INTRODUCTION — At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. It rapidly spread, resulting in an epidemic throughout China, followed by an increasing number of cases in other countries throughout the world. In February 2020, the World Health Organization designated the disease COVID-19, which stands for coronavirus disease 2019 [1]. The virus that causes COVID-19 is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
The rapidly expanding COVID-19 pandemic impacted all areas of daily life, including medical care [2]. In particular, delivering care for patients with cancer or suspected cancer during the crisis was challenging given the competing risks of death from untreated cancer versus serious complications from SARS-CoV-2, and the likely higher lethality of COVID-19 in immunocompromised hosts [3-5]. With the generation of effective vaccines and treatments for individuals with COVID-19, many aspects of medical treatment have returned to previous standards. Nevertheless, certain principles related to management of the patient with cancer and COVID-19 remain clinically relevant and will be reviewed here.
Other topics discuss more general issues related to diagnosis and management of COVID-19, and vaccination against SARS-CoV-2.
●(See "COVID-19: Diagnosis".)
●(See "COVID-19: Evaluation of adults with acute illness in the outpatient setting" and "COVID-19: Management of adults with acute illness in the outpatient setting".)
●(See "COVID-19: Management in hospitalized adults".)
●(See "COVID-19: Vaccines".)
IMPACT OF THE PANDEMIC ON CANCER SCREENING — Delays in cancer screening during the pandemic led to delayed diagnoses, a higher rate of patients diagnosed in an emergency setting, more diagnoses of later-stage cancers with higher tumor burden, and delays in effective treatment for patients with newly diagnosed malignancies [6-17].
Observational data suggest that cancer-specific mortality was higher during the COVID-19 pandemic when compared with pre-pandemic levels. In the United States, the number of cancer-related deaths increased by 3 percent between 2019 (prior to the pandemic) and 2020 (during the pandemic), with higher cancer mortality rates observed during the times when health care capacity was most challenged by the pandemic [18]. Delays in cancer screening and surveillance during the pandemic may also continue to impact future cancer mortality [19,20].
At present, screening programs have resumed in most areas, with clinicians maintaining full adherence to guidelines for limiting the spread of SARS-CoV-2 infection.
CANCER TREATMENT IN UNINFECTED PATIENTS — The approach to cancer treatment in patients uninfected by SARS-CoV-2 has at this point largely returned to pre-pandemic standards. However, for individuals with a known SARS-CoV-2 exposure, particularly those who are not up to date on COVID-19 vaccination or are expected to have an inadequate immune response to vaccination, it is generally recommended to hold treatment until it is clear that the patient will not develop COVID-19 from that exposure. An exception to holding therapy may be made for patients receiving low-risk cancer therapies, such as hormonal treatments.
Precautions to prevent transmission during routine cancer care are appropriate. (See "COVID-19: General approach to infection prevention in the health care setting".)
Given the risk of transmission from patients with asymptomatic infection, some institutions in areas of high viral transmission are routinely testing all cancer patients prior to all immunosuppressive therapies [21-24], in accordance with guidelines from the Infectious Disease Society of America [25]. According to these guidelines, immunosuppressive procedures are defined as cytotoxic chemotherapy, solid organ or hematopoietic cell transplantation, long-acting biologic therapy, cellular immunotherapy, or high-dose corticosteroids. However, this is not a widespread practice, and it is not supported by guidelines from the American Cancer Society, American Society of Clinical Oncology, or the European Society for Medical Oncology [26,27].
Testing in patients who have undergone laryngectomy is discussed below. (See 'Laryngectomized individuals' below.)
APPROACH TO CANCER PATIENTS WITH COVID-19
COVID-19 outcomes among cancer patients and survivors — Most studies suggest a higher risk of severe COVID-19 in adult patients with active cancer [28-31], although data are mixed [32-34] and outcomes have improved with better COVID-19 therapy and earlier diagnosis [35]. Moreover, many studies were performed prior to availability of effective COVID-19 vaccines.
The risk likely varies by type and stage of cancer and treatment received. In particular, the following features have been associated with an increased risk:
●Hematologic malignancies or lung cancer [36-47].
●Advanced and/or progressive cancer [29,36,48-54].
