The changes in the lung scan of Gopal Bajaj’s throat cancer patient were significant enough over the last two days for the team of therapists and radiation physicists to wonder if it could be Covid-19.
“So they flagged me. I compared that scan to his last two scans, and he’s getting a Covid test now,” Bajaj, chairman and medical director of the advanced radiation oncology and proton therapy department at the Inova Schar Cancer Institute in Fairfax, Va., said in an interview.
There have been a fair number of similar anecdotal reports of doctors who administer radiation therapy to treat cancer picking up potential cases of Covid-19 in patients who aren’t showing any symptoms of the respiratory disease. It has prompted an “educational spark within the specialty,” Bajaj said.
The incidences are anecdotal and need to be confirmed with results from a nasal swab test. But the notion that cancer patients could be infected without presenting symptoms raises questions about their treatment—continue, truncate, or suspend?—as well as the health of their doctors. Bajaj’s throad cancer patient is smoker with chronic obstructive pulmonary disease and—if he turns out to have Covid-19—he was still showing no signs of the disease.
The Seattle Cancer Care Alliance, in one of the first U.S. hot spots, said it has identified patients and staff who have tested positive for Covid-19.
“We are following the [Centers for Disease Control and Prevention] and Department of Health guidelines for notifying people who are at risk of exposure and giving them guidance on next steps. Environmental Services has increased the frequency of cleaning of high-touch surfaces such as door handles and elevator buttons. The disinfectants that we use are effective at killing COVID-19,” the center said.
The situation points to a broader problem of asymptomatic Covid-19 carriers, who could unknowingly spread the respiratory disease to vulnerable populations within a health facility. Separately, a study published April 17 suggests the spread of Covid-19 among children is far wider than what has been reported.
“It really kind of boggles the mind in terms of what is potentially the exposure in the general public,” Bajaj said.
Cancer centers like Bajaj’s can either be free-standing facilities, but they are sometimes within the hospital itself.
“I would say probably for most cancer centers or radiation departments around the country, for the majority of them, they will have separate entrances,” Louis Potters, deputy physician-in-chief of Northwell Health Cancer Institute who’s responsible for radiation medicine for New York’s largest health system, said.
The risk of cancer patients requiring admission to an intensive care unit or even death is possibly five times greater than patients without cancer if they become infected with the virus, according a Lancet Oncology paper from scientists in China.
“In my professional capacity, I am used to witnessing primal fear, but I have never seen such widespread panic in my patient population as during the advent of SARS-CoV-2,” Mark A. Lewis, a medical oncologist at Intermountain Healthcare, wrote in a recent New England Journal of Medicine perspective.
Most cancer centers, including Inova, Northwell, and MD Anderson Cancer Center, are requiring temperature checks at the door along with other screening measures to reduce the risk of Covid-19 exposure in the building.
They’re also using more telemedicine to limit the amount of time patients spend at the cancer center. Radiation oncologists are also exploring advances in technology that allow for a shorter treatment time instead of administering a moderate dose of radiation daily over the course of many weeks, Bajaj said.
During radiation treatment, doctors are picking up images that could indicate Covid-19 in patients who are asymptomatic. Had the patients shown a fever or other symptoms, they would have gotten a Covid-19 test first.
Radiation oncologists have to scan patients for treatment planning or to make sure the providers are setting them up for treatment appropriately, Potters explained. “If that scan includes part of the lung, we’ve seen sort of these anecdotal cases of patients with asymptomatic pneumonias,” he said.
“So how much of that is out there? We don’t really know. But we have been able to pick that up. Is it meaningful in an asymptomatic patient? One doesn’t really know. Obviously it’s important because of the patient’s exposure and the staff and the need for [personal protective equipment] if a patient is in fact positive,” Potters said.
Northwell is setting up a study to answer some of those questions, Potter said.
For any patient undergoing a process for treatment planning in which the radiation treatment fields are defined, filmed, and marked out on the skin, Northwell will also run preliminary CT images known as a scout view on that patient’s chest. If the patient consents, that chest scan would happen regardless of whether they are targeting cancers on the neck or the prostate.
“The intent is just to try and understand in a hot area like New York and suburban New York, what the underlying incidence of asymptomatic lung findings would be in cancer patients, obviously,” Potters said.
The proposed study design has been submitted to Northwell’s ethics panel for review. If researchers flag something in the patient’s chest scan, they will send them to get Covid-19 tests.
“Access to testing now is not what it was a month ago. So we can get high-risk patients tested, you know, either the same day or within 24 hours,” he said. “So the goal will be to test those patients before they have further interactions with the department.”
If those patients test positive, it will raise the question of whether doctors should continue chemotherapy radiation, Potters said.
Widespread Among Children
Meanwhile, researchers at the University of South Florida and the Women’s Institute for Independent Social Enquiry estimate that for each child who requires intensive care for Covid-19, there are 2,381 children infected with the virus.
Their research found U.S. pediatric intensive care units admitted 74 children from March 18 to April 6, which they extrapolated to mean an additional 176,190 children were likely infected during this timeframe.
“Although the risk of severe illness from COVID-19 is lower in pediatric cases than adults, hospitals should be prepared and have the proper equipment and staffing levels to deal with a potential influx of younger patients,” Jason Salemi, study author and associate professor of epidemiology in the USF College of Public Health, said in a statement.
“Government officials and policy makers should understand the likelihood of capacity challenges, which underscores the importance of effective mitigation strategies such as frequent and thorough handwashing and persisted social distancing measures,” Salemi said.