#SoMe Peeps, please verify info before sharing

woman having a video call

Photo by Edward Jenner on Pexels.com

In this time of fear and uncertainty regarding COVID-19, please verify info before sharing.

I just read an article being circulated on social media that originally appeared on Medium.com (which states “Anyone can publish on Medium per our Policies, but we don’t fact-check every story”). Medium deleted it. Yet people are pulling it out of webarchive and circulating it anyway.

The information in the article was flat out FAKE. Some clues it was not reliable info:

  • The author was anonymous (never a good sign in articles claiming to offer scientific information)
  • The author offered no medical or scientific credentials
  • The author offered no sources for their “facts”
  • With just a little effort, it was easy to discover “facts” in the article contradicted information found in reliable sources such as the CDC, WHO, and major scientific journals.

Here’s a good guide for evaluating the validity of health information online.

The best way to fight fear is with facts.  Let’s get them right.

P.S. If you have to find a recently-published article on webarchive instead of its original site, it’s a good bet the article got something seriously wrong.

On #COVID19, ventilators and triage

This Photo by Unknown Author is licensed under CC BY-SA-NC

In the age of COVID-19, patients may find themselves in a hospital or emergency department that does not have enough resources to give ICU beds or ventilators to all patients who need them. In an attempt to prepare for such a situation, some hospitals drafted “triage” policies that state who would be prioritized to receive a ventilator or ICU bed.

I want to share my perspective on triage as a both a science geek and a metastatic lung cancer patient in active treatment.

A not-yet-implemented triage policy from the Henry Ford Healthcare System in Michigan was shared online in late March, and caused an uproar in social media.  The metastatic cancer community learned that if resources were limited and that policy were in force, they would be denied a ventilator, along with those who had severe heart, lung, kidney or liver failure, or severe trauma or burns.  Over the next several days, other triage policies surfaced (some that included dementia or disability as a reason to deny care).  Articles about triage policy appeared in medical journalsopinion pieces, and general media.

Many of my fellow lung cancer patients are horrified by the impact such triage policies would have on their lives.  I too am worried about the possibility of not receiving treatment simply because I have metastatic lung cancer.

The lung cancer community has been battling treatment nihilism for years. It angers us—and rightly so—whenever we hear that someone did not receive the most effective treatment available simply because a doctor was unaware of changing statistics in lung cancer survival or the terrific response rate to targeted therapy or immune checkpoint inhibitors.

But this triage thing is not a matter of doctors being unaware of changes in lung cancer treatment, or not believing cancer patients deserve to live. This is an issue of resource shortages. Everyone deserves to live, but emotional pleas don’t give doctors a way to make a fair choice about who lives and who dies.

Reality check:  COVID-19 is redesigning hospital services out of necessity. Surgery theaters are being converted to ICUs. Hospital staffing is being reduced in an attempt to keep healthcare workers healthy and sane. Ventilators are in short supply.  When two patients need a ventilator-equipped ICU bed (whether they suffer from severe COVID-19 pneumonia or a heart attack), and only one bed or ventilator is available, someone will have to decide who gets the scarce resource. The patient who gets it will hopefully live. The patient who doesn’t will probably die. It’s a horrible Sophie’s Choice for healthcare providers who took the hippocratic oath.

This is not a human rights violation. It’s a medical ethics problem born of resource shortages. How should the medical world decide who lives and who dies?  Obviously, no one wants to hear that they are the one who will likely die.  But simply saying everyone has an equal right to life does not solve the resource problem.  We need a fair way to make a gut wrenching, impossible decision.

How can we make a fair decision? One possibility is to assess who is most likely to survive if they were given the respirator. The problem is, we don’t have much data to use in making this assessment. We have some data that cancer patients who get really sick with COVID-19 are less likely to survive, but only a few of those had lung cancer, so it’s not a good sample size on which to base a decision. We have some data that shows people who are 80+ years old are unlikely to survive COVID-19 once their disease has progressed to the point of needing a ventilator.  Thus one could say that when having to choose between a 20-year-old and an 80-year-old, all other things being equal, the younger patient has a better chance of survival and so gets the ventilator.  But what if the younger patient has metastatic pancreatic cancer and no cancer treatment is likely to work for them?  Then the choice isn’t so easy.

The US healthcare system—certainly most healthcare providers—have never faced these sorts of decisions before.  They need time to figure it out. Hospitals are attempting to create triage policies so that individual doctors are not continually faced with violating their Hippocratic Oath by deciding who lives and who dies. Our healthcare providers are already under tremendous pressure by long hours, patient overload, watching patients die alone without being able to offer a comforting touch, being repeatedly exposed to COVID-19 due to lack of personal protective equipment, and separation from their families to avoid infecting their loved ones.  They could use some guidelines.