●Active chemotherapy treatment, particularly more myelosuppressive regimens, has also been described [45,47,55-57], although data are mixed [52,53,58-60]. By contrast, immunotherapy does not appear to worsen outcomes from COVID-19 [53,55,59,61-66], although data in this setting are also conflicting [67,68].
●Older age [28,31-33,37,44,46,52,53,59,67,69] and comorbid conditions [28,31,33,36,37,48-52,58,59,67,70-89] that are independently associated with severe COVID-19 further contribute to the risk in patients with cancer.
•However, at least one large meta-analysis has suggested that younger patients with cancer are at higher risk of worsened outcomes from COVID-19 relative to age-matched controls without cancer [45].
●Some data suggest that being a survivor of a prior cancer is also a risk factor for severe COVID-19, but the risk is lower compared with active cancer [36,77,90], while other studies have not found higher risks among survivors [52,91].
•As an example of available data, in an analysis from the United Kingdom, including records of over 17 million individuals linked to over 10,000 deaths from COVID-19, multivariate analysis found that patients with nonhematologic malignancy diagnosed within one year prior to COVID-19 had a 1.8-fold higher risk of death relative to patients without cancer, and a hematologic malignancy carried a fourfold higher risk [36]. Relative to those diagnosed with cancer within the preceding year, the risks were lower for patients diagnosed with cancer 1 to 4.9 years prior to COVID-19, but still elevated compared with people without cancer; beyond five years, risks for death remained elevated for those with hematologic but not nonhematologic malignancies.
Management of COVID-19 — Overall, the management of COVID-19 in cancer patients is similar to the management used for the general population. However, cancer is considered to be a risk factor for progression to severe COVID-19 (table 1), which influences available treatment options.
●Cancer patients in the outpatient setting – For cancer patients in the outpatient setting with COVID-19, available treatment options (algorithm 1) include antiviral agents such as nirmatrelvir-ritonavir and remdesivir. Previously, monoclonal antibodies were also an option; however, they are not active against increasingly prevalent new Omicron variants worldwide. Further details are discussed separately. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'.)
●Hospitalized cancer patients – The management of hospitalized cancer patients with more severe COVID-19 is the same as that used for the general population and is discussed separately (algorithm 2). (See "COVID-19: Management in hospitalized adults", section on 'COVID-19-specific therapy'.)
If available, convalescent plasma is an additional treatment strategy for hospitalized patients with hematologic malignancies and severe COVID-19 infection. Administration of convalescent plasma is discussed in detail separately. (See "COVID-19: Convalescent plasma and hyperimmune globulin".)
In a randomized, open-label trial in 134 hospitalized patients with severe COVID-19, including 56 patients with cancer, the addition of convalescent/vaccinated plasma to standard of care therapy for COVID-19 did not improve outcomes in the overall population. However, among patients with cancer, convalescent plasma in addition to standard of care resulted in a faster median time to improvement (13 versus 31 days, hazard ratio [HR] 2.50, 95% CI 1.3-4.8) and improved survival (89 versus 57 percent survival at 60 days, HR 0.28, 95% CI 0.06-0.96), relative to standard of care alone [92]. Notably, most patients in this study with cancer had hematologic malignancies (eg, chronic lymphocytic leukemia, acute myelogenous leukemia/myelodysplastic syndrome, non-Hodgkin lymphoma, multiple myeloma), while only a minority (16 percent) had solid tumors. It is possible that some of the benefit observed in patients with hematologic malignancies may be related to their baseline hypogammaglobulinemia (either from their cancer or cancer therapy) and receipt of polyclonal immunoglobulins within the convalescent plasma.
●Thrombosis risk – Patients with cancer do not need to take specific precautions against thromboembolism if they develop COVID-19. Although both COVID-19 and cancer predispose towards hypercoagulability, available evidence suggests that cancer patients who develop COVID-19 are not at a higher risk of clotting from COVID-19 than those without cancer. As an example, in a small study in patients with COVID-19, patients with active cancer had a similar risk of thrombotic events as those without cancer (either arterial or venous) at 28 days (14 versus 18 percent) [93]. Issues surrounding anticoagulation for COVID-19 hypercoagulable state are addressed in detail separately. (See "COVID-19: Hypercoagulability", section on 'Management'.)
