Use of Immunotherapy in Patients With Cancer During the COVID-19 Pandemic

During this process, type II transmembrane serine protease (TMPRSS2) expression seems to be important as a coadjuvant protein to assist SARS-CoV-2 in cell invasion.3,4 Patients who progress to the severe form of the disease have an inflammatory response that leads to a reduction of the expression of cytotoxic CD8+ and CD4+ T lymphocytes. (IFN-.), as well as others, increase.2,4,5 In this context, as with other viral infections, increased expression of regulatory molecules of inflammatory response, like PD-1 and PD-L1, occurs.2, 4-6 COVID19 and Cancer The morbidity and mortality of COVID-19 is higher in elderly and male patients, as well as in those with comorbidities. [...]only observational studies have raised the possibility of the protective effect of IMT, and further data are required to confirm this hypothesis and use it to guide the management of patients with cancer. In the case of SARS-CoV-2 infection in patients receiving IMT, the risk of cytokine release syndrome is high. [...]the second quandary oncologists face is the challenge to correctly diagnosis SARS-CoV-2 infection or IMT-induced pneumonitis.4,6,11 Another important consideration is controlling immune-related AEs in patients who need long-term immunosuppression therapy.

Building on Telehealth's Momentum

[...]the overwhelming majority of provider organizations had little or no experience with telehealth prior to the pandemic. Because these organizations rely so heavily on fee-for-service reimbursement, the complex regulation of telehealth left them with little curiosity about the technology until COVID-19 struck. Since most of this latter group is waiting to find out what the regulation and reimbursement will look like, the answers will determine what they do next. [...]handwringing about potential fraud by telehealth companies, plus preliminary data on quality of care that offered mixed support for telehealth, became the rationale for a recommendation to limit some of the telehealth expansions to only those clinicians participating in Advanced Payment Models (APMs) rather than to all fee-for-service clinicians.

Ajai Chari, MD, Talks Diversity in Multiple Myeloma Research

[...]as new research results emerge, clinicians are learning to manage the real-world considerations associated with these therapies, from effects on the immune system to concerns surrounding therapy sequencing. For the newly diagnosed patients, you have patients who are bedridden or bed-bound, who within a few months are back to their previous quality of life because the therapeutics are so effective and the symptoms of myeloma can be so rapidly reversed. Can you discuss your recent paper on the effects of COVID-19 on patients with multiple myeloma? I was the lead author [analyzing] a global data set;it was a very collaborative effort looking at COVID-19 outcomes in late 2020.1 We found that the risk factors for worse outcomes in myeloma were older age, renal failure, higher-risk myeloma, and uncontrolled myeloma.

Telehealth 2021: Where Do We Go From Here?

Because of COVID-19 and the inability to get to physicians' offices, the door opened up to telehealth, but we've got to do a lot more. Centers for Medicare & Medicaid Services (CMS) took what they were doing in the rural areas and applied it to a nationwide program. Because of all the health care that they're receiving, they are living longer. [...]if you can build controls that enable even Medicare to look in and make sure that it's a true telehealth session-even with using HIPAA [the Health Insurance Portability and Accountability Act] [privacy rules] as a baseline-you'll see that the economics will be a lot better with telehealth built into the system.

Is Telehealth Here to Stay?

Jeremy Gabrysch, MD, a physician and CEO of Remedy, an on-demand urgent care service that delivers doctors right to your front door, recently spoke with Medical Economics®, a sister publication of ONCOLOGY®, to discuss what the future of telehealth may hold. Fortunately, states and larger organizations are working to improve broadband access and cell phone coverage in many of these areas, because that really is imperative if you're going to be able to deliver care in this way. [...]I will tell you that in the states we serve with Remedy, we see lots of patients who live in the rural areas, patients who might be a decent drive from a brick-and-mortar facility, but they're able to get connected to care using virtual care. There are smaller practices in these rural areas who are relying on fee-for-service income, a lot of times from these office visits.