In the March 28 Axiom Zoom webinar on “COVID-19 and the Impact on Thoracic Oncology” (recording available here), I asked the the assembled thoracic oncology experts what they tell their lung cancer patients (especially those with metastatic disease) who are scared that they will be denied treatment simply because of their lung cancer diagnosis. The doctors acknowledged that they too were concerned about this. One surgeon emphasized that doctors must continue advocating for their lung cancer patients to fight the historic nihilism faced by lung cancer patients. Another stated the importance of informing all critical care team members about the improved prognosis for lung cancer patients so that they wouldn’t be automatically left untreated. But no one had a solution that would solve the problem as a whole.

In the follow-up Axiom webinar on April 4 titled “COVID-19 and The Impact on Cancer Patients” (recording available soon), the doctors addressed the topic again. One doctor said she wrote a clinic note for each cancer patient, which the patient could download online and print to keep with them. She didn’t elaborate on the contents of the note, but presumably, the note listed the patient’s diagnosis, treatment and prognosis.

This raises another ethics issue.  What if that patient has a poor prognosis?  What if that patient doesn’t WANT to know their prognosis?  What if the patient is in a clinical trial and the doctor doesn’t know their prognosis?

While some lung cancer patients (such as myself) have had long runs with no evidence of disease on targeted therapy or immunotherapy, there are still many for whom prognosis is not so rosy: Patients who have extensive small cell lung cancer that has progressed after chemo. Patients who have oncogene-driven lung cancers and have blown through all their treatment options. Patients whose cancer is progressing rapidly despite immunotherapy. Patients, advocates, and advocacy organizations won’t have any credibility if we claim that all lung cancer patients have the same likelihood of surviving a severe case of COVID-19 as a healthy person.

Lung cancer patients are not the only group facing discrimination via triage.  This also affects people with disabilities, elders with dementia, children with heart issues, diabetics on insulin, and many others.  I don’t feel right saying lung cancer patients deserve a chance to live, but these other people don’t.  I support the statement published by the Disability Rights Education & Defense Fund (DREDF), The ARC of the United States, and many other disease and disability advocacy organizations (including the GO2 Foundation for Lung Cancer and LUNGevity Foundation) titled “Applying HHS’S Guidance For States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing.” This is the sort of reasoned ethics discussion needed to help the medical community develop guidance on this tough topic.

Speaking as a member of a special interest group (metastatic lung cancer patients), this is a time to search for solutions that are right for EVERYONE, not just for one special interest group. I don’t think my right to live outweighs anyone else’s right to live. Ethically, when resources are limited, decisions on who gets care should be based on who has the better chance of survival based on available facts.  This is a very sensitive issue that could have a significant impact on how patients AND the medical community view lung cancer advocacy organizations.

I prefer to seek solutions to problems that work for the community as a whole. News flash: we are ALL going to die someday–and none of us know when. Patients living with advanced and metastatic lung cancer have become experts on living well despite uncertainty. You can take some steps to make the uncertainty easier for you and those you love.

  1. Identify which events or activities make your life worth living. Is it walking in the woods every day? Visiting distant family? Watching your youngest child graduate from kindergarten? Having lunch with a good friend? Indulging a good book? Petting the cat? Write all of them down, and then make plans to help them happen.
  2. Have an honest discussion with your doctor about your health status, goals of care (see #1), and prognosis. Ask if you are immunocompromised, have scarred lungs or limited breathing capacity, or are at risk of complications if put on a ventilator. Be honest about your fears and your health challenges.
  3. Ask your doctor to provide you with a BRIEF letter (2-3 sentences at most) on letterhead, signed and dated, stating your diagnosis and prognosis. Carry a copy with you in case you must go to the hospital. (It must be brief, or no ED doc will read it).
  4. Think about how you would prefer the end of life to look. Talk with your family NOW about your preferences–if disaster strikes, you might not have another chance. If you need help getting started, visit The Conversation Project.
  5. Prepare legal estate documents, especially a Durable Power of Attorney and Advanced Healthcare Directive. Learn more from the National Institute on Aging.  There are ways to do this even if you are Sheltering at Home during the pandemic–check out “Estate Planning Goes Digital as Many Families Explore Options.”

We can’t control the COVID-19 pandemic, lung cancer, or medical resource shortages. However, we CAN control how we react to them.  Prepare. Stay home. Practice social distancing. Wash your hands. And stay as healthy as you can.

April 6, 2020 Update to the Joint Statement on #Coronavirus #COVID19 From #LungCancer Advocacy Groups

The post below is shared with permission. It can also be found on the websites of the lung cancer advocacy organizations listed at the end of this blog post.

