of admin, get off the ground in a matter of days.  It's reflective of the ability of how the NHS has adapted like never before. 

My PhD swansong will be Journal Club - it has felt somewhat surreal preparing a figure-by-figure analysis of a paper about genetically engineered stem cells whilst simultaneously joining webinars to refresh my understanding about clinically managing COVID.  Maybe someone in journal club will ask me about identifying bilateral pneumonitis on a CXR, or how to interpret an ABG, or vice versa someone in the hospital might want to know about intratumoral genetic heterogeneity?  Unlikely, but a girl can hope!

Life goes on - we've just discovered that our roof will probably require major repairs in the imminent future - and I've got no idea when we'll have time to resolve it.  In reality, it's just going to have to wait until we're the other side of this.  But we're very fortunate - not least to have jobs and ones that keep us busy at that, which I realise not everyone are lucky enough to have. 

So wish us, and our roof, luck.  Fingers crossed we all keep it together in the weeks ahead.

Love in the time of Coronavirus

I have a friend who works as a cruise ship doctor (he's one of life's top humans, by the way. He created the bar for our wedding despite running two businesses and having at least two other jobs. And he is generally chief orchestrator of FUN).  In fact, he's on a cruise ship right now.

Now I know what you're thinking - working on a cruise ship, now? Bold!  And then think that through - can you imagine three months ago thinking that working on a cruise ship could be considered an extreme activity?

It seems prudent to write at this time, if nothing else to serve as part of the record of this once-in-a-lifetime event.  I'm a cancer doctor but as chance would have it, I'm currently a laboratory-based PhD student doing brain cancer research.  I have been doing work on-call (weekends, evenings) since I started in August but basically I'm a scientist in training right now. I feel utterly helpless.  I've had all the support I could dream of in terms of going back to the clinical world, and have indeed been told that I'll probably be drafted in to work clinically.  But it's all about timing, and the time is not now.  For now, I need to try to calm myself and generate some kind of PhD-from-home strategy, and for how long no-one knows.  Meanwhile, Mr KP, who works as an Emergency Doctor, has been living the effects of the day-to-day changing of decisions, policies and patient flow.  Having just finished nights, we've therefore both been at home.  

Mr KP and I are so very lucky.  For one thing, we're a 'we'! Social distancing is a lot more tolerable when there's two of you. And although we are generally not people who talk about work in our home, it's a relief to have someone who understands as much as anyone can right now about how we're going to emotionally deal with this.  Love!  

Our survival strategy - games and gardening!

 

Physical on-your-own isolation must be tough, and I'm reaching out to friends who live alone; but what's been interesting is that this event feels (for me at least), The Opposite of Loneliness.  I've actually had to mute essentially all of my WhatsApp groups and put my phone in another part of the house for large parts of the day.  One evening there were easily 200 messages floating between my two labs and my clinical work WhatsApp groups.  Love, but for me, it's a bit too hot to handle.  

We are incredibly lucky to have such a big group of medical friends who, quite honestly, have been my source of calm in all of this, in spite of the fact they are the very ones on the coalface.  I had a big gathering of my best buds from university in late January (again - timing! Phew!) - forty of us when you include kids, plus a couple of dogs for good measure.  That's the sanest big WhatsApp group of which I'm part.  We've started doing regular video meet ups and it would be a strange irony that being so limited in our ability to physically be together will probably bring us closer together in just about every other way.  Love! Social distancing is so important, but we can find trust and comfort even in physical isolation. For me it's helped me manage my worries about what's ahead.  

Fuelling anxiety helps no-one.  That's what makes it galling when you see the over- or under-playing of the situation either by excessive Twitter anxiety or lack of social distancing respectively.  The result? Anxiety - and actions driven by anxiety - or inaction.  I've seen any number of articles by Dr Blah Blah Blah saying the government strategy is wrong, or it's not enough, or it's too much, or everything in between.  I used to read these articles.  Now I don't.  Why?  Because this is an unprecedented situation, and I am not an expert.  I see in my day-to-day life that uncertainty and ambiguity leads people to be unsure about what to do - so either they fail to change their actions, or feel anxious, or any number of unhelpful things.  We would never trust one individual person's view (our own or someone elses) in our own lines of work, so why do we do so now in an area so complex and multifaceted? Show yourself some love and switch these sources of reading OFF.  

People keep saying to Mr KP in particular that things must be very stressful given his line of work.  Honestly, I think it helps to know that he, and eventually me, are able to be useful.  I appreciate this particularly currently as I feel useLESS.  The need to feel needed is a powerful emotion, and surprisingly stressful.  That in itself makes me feel guilty - and so the cycle continues.  My utility right now is probably to Stay Well, reach out to the lone livers and find a sustainable way of living distantly.  And encourage those I can to Calm Down and #StayTheFHome.  

Rays of light as storm clouds gather

As Hugh Grant (or The Prime Minister) wisely said in That Film - 'General opinion's starting to make out that we live in a world of hatred and greed, but I don't see that. It seems to me that love is everywhere. Often, it's not particularly dignified or newsworthy, but it's always there - fathers and sons, mothers and daughters, husbands and wives, boyfriends, girlfriends, old friends.... If you look for it, I've got a sneaky feeling you'll find that love actually is all around.'

So go and give your loved ones a virtual hug, and thank modern technology that we can!