Delaying Radical Prostatectomy, Cancer Screening, and Care Due to COVID-19

A retrospective analysis published in the Journal of Urology indicated that a delay of up to 12 months did not result in worse outcomes when compared with immediate surgery within 3 months of diagnosis.1 When compared with patients receiving RP within 3 months of diagnosis, patients undergoing surgery 4 to 12 months after diagnosis did not have increased odds of adverse pathology, upgrading on RP, or node-positive disease. The multivariable analysis demonstrated no significant association between surgical delay and upgrading on final specimen (OR, 0.98;95% CI, 0.94-1.02;P = .3), pathologically locally advanced disease (OR, 1.00;95% CI, 0.97-1.03;P = .8), need for adjuvant therapy (OR, 0.96;95% CI, 0.84-1.11;P = .6), or lymph node invasion (OR, 0.88;95% CI, 0.77-1.01;P = .07). While the investigators noted that most men in the study were operated on within a postdiagnosis period of close to 3 months, and they warned of extrapolating the results for much longer treatment delays, similar studies demonstrated that proposals of delays of up to 6 months for high-risk disease were reasonable, while low-and intermediate-risk groups could be delayed further.

Contextualizing COVID-19 Consequences for Cancer Care

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly escalated to a pandemic with significant morbidity and mortality resulting from the associated coronavirus disease 2019 (COVID-19).1 Approximately one-third of patients developing COVID-19 experienced severe complications, including acute respiratory distress syndrome, acute renal failure, acute respiratory injury, septic shock, and severe pneumonia.2 Populations particularly vulnerable to COVID-19 include older adults and immunosuppressed patients. [...]when we looked at some of the early data about which patients are going to have increased mortality from COVID-19, it was those individuals who had cardiovascular disease or diabetes. [...]we have pulled together as an oncology community to determine the safety measures that we can put in place to ensure that someone who may potentially have a cancer diagnosis, or maybe they need a diagnostic image because they felt a lump in their breast or had symptoms related to colorectal cancer, we know cancer doesn't stop because of COVID-19. Regarding chemotherapies and those that reduce the immune system, people will say that any cancer treatment can impact the immune system, and they're right. When it comes to systemic therapies, in addition to those that actually reduce your blood counts and have impact on marrow or impact marrow suppression, there are also data to suggest that immune checkpoint inhibitors like the PD-L1 and the PD-1 Inhibitors may be associated with worse outcomes and may actually be associated with increased morbidity and mortality, although it's fascinating because there was another study seemed to contradict these results.9,10 But all the data that we have suggest that patients getting new checkpoint inhibitors as part of their care may be at increased risk.

Looking Ahead: What's Next for Hematology/Oncology in 2022?

[...]because of the pandemic, many centers are experiencing staffing shortages in their clinical trial offices, leading to longer times for opening trials and, in some cases, halting new enrollments. Tixagevimab in combination with cilgavimab (Evusheld) is a new SARS-CoV-2 spike protein-directed attachment inhibitor that has gained emergency use authorization for individuals who are moderately to severely immunocompromised because of immunosuppressive medications or treatments and may not mount an adequate immune response to COVID-19 vaccination. Clinical trials of this monoclonal antibody combination showed a reduction in symptomatic SARS-CoV-2 illness as well as severe illness or death in the treatment arm.

Delay in Cancer Screening and Diagnosis During the COVID-19 Pandemic: What Is the Cost?