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The number of confirmed cases of COVID-19 continues to grow in the US. As of April 5, 2020, there are 312,089 confirmed cases of COVID-19 in the US. These numbers may be an underestimation of the true burden of the disease due to lack of testing and a high proportion of asymptomatic yet infectious individuals.

To get a real-time understanding of the cases in the US, you can access the map through The New York Times.

In this week’s update, we answer the following important questions:

  1. Is social distancing working?
  2. Do I continue to social distance?
  3. Do I leave my city to go to someplace safe — such as a rural area?
  4. Should I use homemade masks to protect myself?
  5. Can I travel within the United States?

 

  1. Is social distancing working?

 YES, IT IS!  Washington and California quickly imposed state-wide social distancing through stringent shelter-in-place or Stay at Home policies once deaths occurred within their borders.  The graph below shows that COVID-19 deaths are still increasing in these two states, but not as fast as in other states. Deaths in New York State are doubling every 2 days, but in Washington State deaths are doubling only every 7 days.

The most up-to-date version of the graph below can be accessed from the New York Times website here.

 The CDC continues to recommend social distancing to help decrease transmission of COVID-19 within the community.  Social distancing measures, such as cancelling public gatherings and avoiding crowds, can slow the spread of the virus and spread cases out over a longer period of time, which can help hospitals provide care while avoiding being overwhelmed by patients. Social distancing helps “flatten the curve” in the spread of an infectious disease.

This is especially critical because hospitals and health systems are working at full capacity. Flattening the curve ensures that systems are functional and people who require care the most can get the attention they need. The CDC recommends a distance of 6 feet or 2 meters as the minimum distance between individuals as part of COVID-19 mitigation strategy.

We encourage you to check out CDC’s COVID-19 community mitigation strategies here.

 

  1. Do I continue to social distance?

YES, social distancing is currently the only known public health measure that can protect us from SARS-CoV-2. Social distancing minimizes risk of exposure to the virus. It is important to keep in mind that social distancing is NOT the same as social isolation. We encourage you to keep in touch with all your family, friends, and loved ones through phone and video conversations. Just because we are social distancing doesn’t mean we have to be socially isolated.

Social distancing is different from self-quarantine. Self-quarantine should be practiced by people who have been exposed to SARS-CoV-2 and who are at risk for coming down with COVID-19. It involves:

  • Using standard hygiene such as frequently washing your hands and not touching your face
  • Not sharing things like towels and utensils with other people who share the same household
  • Staying at home and not having any visitors
  • Staying at least 6 feet away from other people in your household

You do not need to have symptoms of COVID-19 to self-quarantine. Caregivers who have travelled or are leaving their homes frequently to run errands may choose to self-quarantine especially in COVID-19 hot zones.

 

  1. Do I leave my city to go to someplace safe — such as a rural area?

NO! You should not be leaving your urban apartment or home and move to a rural area for the following reasons:

  • You do not know if you or a loved one has been infected with SARS-CoV-2. An infected individual might not have any symptoms but still can continue to infect others
  • You may not have access to your regular doctors and healthcare in a rural setting
  • Small rural areas are not equipped to handle an influx of people. They may not have adequate number of grocery and produce stores. More importantly, they may not have adequate medical care facilities should there be an emergency

Do not indulge in “disaster gentrification” for your own safety, the safety of your loved ones, and that of other community members. It is our duty to keep rural communities insulated from this disease as much as possible.

 

  1. Should I use homemade masks to protect myself?

YES! The CDC reports that a significant portion of individuals with COVID-19 lack symptoms (“asymptomatic”) and that even those who eventually develop symptoms (“pre-symptomatic”) can transmit the virus to others before showing symptoms.  This means that the virus can spread between people interacting in close proximity—for example, speaking, coughing, or sneezing—even if those people are not exhibiting symptoms.  In light of this new evidence, CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission.

Masks should be worn in conjunction with maintaining adequate social distancing. It is also important to keep in mind that these face masks are not surgical masks or N95 masks (to be used primarily by healthcare works as part of personal protective equipment).

Please watch this handy video to make your own homemade masks:

 

  1. Should I travel within the US?

Though the CDC does not typically make suggestions about domestic travel, they highly recommend avoiding all non-essential travel within the US. Several cities and states already have a shelter-in-place order. Points to keep in mind should you need to consider domestic travel (from the CDC):

  • Is COVID-19 present in your home community? If so, avoid traveling to avoid spreading the virus. You might be required to enter quarantine at your destination.
  • Is COVID-19 spreading in the area where I am travelling to?
  • Will you or your travel companion(s) be in close contact with others during your trip?
  • Are you or your travel companion(s) more likely to get severe illness if you get COVID-19?
  • Do you have a plan for taking time off from work in case you are told to stay home for 14 days for self-monitoring or if you get sick with COVID-19?
  • Do you live with someone who is older or has a serious, chronic medical condition (especially important for caregivers)?

