COVID-19 (novel coronavirus) and Bladder Cancer: What patients and families need to know.
It is important that both patients and their caregivers take precautions to lower their risk of getting COVID-19. The Bladder Cancer Advocacy Network has received questions from our bladder cancer community about how to safely treat their disease while reducing their risks for the current pandemic. BCAN is deeply grateful to our expert medical advisors for their input answering questions from patients and their families about bladder cancer and the COVID-19 pandemic.
Participants in putting together this document include the following experts:
- Rick Bangs, BCAN/SWOG Patient Advocate
- Ashish M. Kamat, MD, Urologic Oncology, MD Anderson Cancer Center, Houston, TX
- John L. Gore, MD, MS, Urologic Oncology, University of Washington Medical Center, Seattle, WA
- Seth Lerner, MD, FACS, Urologic Oncology, Baylor College of Medicine, Houston, TX, and BCAN Board of Directors
- Neal Shore, MD, FACS, Urologic Oncology, Carolina Urologic Research Center, Myrtle Beach, SC, and BCAN Board of Directors
- Parminder Singh, MD, Medical Oncology, Mayo Clinic, Phoenix, AZ
- Gary D. Steinberg, MD, FACS, Urologic Oncology, NYU Langone Health and BCAN Scientific Advisory Board Chairman
- Laila E. Woc-Colburn, MD, DTM&H, FACP, FIDSA, Infectious disease, Baylor College of Medicine, Houston, TX
Bladder Cancer & COVID-19 | FAQ Regional Updates for Patients
A bladder cancer diagnosis is stressful for patients and families on its own. That has been escalated with the current COVID-19 pandemic and social and medical distancing. How does where you live impact your access to treatment? What do bladder cancer patients and their families need to know about:
- When is it ok to have delays in treatment and surveillance?
- What constitutes an urgent need for care and what should patients/families know about what to expect at a hospital or doctor’s office?
- Medical distancing – how are protocols at hospitals changing to protect patients and staff?
- How might things evolve as we learn more about COVID-19 in bladder cancer patients?
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A diagnosis of bladder cancer does not increase your risk of acquiring the COVID-19 virus. However, there are several concerns that patients and their families should know about bladder cancer treatments and risk of acquiring or developing COVID-19.
Because bladder cancer is a solid tumor, it does not directly impact your body’s immune cells as a function of the disease. It is important to be aware that a bladder cancer diagnosis requires frequent visits to the doctor. Our experts are urging you to call your doctor’s office to speak with him or her before going into the office. Talk about your specific need for some of the typical bladder cancer appointments in the current pandemic situation. These visits to medical offices can put you and your families at risk for being infected. It also can expose healthcare professionals to unnecessary risk of acquiring the virus.
We have no reports that patients getting intravesical BCG are getting COVID-19 more than patients who do not. Clinical trials are underway to assess the impact of BCG vaccination on risk of infection with COVID-19 virus.
It is important to note that coming to a hospital to get this therapy could potentially put patients at risk for catching the COVID-19 infection. If a patient has had four doses of induction, it is possible to wait a few weeks before receiving the remaining doses of BCG. The risk of contracting the virus when coming to a healthcare facility for this treatment is higher than any risk of delaying dose five and six for several weeks.
If a patient is getting induced and is still on dose number three, experts suggest that they try to get to dose four before they take a break from the remaining treatments. If they’re on maintenance therapy, then getting one and two and skipping dose three completely is acceptable. Speak to your doctor. It is likely that delaying BCG is much less risky than the risk of contracting COVID-19.
Chemotherapy may increase your risk. There are two ways to administer chemotherapy for bladder cancer. One is putting the chemotherapy inside the bladder, which is intravesical, and the other is intravenous (IV), which is getting systemic chemotherapy. Systemic chemotherapy has the potential to cause greater immunosuppression. Two different types of chemotherapy that are used, dose dense MVAC and GemCis. MVAC causes more neutropenia than the GemCis. Neutropenia is a condition associated with a low white blood cell count. These types of white blood cells, called neutrophils, are made in the bone marrow and fight off infections. But either of those could impair a patient’s system depending on what their baseline health status is, (i.e., age and other factors). So, having systemic chemotherapy puts patients at increased risk. Early data from other cancer centers show that patients who had any type of cancer and received chemotherapy who also got the COVID-19 infection had worse outcomes than those who did not have chemotherapy.
Immunotherapy helps the immune system fight the cancer. However, one out of six patients who are on immunotherapy may have a treatment-related complication where there is an autoimmune side effect. An autoimmune disease is an illness that causes the immune system to produce antibodies that attack normal body tissues. Those patients may have to have high doses of steroids or immunosuppressive therapy. In that situation patients can clearly be at risk of catching a COVID-19 infection.
Early mortality rates in patients from age sixty, to seventy, to eighty that have been reported from China and Italy, show deaths from COVID-19 increase significantly as we age due. Most bladder cancer patients will fall into these older age groups. Patients this age are already high risk. Their resilience to an infection like COVID-19 is going to be particularly compromised by recovering from this big surgery.