[...]standard cancer screening such as breast cancer screenings dropped by 89.2% and colorectal cancer screenings dropped by 84.5% through May 2020.1 These pandemic control efforts translated into a significant decline in the number of new cancer diagnoses, resulting in a decrease of 65.2% incidence of new cancer diagnoses in April 2020.1 In evaluating specific types of cancer diagnosis, patients with a new diagnosis of melanoma dropped 67.1% in April 2020 compared with 2019 and a diagnosis of a new lung cancer which dropped 46.8% over the same time.1 This study and others have demonstrated an alarming decrease in the diagnosis of new cancers which will potentially increase the number of patients with later-stage cancers leading to decreased survival for these patients.2,3 Using National Health Service (NHS) data on cancer diagnosis and hospital administrative datasets, the investigators' modeling study evaluated estimated changes in future death rates. Across different scenarios as compared with prepandemic figures, the investigators estimated a 7.9% to 9.5% increase in deaths from breast cancer up to 5 years from diagnosis.3 In addition, a 15.5% to 16.6% increase in colorectal cancer deaths and a 4.8% to 5.3 % increase in lung cancer deaths were estimated.3 In addition to health care facilities decreasing routine screening and nonurgent surgeries to increase capacity for patients with COVID-19 complications, patients themselves have in some cases expressed concern about visiting the health care facilities to do routine cancer screenings for fear of COVID-19 exposure. Prior to the COVID-19 pandemic, the US cancer statistics had continued to improve over the last few decades including a 25% drop in cancer mortality over the past 25 years.4 However, with less cancer screening comes the potential for malignancies to be diagnosed at a later stage.

2021 American Society of Hematology: Program Highlights

Throughout the meeting, a number of awards and lectureships based upon the awardees' work were presented, including: P Wallace H. Coulter Award for Lifetime Achievement in Hematology to Harvey F. Lodish, PhD, professor of biology and biomedical engineering at Whitehead Institute for Biomedical Research and Massachusetts Institute of Technology, for his key contributions and studies of the structure and biogenesis of red blood cells;P Ernest Beutler Basic Science Award to Margaret A. Shipp, MD, director of the Dana-Farber/Harvard Cancer Center Lymphoma Research Program, for her work on the genetic basis of PD-1-mediated immune evasion in Hodgkin lymphoma and primary mediastinal B-cell lymphoma;and P Ernest Beutler Translational/Clinical Award to Stephen M. Ansell, MD, PhD, chair of the Mayo Clinic Lymphoma Group, for his work in understanding the tumor microenvironment in lymphomas, including PD-1 blockade. A focus on diversity, equity, and inclusion included informative sessions on barriers to clinical trial design and enrollment, availability of transplantation to minority patients, race and science, and lessons from a global pandemic. Topics of s in the plenary session included: P SARS-CoV-2 and the pathologic mechanism of prothrombotic events caused by the virus;P Studies of the molecular landscape of TP53-mutated leukemic transformation in myeloproliferative neoplasms;P Primary analysis of the ZUMA-7 study (NCT03391466): a phase 3 randomized trial of axicabtagene ciloleucel (axi-cel) versus standardof-care therapy in patients with relapsed/refractory large B-cell lymphoma;P Efficacy and safety of fitusiran, an siRNA therapeutic, in a multicenter phase 3 study in individuals with hemophilia A or B, with inhibitors;P Decreased risk of Alzheimer disease in patients with clonal hematopoiesis of indeterminate potential;and P Profiling of circulating tumor DNA for noninvasive disease detection, risk stratification, and minimal residual disease monitoring in patients with central nervous system lymphoma.

The Future of Telehealth for Hematology/Oncology Care

Telehealth as a method of health care delivery has taken on greater significance due to the COVID-19 pandemic, as well as for its ability to increase access to care for those who live greater distances from their doctor's office and those unable to leave their homes. Under its section 1335 waiver authority, the Centers for Medicare & Medicaid Services (CMS) approved temporary expansion of telehealth services during the public health emergency (PHE) to a patient's place of residence. With hematology/oncology care facilities located in cities close to state lines or rural areas, telehealth video and telephone visits have been a great improvement for patient care.