 

Resources and websites:

  1. IASLC’s Guide to COVID-19 and Lung Cancer
    https://www.lungcancernews.org/iaslcs-guide-to-covid-19-and-lung-cancer/
  1. The National Cancer Institute has a special website for COVID-19 and emergency preparedness. COVID-19: What People with Cancer Should Know – https://www.cancer.gov/contact/emergency-preparedness/COVID-19
  2. We are following updates provided by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), which can be found here:
  1. Johns Hopkins COVID-19 Resource Center is one of the best places to get current updates. https://COVID-19.jhu.edu/
  2. Interactive map of US COVID-19 cases by statehttps://www.politico.com/interactives/2020/COVID-19-testing-by-state-chart-of-new-cases/
  3. The One-Two Punch: Cancer And COVID-19 (an important perspective for cancer patients) – https://www.forbes.com/sites/miriamknoll/2020/03/20/the-one-two-punch-cancer-and-COVID-19/#73744a4358e6
  4. You can find information specific to your state or city or town on your health department’s website.
  1. The American Medical Association is also maintaining a resource website for healthcare providers. You can find more information here:
    https://www.ama-assn.org/delivering-care/public-health/covid-19-2019-novel-COVID-19-resource-center-physicians
  2. If you cannot avoid air travel, check out this handy article on “Dirtiest Places on Airplanes: How to Avoid Germs
    https://time.com/4877041/dirtiest-places-on-airplanes/


GO2 Foundation for Lung Cancer
(Amy Moore, PhD amoore@go2foundation.org )
LUNGevity Foundation (Upal Basu Roy, PhD, MPH ubasuroy@lungevity.org )
Lung Cancer Foundation of America (Kim Norris KNorris@lcfamerica.org )
Lung Cancer Research Foundation (Jan Baranski, PhD jbaranski@lcrf.org)
LungCAN (Kimberly Lester kimberly@lungcan.org)

“Disaster gentrification” is now a thing

“Disaster gentrification” has become a thing.

When people flee urban areas to second homes or rural areas to avoid the COVID-19 pandemic, they put the locals who live permanently in the area of their “disaster” home at risk, and strain local services. Small town groceries are not designed to supply large populations. Small town medical center are not equipped to handle several (if any) critically ill people. Rural Internet does not have the capacity to support work from home or streaming video.

“Shelter in Place” and “Stay at Home” do not translate as “travel to an escape home.” You’re supposed to stay put and avoid spreading the disease.

It doesn’t matter that you feel healthy. Current estimates say 50% of people who are infected with the novel coronavirus will exhibit absolutely no symptoms, yet they are still able to spread COVID-19 to others. And some who feel healthy today might develop symptoms in the next two weeks.

Stay home. Stay safe. Save lives.

The article below is long, but worth the read.

This Pandemic Is Not Your Vacation (Buzzfeed 31-Mar-2020)

#COVID19 and #lungcancer #Surgery: A Q&A with @BrendonStilesMD

The post below is shared with permission. It can also be found on the websites of the lung cancer advocacy organizations listed at the end of this blog post.

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COVID-19 and surgery: How long can I wait? – April 2, 2020 Update

This update has been written in collaboration with Dr. Brendon Stiles. He is a thoracic surgeon at New York-Presbyterian Hospital and an Associate Professor of Cardiothoracic Surgery at Weill Cornell Medicine.

That question must be on the mind of many lung cancer patients as they consider treatment during the COVID-19 pandemic.  We are currently in the middle of an unprecedented crisis that has left hospitals short on resources and personnel.  That has led to shutting down “elective” surgical cases (surgeries that are not considered to be of medical emergency) at many hospitals, particularly in places such as New York City that are COVID-19 hotzones.

Are cancer cases truly “elective”?  And how long can patients and their surgeons actually wait? 

We don’t have a lot of data making a strong case for waiting or not waiting.  Some lung cancer-specific data suggests that the decision should be made based on how “quickly” the lung cancer grows. It takes on average 13.2 years for a lung adenocarcinoma to get to 1 cm in size and 14.4 years to get to 3 cm.  While other subtypes of lung cancer and other cancers may move much more quickly, this would obviously suggest that there is some time allowable prior to treatment for many cancers.  In that context, postponing surgery a few weeks or months may outweigh the risks of exposure to COVID-19. It is however unclear what is the appropriate waiting time for each individual patient.   Most studies have suggested that for early stage lung cancer, there is some risk of tumor progression that comes with delayed treatment.  That said, the risk appears to be small and not particularly predictable.  At this time for hospitals which still have resources, the American College of Surgery recommends surgical resection as soon as feasible for patients with solid or predominantly solid cancer over 2 cm in size, while it recommends deferring lung cancer resection even in these hospitals for tumors less than 2 cm or for those that are predominantly ground glass.

