Suffering from Cancer in Guatemala during the COVID-19

(To treat or not to treat is the dilemma... a personal criterion)

Cancer is a term that groups together a large and extremely heterogeneous number of diseases, which share the common characteristic of having uncontrolled growth, not respecting normal cells and invading locally to neighboring tissues or in the worst case spreading remotely through the lymphatic and/or bloodstream (metastasis).

This is a complex disease, so in times like these, we tell you all about suffering from cancer in Guatemala at the time of Covid-19.

Cancer is by far the second cause of death in many countries and in others it is already the first cause. According to data published by the World Health Organization and Globocan, it is estimated that in 2018, there will be more than 18 million new cases of cancer and 9.6 million deaths as a result of this disease.

The treatment of cancer has traditionally been based on four pillars: Surgery, Radiotherapy, Hormone Therapy, and Chemotherapy.  With the advent of molecular biology these have been incorporated: Monoclonal antibodies and target therapy directed to specific molecular mutations of tumor cells.

Of course, it cannot be left in a different and specific section to Immunotherapy, which has radically changed not only the treatment approach but also the prognosis of many neoplasms, previously totally untreatable, using it both in isolation and in combination.

The use of this new and sophisticated therapeutic armament has increased the response rate and survival rates in many, many tumors and has given others the opportunity to become chronically ill. 

The vast majority of people associate cancer treatment with extreme toxicity (nausea, vomiting, diarrhea, hair loss, dehydration, and immunosuppression, among others). These side effects typically occurred significantly, in the past when we did not have the drugs for side effects, which we have today.

Among the side effects on, in particular, takes relevance at present, due to this Pandemic by the COVID-19- 19, the Immunosuppression, said of another form, the reduction of the innate capacity to defend us before a viral, fungal or bacterial infection.

We must clarify that Immunosuppression is associated in most cases with Chemotherapy, however, when we apply this therapy, the damage caused to the defenses is for bacteria and not necessarily for viral processes, which continue to function normally. 

In fact, we can avoid such immunosuppression for bacteria by administering, in conjunction with chemotherapy, factors that stimulate the function and number of white blood cells known as neutrophils or granulocytes that are responsible for the defense of bacteria.  Under normal conditions, our patients receiving chemotherapy are much more frequently complicated by bacterial and non-viral infections.

Other therapeutic modalities used in non-hematological tumors (known as solid tumors), such as hormone therapy, target therapy, or immunotherapy, are not commonly associated with an increased incidence of acute viral processes. In rare cases, special care should be taken with viral reinfections or tuberculosis using some monoclonal antibodies such as Rituximab.

Of course, certain types of hematological cancer, especially Chronic Lymphocyte Leukemia, aggressive lymphomas, Multiple Myeloma, patients who have received bone marrow transplants or chronic use of cortisone, may have a state of immunosuppression characteristic of these diseases, should be more susceptible and should be much more careful in these cases. (Viral infections by herpes simplex, herpes zoster, cytomegalovirus, adenovirus, and influenza are much more common than by coronavirus).

Large hospital centers in Europe and the United States, which are currently overwhelmed by the urgent care of patients with SARS-CoV-2 or COVID 19 infection, have put many treatments on hold and many oncology medical associations have set very rigid guidelines for treating cancer patients, favoring those with high cure rates and leaving others on hold, which is understandable by hospital demand, however in private day-to-day practice, this situation may be different. This is just one way of looking at cancer in Covid-19 times around the world.

The data published in www.worldometer.info, reports that of the more than 7 billion inhabitants in the world, there have been more than 16 million deaths from January 1 to April 1, 2020, of which 108,586 correspond to this date to patients with COVID-19 while more than 2 million have died of cancer in the same period. These data reflect the significant difference in cancer mortality at the time of Covid-19.

Decisions are difficult and must be made and agreed upon by medical associations specialized in Hemato-Oncology, establishing levels of evidence, but above all the final decisions are those of the patient suffering from the disease, supported if possible by his family and endorsed by his Hematologist or Oncologist. 

In the most widely referenced article written by Wenhua Liang and published in Lancet Oncology, Vol. 21, March 2020, 18 patients with cancer out of 1,590 are described, and of these, only 4 patients had received chemotherapy one month earlier. Most of these 18 patients were older than the rest and had a higher incidence of morbidities and a higher incidence of smoking. We cannot make any decision based on such a low percentage of patients and with so many biases. 

It is NOT possible, nor should it be, to generalize and say that all cancer patients are at greater risk of suffering from COVID-19 or if they present a more aggressive infection, due to the enormous heterogeneity of the different types of cancer that exist. 

Finally, it should be noted that the cost in human lives and the economic cost due to the failure to respond or relapses from cancer that will be seen in the medium and short term and the mortality related to the lack of specific treatment, must be weighed, above all on the basis that we firmly maintain as a strictly personal criterion, that the cancer patient in general, except for the circumstances described above, does NOT have a higher incidence or worse prognosis during this Pandemic.

Cancer in times of COVID-19 is a battle that must be studied in order to prioritize people’s lives and create adequate processes and methods for the treatment of patients.

Dr. Luis Miguel Zetina-Toache
Clinical Hematology, Medical Oncology, Internal Medicine

American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), Sociedad Española de Oncología Médica (SEOM)

See profile of Dr. Luis Miguel Zetina-Toache

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