Jun 03, 2020
By Geraldine Carroll, ASCO Publishing
The COVID-19 pandemic is reverberating through the world of oncology as physicians consider whether to modify their care strategies and how best to talk to patients about implications for their treatment. The new normal will likely generate a series of articles in oncologic literature on issues including the extent to which morbidity can be affected by COVID-19 and whether patients with compromised immunity during their treatments are at higher risk of contracting the disease. In the article “Challenges Faced by Medical Journals During the COVID-19 Pandemic,” published in the Journal of Clinical Oncology (JCO), editor in chief Stephen A. Cannistra, MD, and his co-authors assess best practices in evaluating early research on these topics. As he notes, such data and conclusions, though well-meaning, should be interpreted with caution at this stage.
What kind of fast turnaround research are you seeing as oncologists start to grapple with the implications of COVID-19 for patients with cancer, and what are the limitations of such early data?
SC: JCO has thus far received numerous correspondences, commentaries, and other article types that are very descriptive, do not provide practice-changing information, offer little in the way of clinical innovation, and have therefore not met our standards for publication. These typically involve very small numbers of hospitalized patients with cancer with COVID-19 infection, attempting to describe their outcomes compared to non-hospitalized patients, with or without COVID-19 infection, or with or without cancer. One can immediately appreciate the limitations of making such "apples to oranges" comparisons. These comparator groups are often very different, subject to selection bias, and not necessarily balanced for important risk factors that could affect outcome. This makes meaningful interpretation almost impossible. During these stressful times, JCO feels that it is counterproductive to add even more stress to patients and their oncologists by publishing confusing and potentially misleading information.
Where should oncologists and researchers place the balance between an urgent need to consider the impact of COVID-19 on patients with cancer and the traditional protocols for rigorous peer-reviewed research?
SC: There are already many sources that provide excellent guidance for oncologists and patients with cancer during the COVID-19 pandemic, including ASCO’s own resources. These resources provide information based upon sound clinical judgment and the desire to treat cancer effectively while maintaining good principles of infection control. Many of these principles are time-tested and have been recognized for years, and they are now being organized into a coordinated response to the COVID-19 pandemic. We realize that patients with cancer might be more susceptible to infection, including COVID-19, and the medical community is already taking measures to reduce this risk. Thus far, I have seen no reports submitted to JCO that establish novel or creative principles in oncologic care or infection control that we did not already know, and that are not already being implemented. That said, we would certainly be receptive to quickly assessing and publishing such research when it becomes available, using JCO's well established Rapid Review pathway. We also intend to keep an open mind regarding hypothesis-generating clinical studies that, while not definitive, offer sufficiently compelling and innovative approaches that are likely to prove correct, and that deserve further testing by the oncology research community.
What is the impact on the public, and especially patients, of this early research when it gets into the media?
SC: We have seen patients who are now frightened to receive treatment for their cancer because these small reports have been misinterpreted to imply that the risk of COVID-19 is often greater than the risk of cancer itself. Such reports, while certainly attracting media attention, have the potential to influence the behavior of patients in ways that could prove deleterious to their health, and which make it more difficult for oncologists to provide essential care.
What guidelines do you suggest for JCO readers to assess the value and conclusions of future COVID-19 studies?
SC: JCO is interested in high-quality research involving COVID-19 that goes beyond descriptive studies and provides actionable information that will improve our ability to deal with this pandemic. Such research might involve accurately quantifying the risk of becoming infected with COVID-19 in patients receiving chemotherapy, determining whether certain types of cancers or chemotherapy regimens might place patients at higher risk of infection than others, and assessing how such regimens might be modified to reduce risk while at the same time preserve efficacy. We are also interested in research that provides definitive guidance regarding the best ways to care for patients who have already developed COVID-19 infection while undergoing chemotherapy or radiation treatment. Such information might enable us, for instance, to safely delay chemotherapy for some patients, choose another type of treatment regimen for some patients, or not make any changes to their cancer management plan because the risk of delaying treatment might outweigh the risk posed by COVID-19 infection.
At the moment, oncologists around the world are using their best judgment to make these decisions, but I look forward to publishing good quality research that provides definitive answers to these and similar questions. Research involving large, centralized, well-annotated databases that may eventually provide actionable information would also be of interest, such as the ASCO Registry.
How should such conclusions then be communicated to patients with cancer?
SC: Patients are aware of the stress that this pandemic has caused, and they are grateful for the care that is being provided by oncology health care professionals who are placing themselves in harm's way to help others. It goes without saying that oncologists should clearly and transparently communicate the rationale for their management decisions, including what modifications in the treatment plan might be necessary to ensure patient safety during this pandemic, while still providing excellent quality care. Much of this information can be conveyed to patients in person, sometimes through telemedicine or reputable online resources, but always with compassion and dedication to our mission.