In the current situation, patients with early stage lung cancer should also consider alternatives to surgical resection.  This is particularly true in areas that are the most affected by COVID-19, where surgery may not be an option for an extended time period.  Outpatient centers likely have less exposures than inpatient where we know there are many COVID patients.  Also, patients spend less time in radiation treatment facilities.  Finally, radiation (at least early on) preserves lung function and doesn’t risk immediate decrease in lung capacity which may put patients at risk for more complications should they become infected. Good data is available on the efficacy of stereotactic ablative radiotherapy (SABR or SBRT) for the treatment of early stage lung cancer.  It is also worth noting that radiation, particularly stereotactic, doesn’t preclude surgery down the road.

It is not clear how data on treatment delay can be applied to patients with later stage disease.  Certainly patients with clear cut stage II or III lung cancer could be started on outpatient chemotherapy or chemoradiation with surgery pushed down the road several months if needed

GO2 Foundation for Lung Cancer (Amy Moore, PhD amoore@go2foundation.org )
LUNGevity Foundation (Upal Basu Roy, PhD, MPH ubasuroy@lungevity.org )
Lung Cancer Foundation of America (Kim Norris KNorris@lcfamerica.org )
Lung Cancer Research Foundation (Jan Baranski, PhD jbaranski@lcrf.org)
LungCAN (Kimberly Lester kimberly@lungcan.org)

March 30, 2020 Update to the Joint Statement on #Coronavirus #COVID19 From #LungCancer Advocacy Groups

The post below is shared with permission. It can also be found on the websites of the lung cancer advocacy organizations listed at the end of this blog post.

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As of March 30, 2020, cases of the virus surge in countries around the world. The United States now has the highest number of COVID-19 cases globally. The CDC has issued a travel advisory for the New York tri-state area, which has the highest number of cases in the country.

In this week’s update, we discuss lung cancer treatment and clinical trials in the era of COVID-19. The information presented in this update, though current, is a work-in-progress built on very little data. Implementation across institutions and trial sites will vary based on availability of resources and healthcare workers.

Also, please don’t forget to check out the Resources list.

Lung cancer treatment and COVID-19

The oncology community is currently balancing treatment decisions for lung cancer patients, in light of the COVID-19 pandemic. Two factors are being used to decide what’s best for our patients:

  • Whether a delay in cancer diagnostic tests or treatment presents more risk than potential COVID-19 exposure in the clinic
  • Whether a difference in treatment approach can help reduce clinic visits and interactions with others

The CDC continues to recommend social distancing to help decrease transmission of COVID-19 within the community. Social distancing measures, such as cancelling public gatherings and avoiding crowds, can slow the spread of the virus and spread cases out over a longer period of time, which can help hospitals provide care while avoiding being overwhelmed by patients. Social distancing helps “flatten the curve” in the spread of an infectious disease. This is especially critical because hospitals and health systems are working at full capacity. Flattening the curve ensures that systems are functional and people who require care the most can get the attention they need. The CDC recommends a distance of 6 feet or 2 meters as the minimum distance between individuals as part of COVID-19 mitigation strategy.

Currently, lung cancer patients may need to engage with the oncology care system for the following reasons:

  • clinic visits
  • tissue and liquid biopsies
  • surgical procedures
  • infusion sessions for chemotherapy or immunotherapy (or both)
  • refill targeted therapy drugs
  • radiation treatments
  • hospital admissions
  • blood draws for laboratory tests, and
  • imaging tests to check if treatments are working

Also, family members may sometimes accompany patients when they are visiting their doctors.

Recent studies out of China suggest that hospital admissions and repeated clinic visits increase the risk of COVID-19 exposure for patients. Further, a JAMA Oncology study reported that the infection risk for cancer patients in a tertiary care institution was 2-fold higher than the cumulative incidence observed in the city of Wuhan over the same time period. In light of these data and the rapidly evolving COVID-19 pandemic, the oncology community has come up with the following suggestions for cancer treatment. Please be advised that these recommendations are subject to change.

Small Cell Lung Cancer (SCLC):

If you have a confirmed diagnosis, you may not wish to delay treatment (such as chemotherapy and radiation). You and your doctor should discuss what’s right for you.