Addressing Stress and Burnout in Hematology/Oncology Physicians

Practice changes during the pandemic have included treatment delays and modifications, clinical trial suspensions or delays, isolation of patients without family support, and increased use of telehealth care. [...]promoting flexibility, fostering resiliency, and encouraging good work/life balance are other key components of successful intervention. A randomized controlled trial evaluating the effect of COMP ASS (COlleagues Meeting to Promote and Sustain Satisfaction) small group sessions on physician well-being, meaning, and job satisfaction.

Copper Deficiency Mimicking Myelodysplastic Syndrome: Zinc Supplementation in the Setting of COVID-19

While copper deficiency is rare, it can have serious consequences, including pancytopenia and neuropathy. This treatable micronutrient deficiency can present very similarly to myelodysplastic syndrome (MDS), a group of myeloid neoplasms which can carry devastating prognoses. Copper deficiency is an essential differential diagnosis in suspected MDS, as it can present with similar laboratory findings, bone marrow biopsy, and clinical picture. While copper deficiency has multiple potential causes, it typically occurs in patients with a predisposing gastrointestinal pathology. One possible cause of copper deficiency is zinc overload. Interestingly, zinc over-supplementation has been prevalent during the COVID-19 pandemic, as some believe that zinc can help prevent COVID-19 infection. Multiple case reports have illustrated the similarities between copper deficiency and MDS. They have also highlighted zinc over-supplementation as a potential cause. The following case report is unique in that our patient lacked gastrointestinal pathology. He still presented with the clinical and laboratory findings of MDS in the setting of copper deficiency. These include anemia, leukopenia, fatigue, and neuropathy. Further, this deficiency was caused by zinc over-supplementation in efforts to prevent COVID-19. The deficiency and the accompanying symptoms were treated with copper supplementation and cessation of zinc intake.

Advanced Technology Will Help Drive Reimbursement Change

According to McKinsey & Company, United States consumer telehealth adoption has skyrocketed from 11% in 2019 to 46% currently. In addition to the explosion of telehealth usage by patients covered by both Medicare and commercial health plans, US policy makers have also embraced reimbursement for additional technologyenhanced methods to remotely monitor patients and identify those who could have care intervention prior to deterioration, and potentially prevent a full clinical deterioration. Continuous remote patient monitoring (cRPM) is an important addition to traditional telehealth sessions for patients with chronic health issues. cRPM continuously monitors vital signs while the patient is at home and alerts the provider if health deterioration begins to occur-often before the patient feels any symptoms.

The Negative Impact of the COVID-19 Pandemic on Oncology Care at an Academic Cancer Referral Center

Methods Patient Cohort Under a protocol approved by the University Hospitals Seidman Cancer Center Institutional Review Board, a search of all appointment data from patients with cancer in the in the Seidman Cancer Center was performed. For each of the 4 groups of appointment types, rates of cancellation (cancellation count divided by appointment count) were stratified by age group (0-39 years, 40-64 years, 65 years or older),10 sex (male or female), and race (White, Black, or other) on a monthly basis. Descriptive statistics were used to assess any association of cancellation rate between 2019 and 2020 for both overall data, and stratified by age group, sex, and race for each appointment type respectively, where the ÷2 test of independence was used for comparison. The trend comparison of appointment rates was also examined by trend plot both for overall data and stratified by age group, sex, and race for each appointment type respectively.

Are COVID-19 Delays a Basis for Concern? Can We Use This for Future Good?

For all but the most severe cases of localized prostate cancer, modest delay of 2 to 6 months is unlikely to affect long-term survival. Prostate cancer screening with the prostate-specific antigen (PSA) blood test has been controversial and hotly debated since 2011, when the US Preventive Services Task Force (USPSTF) gave PSA screening a "D" rating (more harm than good).12 Many advocates for patients with prostate cancer feel this rating was misguided by poor or immature data from 2 randomized controlled trials. In our practice, we began partnering with our Duke primary care network in 2018 (corresponding to the USPSTF change) to reengage prostate cancer awareness and PSA screening, focusing on our large minority high-risk population.