●Persistent infection in immunocompromised patients – Active, persistent SARS-CoV-2 infection can uncommonly occur in immunocompromised patients, particularly those with severe B-cell depletion due to cancer therapy (eg, rituximab, hematopoietic cell transplantation). Such patients typically test positive for SARS CoV-2 on reverse-transcriptase polymerase chain reaction for prolonged periods of time (weeks to months) with a low cycle threshold (which suggests a high viral RNA level). These findings may indicate replicating, transmissible virus. Genomic studies have distinguished such persistent infection from reinfection with prevalent variants by the pattern of viral evolution [94]. (See "COVID-19: Diagnosis", section on 'Cycle threshold' and "COVID-19: Diagnosis", section on 'Diagnosis of reinfection'.)
Data are limited for the optimal management of these patients, and clinical practice is variable. Persistent infection can often be difficult to treat due to the accelerated pace of viral evolution and development of escape mutations [95-98]. Observational studies suggest some efficacy with the combination of antiviral therapy (eg, remdesivir) and passive immunization (eg, convalescent plasma) [95,99-101]. The efficacy of these and other COVID-19 treatments is discussed separately. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'.)
Cancer therapy in infected patients
General principles — In the event of a positive SARS-CoV-2 test result, decisions regarding anticancer therapy should be individualized. General principles are as follows:
●Systemic therapy
•For most patients, chemotherapy or immunotherapy should be interrupted, whether patients are symptomatic from COVID-19 or not [102,103]. However, in cases where expeditious cancer treatment is necessary and patients are asymptomatic or have only mild symptoms of COVID-19, some cancer centers have infusion rooms dedicated to patients who have tested positive for COVID-19 or have had an exposure [104]. Limited data also suggest worsened COVID-19 outcomes with administration of human granulocyte colony-stimulating factor [105].
•Nonimmunosuppressive therapies such as hormonal therapies (eg, for breast and prostate cancer) and some oral targeted therapies typically may be continued [106]. Case reports have suggested safety with continuation of anaplastic lymphoma kinase- and c-ROS oncogene 1-targeted therapies among those with the relevant cancer genotypes and COVID-19 pneumonia [107].
•Although data are limited, observational studies in chronic lymphocytic leukemia have suggested that Bruton tyrosine kinase inhibitors may be associated with less severe infection [108-111], and continuation of this class of drugs should be considered on a case-by-case basis [112].
•Decisions regarding systemic glucocorticoids must be individualized, depending on the dose and indication for the glucocorticoid. As an example, for those with an immunotherapy-related adverse event, it may be reasonable to continue glucocorticoid treatment; by contrast, in a patient with nausea, glucocorticoids could be omitted or an alternative therapy provided. The role of glucocorticoids in COVID-19 management is discussed separately. (See "COVID-19: Management in hospitalized adults", section on 'Dexamethasone and other glucocorticoids' and "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Therapies of limited or uncertain benefit'.)
●Radiation therapy – Cancellation or delay in radiation may be appropriate for patients with COVID-19, after a reassessment of the patient's goals of care. Other potential options, such as modifications to the radiation therapy schedule (eg, hypofractionation), may be considered.
●Surgery – The risks of perioperative morbidity and mortality are increased in patients with COVID-19, and the decision to perform surgery must balance this risk against the risks of delaying or avoiding the planned procedure.
When can cancer treatment be safely restarted? — For patients who have discontinued cancer therapy due to infection with COVID-19, we typically resume cancer-specific treatment once transmission-based precautions can be discontinued. More detailed information on discontinuing precautions in immunocompromised patients are presented separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Considerations in immunocompromised patients'.)
However, earlier resumption of certain therapies (eg, oral chemotherapy or targeted agents, if they have been held) is reasonable, if COVID-19 symptoms are mild and/or improving.
COVID-19 VACCINATION
Whom to vaccinate
Vaccination for cancer patients and survivors — All individuals with active or prior cancer should receive up to date COVID-19 vaccination to prevent SARS-CoV-2 infection. Cancer patients with moderate to severe immunocompromising conditions may have attenuated immunogenicity to the COVID vaccines, but vaccination should still occur in this population. Examples of such moderate to severe immunocompromising conditions include active chemotherapy, hematologic malignancies, hematopoietic stem cell or solid organ transplant, or the use of immunosuppressive medications (eg, rituximab, prolonged use of glucocorticoids). Specific recommendations for COVID-19 vaccination schedules are discussed separately. (See "COVID-19: Vaccines", section on 'Immunocompromised individuals' and "COVID-19: Vaccines", section on 'Dose and interval (for immunocompetent individuals)'.)