Early stage non-small cell lung cancer (NSCLC) (Stage I to IIIB):

  • If you have already had surgery, your doctor may decide to not start with adjuvant chemotherapy and/or radiation.
  • If you have not yet had surgery, you and your doctor may decide to wait on the surgery or your doctor may suggest stereotactic body radiation therapy (SBRT).
  • If you are currently having chemo-radiation, your doctor may decide to continue with your treatment or wait on additional treatment.

Advanced stage non-small cell lung cancer (NSCLC) (Stage IIIC-IV):

  • If you are on a targeted therapy (pill), you may continue with your treatment as planned. Make sure to check with your doctor and pharmacist to ensure an adequate supply of your cancer medication.
  • If you are already on immunotherapy or chemotherapy, your doctor may decide to continue with your treatment, space out infusions, or postpone treatment. They may decide to have you receive infusions at your local clinic or even home infusion, as needed.
  • If you are already undergoing radiation therapy, your doctor may choose to hold off on additional treatment, reduce the number of treatments, or keep you on treatment as planned, based on your individual health situation. 

Several recent forums have discussed the management of lung cancer during the COVID-19 pandemic. Topics that are currently being addressed by lung cancer providers/thought leaders include:

  • How to determine whether pneumonitis is resulting from checkpoint inhibitor or COVID-19 infection
  • Should immunotherapy be withheld from patients whose tumors do not have known driver mutations (as determined by molecular testing)?
  • Spacing out or postponing infusions for patients on pemetrexed or immunotherapy maintenance
  • Reducing the number of fractions used in radiation therapy
  • Uncertainty regarding how COVID-19 treatments in clinical trials (such as remdesivir and hydroxychloroquine) may interact with immunotherapy drugs and tyrosine kinase inhibitors
  • The growing role for liquid biopsies in places where surgical biopsies are not currently practical (use of mobile phlebotomy too)
  • Challenges of spacing out chemotherapy schedules in light of current reimbursement
  • Growing role for telemedicine (effective for managing patients but loss of doctor-patient bond)
  • Educating others on their care teams to overcome lung cancer nihilism and stigma

All treatment decisions should be made jointly by you and your doctor. Do not change your treatment plan or doctor’s visit without consulting your doctor first.

Telehealth or remote consults may be an option for checking in with your doctor. Also, there may be the option to be referred to a “COVID-19-free” hospital or treatment center.

Clinical trials and COVID-19

Clinical trials continue to be a source of life-saving therapies for lung cancer patients. The COVID-19 pandemic has affected the conduct of clinical trials due to the following reasons:

  • Questions related to safety of patients traveling to trial sites and undergoing trial-related procedures
  • Potential shortage of healthcare providers to conduct trial-related activities
  • Interruptions to the supply chain of the drug(s) being tested

The US Food and Drug Administration has recently issued guidance to help clinical trial sponsors figure out the best approaches to ensure that trials can proceed within resource-constrained settings. A clinical trial sponsor in this case is defined as any entity (for example, a pharmaceutical company) involved in the development and testing of drugs and other interventions in clinical trials. Below we have summarized key points from the FDA guidance that are important from the patient perspective.

For clinical trials that are already ongoing:

  • Sponsors should consider each circumstance, assess the potential impact on the safety of trial, and modify study conduct accordingly. Decisions regarding this could include continuing trial recruitment, continuing use of the new drug(s) for patients already involved in the trial, and the need to change patient monitoring schedules throughout the trial. Clinical trial participants should be kept updated on any changes that a sponsor decides to implement.
  • Sponsors, doctors involved in the trials, and Institutional Review Boards (IRBs) may decide that the protection of a patient’s safety, welfare, and rights would be best served by continuing or by discontinuing use of the investigational product or participation in the trial. However, such decisions will depend on the specific circumstances of the clinical trial and the patients enrolled.
  • Given that trial participants may be unable to come to investigational sites due to protocol-specified visits, sponsors should assess whether alternative methods for safety evaluations could be implemented when necessary and feasible. Additionally, in deciding to continue or discontinue use or administration of the new drug(s), sponsors should consider whether the safety of participants can be ensured by implementing the alternative approach of monitoring such as local scans and blood tests. Sometimes, patients may require additional safety monitoring.

Several sponsors already have different measures in place to allow conduct of clinical trials and avoid as much disruption as possible, such as:

  • Allowing patients to have blood draws and CT scans at local cancer centers and clinics
  • Shipping drug supplies to patients, especially for targeted therapy (pills) trials
  • Remote consent
  • Mobile phlebotomy

If you are part of a clinical trial, we recommend you discuss your trial participation immediately with your research team.  If you were considering enrolling in a clinical trial, you may want to discuss with your treating physician what options are available for you. Any decision about trial participation should be made jointly by you and your healthcare team.

