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.
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.