If vaccine supply is limited, guidelines suggest prioritizing patients with active cancer who are either on or planning to start treatment (including hematopoietic cell transplant [HCT] and cellular therapies), and those within six months of treatment, except for those receiving only hormonal therapy. Additional factors linked to adverse outcomes from COVID-19, which may increase the priority for vaccination, include age, comorbidities, and sociodemographic factors (eg, poverty, limited access to health care, and under-represented minorities [46]). (See 'COVID-19 outcomes among cancer patients and survivors' above.)
Assessment for potential vaccine contraindications — This subject is discussed in detail separately. (See "COVID-19: Allergic reactions to SARS-CoV-2 vaccines", section on 'Uncertain role of polyethylene glycol'.)
Thrombotic risks are not a contraindication — Although single-dose adenoviral vaccines have been associated with a rare risk of thrombosis with thrombocytopenia after vaccination, no risk factors for this have been identified. Therefore, a prior history of venous thromboembolism (VTE), or predisposition to VTE, is not a contraindication to vaccination with any type of vaccine. (See "COVID-19: Vaccine-induced immune thrombotic thrombocytopenia (VITT)", section on 'Individuals with thrombotic risk factors, prior thrombosis, or prior HIT'.)
Safety and efficacy — Available data suggest that COVID-19 vaccination is safe in patients with cancer and reduces the risk of SARS-CoV-2 infection and long-term sequelae [113-116], although the risk of breakthrough infections may be higher than in those without cancer.
As examples,
●One study found that the vaccine was 58 percent effective at preventing SARS-CoV-2 infections in patients with cancer, two weeks after the second dose [114]. However, studies also suggest that vaccine efficacy is reduced in those with active cancer relative to those without cancer, especially hematologic malignancies and particularly those on anti-CD20 antibody treatment [117-134].
●In a registry study including 6860 partially or full vaccinated patients with an mRNA vaccine who developed COVID-19, including 1460 patients with cancer, cancer was associated with higher risks for breakthrough infection (odds ratio [OR] 1.1) and severe outcomes (OR 1.3) compared with not having cancer, after adjustment for other clinical factors [133]. Compared with solid tumors, hematologic malignancies were at increased risk for breakthrough infections (eg, adjusted OR for lymphoma 2.1; and for lymphoid leukemia 7.3). Breakthrough risks were lower for those who received a second dose of the vaccine, as well as for those who received the mRNA-1273 (Moderna COVID-19) rather than the BNT162b2 (Pfizer COVID-19) vaccination.
●A study in 45,000 vaccinated patients with cancer suggested that the risk of breakthrough infections in patients with all cancer was approximately 14 percent, with highest risk for pancreatic (25 percent), liver (23 percent), lung (20 percent), and colorectal (18 percent) cancers; and lowest risks for thyroid (10 percent), endometrial (12 percent), and breast (12 percent) cancers versus 4.9 percent in the noncancer population [135].
Immunogenicity studies also suggest decreased immune response among cancer patients, particularly those with hematologic malignancies [123,124,136-140]. As an example, in a study of 200 patients with cancer who had been vaccinated (with either two doses of the mRNA vaccines or one dose of the adenoviral vaccine), the seroconversion rate was 94 percent overall, 98 percent among those with solid tumors, and 85 percent in those with a hematologic malignancy [124]. Among those receiving anti-CD20 therapies or following HCT, the seroconversion rate was approximately 70 percent. Separately, an inverse association has been described between the SARS-CoV-2 spike protein antibody vaccine response and infection severity in patients with cancer [141].
Overall, these data underscore the need to maintain appropriate precautions in all patients with cancer, and to not delay the timing of additional doses, if possible [128,130,142-151].