If a patient is doing well, there’s no reason for them to come in to the clinic during the peak of this pandemic. Telemedicine can help doctors monitor the incision and stoma through the video visit.
Experts agree that everyone needs to be very, very careful about choosing to have radical cystectomies now and for the next few weeks. The hospital readmission rate for radical cystectomy is 30%. This puts them in a vulnerable position. They should not be in the Emergency Room if they can avoid it. In cities with a large number of COVID-19 patients, there may not be a hospital bed for them to go to. There may be very few open beds in the ICU if they need them.
In New York City, all cancer patients, unless they risk the loss of limb or organ function or obstruction as a result of their tumor, are having their surgeries delayed for at least two weeks. Many medical teams are not doing any cystectomies for at least another two, three, four weeks. Delaying a month in these difficult times of the pandemic, even delaying six weeks, is not likely to be detrimental to bladder cancer treatment. If you are waiting for a cystectomy, speak with your medical team about your options, including neoadjuvant chemotherapy or other options.
After surgery, when a patient’s blood counts have recovered and their wounds have healed, and they are on regular follow-up every three months, they are at normal risk for exposure and catching infections from COVID-19.
There is not a big difference between community practice compared to the larger academic or urban practices for bladder cancer treatment. The risk is driven by where you are regionally within the country. The current COVID-19 epicenters are New York and Washington state, mainly Seattle, and potentially some other larger cities. That’s going to change over the next weeks. The forecast by the CDC and other organizations tracking the spread of the virus is that even in the Midwest and the South, it’s going to change significantly. Even though, for example, a county and hospital has only a few reported cases, they are treating this extremely seriously.
Remember, social distancing helps to reduce your risk. Stay away from people who may not know they are even infected. Early research from China and other countries has suggested that people with a history of cancer may indeed be more vulnerable to infection and severe events related to COVID-19. Some doctors are also proposing “medical distancing” — reducing the number of cancer patients who visit health care facilities wherever possible — to decrease the risk of coronavirus exposure and transmission in this population. If you are getting intravesical or other treatments and they can be delayed, especially as we try as a nation to flatten the exposure and incidence of new cases projection curve, you need to stay home, and not put yourself and the medical personnel who take care of you at risk. That’s the bigger overarching issue.
We know that the checkpoint inhibitors have a long half-life in your body. Is there a way to reduce the risk so a patient doesn’t have to expose themselves to COVID-19 by the commute to the clinic or by being near other patients?
In metastatic disease patients, the goal of immunotherapy is more palliative or managing the symptoms such as pain. Doctors may prioritize patients on therapy with curative intent while reducing visits for patients with metastatic disease. In the current clinical environment, it is appropriate to skip a dose of immunotherapy.
Patients with high-risk NMIBC refractory to BCG may also be candidates for and FDA approved immunotherapy. The experience from the clinical trials show limited benefit such that risk of visit to the health care center and potential toxicity may be higher in the current environment. Talk to your physician if it is appropriate to delay or skip a treatment.
If the intent of their treatment is curative or immediate control of disease, then our choice would be different. As in the case of neoadjuvant chemotherapy, (chemotherapy before the planned removal of the bladder), the goal is a cure. Even though chemotherapy leads to immunosuppression, we would still recommend that a patient come to the clinic and get chemotherapy, despite COVID-19 being an easily transmitted disease. understanding the fact that this is an easily transmitted disease.
Patients and caregivers need to take good universal precautions. This includes continuing isolation and social distancing, and making sure they are washing hands and washing their faces. We can potentially get them through this because the intent is a cure. If patients understand what the intent of therapy is, we hope they will understand if we delay or postpone their treatment.
The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services defines telehealth as the use of electronic information and telecommunications to support and promote long-distance clinical health care.
Telehealth technologies include videoconferencing, store-and-forward imaging, and streaming media. For a health care encounter, a telemedicine visit requires live audio and video conferencing. Telemedicine allows bladder cancer patients to have conversations with their medical team and avoids exposing both patients and members of the health care team to COVID-19 positive patients.
Screening patients by phone before they come to a clinic may help to eliminate potentially redundant routine follow-up visits and lower the risk of infection.
With COVID-19 reaching every corner of the health care field, clinical trials for the development of life-saving cancer drugs have seen an enormous impact and reduction in the number of active trials. The FDA has put out guidance and a code of conduct on clinical trials during the COVID-19 pandemic. Individual cancer centers are responding based on the local spread of the virus. If you are in a cancer treatment clinical trial, please call your clinical trial research team and follow their guidance.
Prior to the current pandemic crisis, BCAN encouraged patients to think about seeking a second opinion. It might be possible to get a second opinion from the comfort and virus-free safety of their own home. You should check with the cancer center you are trying to seek an opinion from, if they provide telehealth services to new patients.
Delays and cancellations are likely in this environment given the risks described above in both visits and treatments. Patients and doctors should agree upon an appropriate time for following up.