Resources and websites:

  1. IASLC’s Guide to COVID-19 and Lung Cancer –  https://www.lungcancernews.org/iaslcs-guide-to-covid-19-and-lung-cancer/
  2. The National Cancer Institute has a special website for COVID-19 and emergency preparedness. Coronavirus: What People with Cancer Should Know – https://www.cancer.gov/contact/emergency-preparedness/coronavirus
  3. We are following updates provided by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), which can be found here:
  1. The American Medical Association is also maintaining a resource website for healthcare providers. You can find more information here:
    https://www.ama-assn.org/delivering-care/public-health/covid-19-2019-novel-coronavirus-resource-center-physicians
  1. If you cannot avoid air travel, check out this handy article on “Dirtiest Places on Airplanes: How to Avoid Germshttps://time.com/4877041/dirtiest-places-on-airplanes/


GO2 Foundation for Lung Cancer
(Amy Moore, PhD amoore@go2foundation.org )
LUNGevity Foundation (Upal Basu Roy, PhD, MPH ubasuroy@lungevity.org )
Lung Cancer Foundation of America (Kim Norris KNorris@lcfamerica.org )
Lung Cancer Research Foundation (Jan Baranski, PhD jbaranski@lcrf.org)
LungCAN (Kimberly Lester kimberly@lungcan.org)

March 23, 2020 Update to the Joint Statement on #Coronavirus #COVID19 From #LungCancer Advocacy Groups

The post below is shared with permission.

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From Lung Cancer Advocacy Groups

As cases of the virus surge in countries around the world, with Italy being particularly hard hit, many nations are taking extreme steps to mitigate the outbreak, including whole country lockdowns. Here in the United States, the President declared a national emergency on March 13, 2020. Several states have declared shelter-in-place to minimize non-essential activities and mitigate transmission. President Trump has declared California, New York State, and Washington State to be major disaster areas.

In this week’s update, we discuss the following topics related to COVID-19:

 

Origin of SARS-CoV-2

SARS-CoV-2 is the seventh coronavirus known to infect humans. SARS-CoV, MERS-CoV, and SARS-CoV-2 can cause severe disease, whereas HKU1, NL63, OC43 and 229E are associated with mild symptoms. There has been a lot of speculation on the origin of SARS-CoV-2. Scientists have now sequenced the genetic material of the virus isolated from different patients. These sequencing results clearly establish that SARS-CoV-2 is not a genetically engineered virus, meaning it is not manmade.1

The researchers provide two scenarios for the origin of SARS-CoV-2. In one scenario, the virus evolved to its current pathogenic (disease-causing) state through natural selection in a non-human host and then jumped to humans. This is how previous coronavirus outbreaks have emerged, with humans contracting the virus after direct exposure to civets (SARS) and camels (MERS). The researchers proposed bats as the most likely reservoir for SARS-CoV-2 as it is very similar to a bat coronavirus. In the other proposed scenario, a non-pathogenic version of the virus jumped from an animal host into humans and then evolved to its current pathogenic state within the human population. For instance, some coronaviruses from pangolins, armadillo-like mammals found in Asia and Africa, have similarities to SARS-CoV-2. A coronavirus from a pangolin could possibly have been transmitted to a human, either directly or through an intermediary host such as civets or ferrets.

 

Which age groups have severe responses to COVID-19?

Initial data on COVID-19 suggested that when stratified by age, the elderly were the most likely to develop a more severe form of COVID-19. Recent data released by the CDC demonstrated that this is not the case anymore.  As shown in the figure below, almost all age groups are susceptible to a serious form of COVID-19 that requires hospitalization.2

This is especially important to keep in mind given that younger people have been more resistant to social distancing.

 

How long does SARS-CoV-2 survive outside the body?

The researchers were able to detect viable viral particles for at least 72 hours on the four surfaces studied. This suggests that transmission of SARS-Cov-2 is possible through aerosols and fomites (solid objects and surfaces that are able to carry pathogens and transmit infections).

We recommend that after you bring articles into your home, you do the following:

  • Wash your hands after carrying delivered items into your home.
  • After accepting a package that’s in a cardboard container, put it aside or in the garage and let it sit for a day or two before opening (if possible).
  • After opening a package, wipe down all articles that have solid surfaces with chlorine wipes or disinfect with an alcohol-based solution.
  • At this time, there is no guidance on how to disinfect edible items such as fruits and vegetables.
  • Follow cleaning and disinfecting procedures listed on the gov website

 

Community transmission of SARS-CoV-2 by asymptomatic individuals

Data from initial cases of COVID-19 suggested that most transmissions were occurring through individuals who showed signs and symptoms of COVID-19. This is however not the case. It is now estimated that as many as 31% of new COVID-19 infections are being caused as a result of transmission through asymptomatic individuals – those who have been infected with SARS-CoV-2 but don’t shown signs and symptoms of the disease.4 This is an especially important aspect of SARS-CoV-2 transmission and reinforces why we need to practice stringent social distancing to flatten the curve.