There are limited studies directly comparing the available vaccines in cancer patients. Although most evaluated the use of mRNA vaccines (BNT162b2 [Pfizer COVID-19 vaccine] and mRNA-1273 [Moderna COVID-19 vaccine]), observational data in patients with solid organ or hematologic cancers suggest that one dose of the Ad26.COV2.S (Janssen COVID-19 vaccine) is associated with lower protective immune responses compared with two doses of the mRNA vaccines [119,122], which has been also seen in the general population. (See "COVID-19: Vaccines", section on 'Approach to vaccination in the United States'.)
None of these vaccines can cause SARS-CoV-2 infection, regardless of immunosuppression. In contrast to other vaccines that consist of live or attenuated virus, none of the currently available COVID-19 vaccines contain infectious SARS-CoV-2. Although Ad26.COV2.S (Janssen COVID-19 vaccine) uses an adenoviral vector platform, the adenovirus is nonreplicative. (See "Immunizations in adults with cancer", section on 'General approach' and "COVID-19: Vaccines", section on 'General principles'.)
Timing
Relative to therapy — For patients receiving immunosuppressive therapy, our approach is to administer the vaccination between treatment cycles, when immunosuppression from treatment is minimized. However, for patients with marrow failure from disease and/or therapy who are expected to have limited or no recovery, as well as those receiving continuous treatment with targeted agents, vaccination should be administered when it is available. This approach is generally consistent with that from expert groups [152,153].
For those who received COVID-19 vaccination prior to HCT or chimeric antigen receptor modified T (CAR-T) cell therapy, the CDC recommends repeat vaccination with a full primary series at least three months after the transplant or CAR-T administration. (See "Immunizations in hematopoietic cell transplant candidates, recipients, and donors", section on 'COVID-19'.)
Some expert groups recommend holding certain immunosuppressive agents around the time of vaccination or adjusting the timing of vaccination to account for receipt of such agents to try to optimize the vaccine response. As an example, for patients receiving rituximab, the American College of Rheumatology suggests scheduling vaccination so that the series is initiated approximately four weeks prior to the next scheduled rituximab dose and delaying administration of rituximab until two to four weeks after completion of vaccination, if disease activity allows [154]. (See "COVID-19: Care of adult patients with systemic rheumatic disease", section on 'Coordinating vaccine administration with immunosuppressive therapy'.)
Relative to radiologic imaging — While previous recommendations suggested scheduling imaging prior to a dose of a COVID-19 mRNA vaccine, or four to six weeks after a dose, we no longer alter imaging schedules around COVID vaccination schedule; rather, radiologists take into consideration COVID vaccination history in interpretation of imaging findings.
Further details regarding mammography for breast cancer screening in the context of COVID vaccination are found elsewhere. (See "Screening for breast cancer: Strategies and recommendations", section on 'Recent COVID-19 vaccination'.)
Vaccine-associated lymphadenopathy — For cancer patients and survivors with an identified primary tumor site (eg, breast cancer, melanoma, head and neck cancer), it is preferable to administer the COVID-19 vaccine into the arm contralateral to the primary tumor to avoid confusing benign vaccine-associated adenopathy with malignant adenopathy on imaging studies [155-157]. By using this approach, lymphadenopathy that is detected after vaccination can often be observed for resolution, potentially reducing the need for further diagnostic imaging and biopsies.
Axillary swelling or tenderness has been reported in approximately 12 percent of patients after the first dose of mRNA-1273 (Moderna COVID-19 vaccine) and in 16 percent after the second dose [158]. Lymphadenopathy of the arm and neck has also been reported as an unsolicited event in 1 percent or fewer patients [159]. Clinically symptomatic lymphadenopathy generally developed within two to four days of vaccination and resolved within two weeks by exam [159], but can persist subclinically for weeks on imaging, with one study reporting a median of 97 days [158].
Reported rates and duration of lymphadenopathy in both trials were based upon clinical assessment, and therefore, the rates of subclinical adenopathy detected by radiologic imaging might be higher, as high as 53 percent in one study, in which most of the imaging was performed by positron emission tomography/computed tomography [160].
Impact of immune checkpoint inhibitors — We do not consider immune checkpoint inhibitors (ICIs), which stimulate immune system function, to be a contraindication to COVID-19 vaccination. Available data on patients with cancer who received COVID-19 vaccinations and are treated with ICIs suggest that vaccination is effective and well tolerated [147,150,161], without increased risk of immune-related adverse events [162]. It is also likely that the benefits of vaccination in preventing severe COVID-19 infection outweigh the potential risks in this population.
