key: cord-0980145-19w5q53a
authors: Alhalabi, Omar; Iyer, Swami; Subbiah, Vivek
title: Testing for COVID-19 in patients with cancer
date: 2020-05-03
journal: EClinicalMedicine
DOI: 10.1016/j.eclinm.2020.100374
sha: 6e0edef78a8b22fafc5ba1f54028c33e8419980c
doc_id: 980145
cord_uid: 19w5q53a

nan

Patients with cancer could present several scenarios that include presentation with active COVID-19 infection, as symptomatic or asymptomatic carriers, history of COVID-19, exposed to COVID-19, or unexposed to COVID-19. We need to manage all these situations in the context of cancer therapy.

First, in the absence of an effective vaccine or anti-viral therapy, we should try to prevent patients with cancer from contracting infection. Second, how do we adjust cancer therapy in patients with COVID-19? Evidence is lacking to support changing or withholding chemotherapy or immunotherapy in cancer patients. However, the general expectation is to continue treatments if lifesaving. For non-curative treatments, like maintenance therapy in follicular lymphoma (FL), delaying drug dosing is reasonable.

Alongside chemotherapy, steroids are frequently used in cancer management and have been linked to adverse outcomes of COVID-19 3 arguing for routine testing in patients receiving them. As to immunotherapy, it is not known if their use puts patients at a higher risk for pneumonitis or cytokine storm. Managing COVID-19 and its complications should be prioritized over management of cancer. However, clinical decisions should be individualized to consider factors such as the risk of cancer relapse if treatment is modified, the number of cycles already completed, and the patient's tolerance of therapy. Third, in asymptomatic patients who are carriers of COVID-19 planning ahead could help minimize complication rate of chemotherapy. Cancer directed therapy (e.g. anti-CD20 monoclonal antibody) has been known to reactivate certain viral infections. In these circumstances, delaying or de-intensifying semi urgent chemotherapy should be considered.

Antibody testing could aid decision of when to proceed with immune compromising chemotherapy especially those with curative intent. A return-tochemotherapy criteria could be entertained once reliable antibody testing and viral titers are developed (Figure 1) . After development of an effective vaccine, antibody testing may aid in vaccinating those with low titer of protective antibodies. Patients with B cell malignancies such as lymphoma, chronic lymphocytic leukemia, or multiple myeloma will likely have distinct antibody responses and may require a specialized pathway.

Finally, patients with a known exposure need to be tested for COVID-19, quarantined and closely followed up.

Delaying may not be clinically feasible due to urgency and need for therapy and unknown cycle of the COVID-19 pandemic. Testing all patients with lung cancer for COVID-19 has been suggested 4 . Herein, we offer a tiered model (Figure 1) Several limitations exist facing current panels that include availability, underestimating rate of false-positivity or false-negativity (Figure 1) . However, technology is evolving at a rapid pace and, hopefully, viral RNA and antibody testing will mature over time and become more available. In summary, cancer patients represent a special situation during this pandemic and a tiered approach to testing could help provide them with life-saving chemotherapy without jeopardizing their chances of benefit. 

The Untold Toll -The Pandemic's Effects on Patients without Covid-19

Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal

Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease

Testing for COVID-19 in lung cancer patients

Convalescent plasma as a potential therapy for COVID-19

Others report no conflict of interest.