 

COVID-19 patients may present with non-respiratory symptoms even before they have respiratory symptoms

Individuals infected with SARS-CoV-2 may present with gastrointestinal symptoms such as anorexia (83.8%), diarrhea (29.3%), vomiting (0.8%), and abdominal pain (0.4%).5 These gastrointestinal symptoms may show up even before respiratory symptoms of COVID-19. Furthermore, a small sample of patients presented with only gastrointestinal symptoms. If you have unexplained gastrointestinal issues, we suggest that you talk to your doctor promptly.  Also, conjunctivitis may be present in a small subset of patients as well. 6

 

Prepare your legal documents

Given the uncertainty over availability of medical care during the COVID-19 emergency, we suggest everyone review their legal documents and ensure they have a current Durable Power of Attorney and Advance Directive. This virus can progress very rapidly and seriously interfere with breathing, which means you cannot be certain that you will be able to make your wishes known verbally if you get severely ill. Discuss your wishes with your family and ensure everyone knows where to find these important documents.

If you haven’t completed these legal documents, some estate planning attorneys may be willing to help prepare and witness them via video conferencing so that you do not have to leave your home.

If you are not sure how to get started, please review the resources available at https://theconversationproject.org/

 

Can I take ibuprofen when I have COVID-19?

Short answer, yes.  Long answer: we’re not sure.

On March 18, the World Health Organization (WHO) posted an article suggesting that patients who have COVID-19 avoid taking ibuprofen, based on observations of patients in France.7 However, later the same day, WHO changed their stance and said patients who have COVID-19 should not avoid taking ibuprofen.8

This is a good example of how quickly information is evolving during this pandemic. It’s difficult for doctors to know whether to act on information that is based on the experience of only a few (or even one) patient.

Resources and websites:

  1. The National Cancer Institute has a special website for COVID-19 and emergency preparedness. Coronavirus: What People with Cancer Should Know – https://www.cancer.gov/contact/emergency-preparedness/coronavirus
  2. We are following updates provided by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), which can be found here:
  1. Johns Hopkins Coronavirus Resource Center is one of the best places to get current updates. https://coronavirus.jhu.edu/
  2. Interactive map of US COVID-19 cases by statehttps://www.politico.com/interactives/2020/coronavirus-testing-by-state-chart-of-new-cases/
  3. The One-Two Punch: Cancer And Coronavirus (an important perspective for cancer patients) – https://www.forbes.com/sites/miriamknoll/2020/03/20/the-one-two-punch-cancer-and-coronavirus/#73744a4358e6
  4. You can find information specific to your state or city or town on your health department’s website.
  1. The American Medical Association is also maintaining a resource website for healthcare providers. You can find more information here: https://www.ama-assn.org/delivering-care/public-health/covid-19-2019-novel-coronavirus-resource-center-physicians
  1. If you cannot avoid air travel, check out this handy article on “Dirtiest Places on Airplanes: How to Avoid Germshttps://time.com/4877041/dirtiest-places-on-airplanes/

 

References:

  1. Anderson K, Rambaut A, Lipkin W, Holmes E, Garry R. The proximal origin of SARS-CoV-2. Nature Medicine. 2020.
  2. CDC. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020.
  3. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020.
  4. Nishiura H, Kobayashi T, Suzuki A, et al. Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19). Int J Infect Dis. 2020.
  5. Pan L, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. American Journal of Gastroenterology. 2020.
  6. AAO. Alert: Important coronavirus updates for ophthalmologists. https://www.aao.org/headline/alert-important-coronavirus-context. Published 2020. Accessed March 23, 2020.
  7. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020.
  8. ScienceAlert. Updated: WHO Now Doesn’t Recommend Avoiding Ibuprofen For COVID-19 Symptoms. https://www.sciencealert.com/who-recommends-to-avoid-taking-ibuprofen-for-covid-19-symptoms/amp?fbclid=IwAR0f9eZt8u9s_xfiY06bJ0Sei2NasHQj_b_eosKGjBeJiJXi5LXQV3EIj7w. Published 2020. Accessed March 23, 2020.

GO2 Foundation for Lung Cancer (Amy Moore, PhD amoore@go2foundation.org )
LUNGevity Foundation (Upal Basu Roy, PhD, MPH ubasuroy@lungevity.org )
Lung Cancer Foundation of America (Kim Norris KNorris@lcfamerica.org )
Lung Cancer Research Foundation (Jan Baranski, PhD jbaranski@lcrf.org)
LungCAN (Kimberly Lester kimberly@lungcan.org)