Is there a way to assess for successful immunization? — Although some antibody titers may correlate with vaccine efficacy, they cannot be reliably used to assess for immunity against COVID-19 following vaccination. Further details on assessing postvaccination serologies are discussed separately. (See "COVID-19: Vaccines", section on 'Limited role for post-vaccination testing' and "COVID-19: Diagnosis", section on 'Testing following COVID-19 vaccination'.)
SPECIAL CONSIDERATIONS
Differentiating lymphangitic spread, pneumonitis, and COVID-19 — Some systemic cancer treatments are associated with a risk of pneumonitis (eg, immune checkpoint inhibitors, gemcitabine, mechanistic [previously referred to as mammalian] target of rapamycin inhibitors). In other cases, new infiltrates on radiographic imaging may reflect disease progression (eg, lymphangitic spread) or radiation pneumonitis [163]. (See "Toxicities associated with immune checkpoint inhibitors", section on 'Pneumonitis' and "Pulmonary toxicity of molecularly targeted agents for cancer therapy".)
Besides the fact that treatment-related pneumonitis might increase the risk of serious complications if the patient develops COVID-19, it may be difficult to distinguish therapy effect versus disease progression versus viral infection. In this setting, cancer treatment should be held until the diagnosis is clarified. Testing for COVID-19 is appropriate in such circumstances, similar to the approach taken for patients with new respiratory symptoms. (See "COVID-19: Diagnosis".)
If testing for COVID-19 is negative, other diagnostic and therapeutic interventions for potential drug induced pneumonitis may be pursued. (See "Toxicities associated with immune checkpoint inhibitors", section on 'Pneumonitis' and "Pulmonary toxicity associated with systemic antineoplastic therapy: Clinical presentation, diagnosis, and treatment".)
Incorporation of telehealth — The benefits of virtual visits in oncology care include enabling care (including the maintenance of participation in clinical trials) during the pandemic while avoiding communicable disease exposure, increased patient access, and convenience. Accumulating data support mostly favorable outcomes in cancer patients [164-171]. Further discussion of telehealth is found separately. (See "Telemedicine for adults".)
Limited roles for pre- and postexposure prophylaxis — There is a limited role for pre-exposure prophylaxis with monoclonal antibodies in individuals at high risk for severe COVID-19 (eg, solid organ and hematopoietic cell transplant patients), even if they are expected to have suboptimal protection from vaccination (table 2), or are unable to receive vaccination. The activity of monoclonal antibodies has varied since the emergence of SARS-CoV-2 due to the ability of Omicron subvariants to escape neutralization. Similarly, there is only a limited role for monoclonal antibodies as postexposure prophylaxis. Further details are discussed separately. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Limited role for monoclonal antibodies in selected patients'.)
Laryngectomized individuals — Some head and neck cancer survivors will have undergone permanent laryngectomy during treatment of their cancer. In general, such patients should wear a highly efficient heat and moisture exchanger over the stoma at all times, especially when around other people. In addition, they can wear a surgical mask (preferably an N95 respirator) over the stoma, and an additional surgical mask or respirator over the nose and mouth [172,173]. (See "Alaryngeal speech rehabilitation".)
When carrying out COVID-19 testing in persons with a laryngectomy, swabbing and analysis from both the stoma and the nose may increase sensitivity [174,175]. At least one case report documents a laryngectomee who had a positive COVID-19 diagnostic test from the nasopharyngeal swab and a negative result from a tracheal swab [176].
SUMMARY AND RECOMMENDATIONS
●Cancer screening and surveillance – During the pandemic, delays in cancer screening and diagnostic/surveillance testing were frequent. However, most screening programs have resumed. (See 'Impact of the pandemic on cancer screening' above.)
●Cancer treatment in uninfected patients – Cancer care is largely proceeding along the lines of pre-pandemic standards. However, for individuals with a known severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure, particularly those who are not up to date on COVID-19 vaccination or are expected to have an inadequate immune response to vaccination, we typically hold treatment until it is clear that the patient will not develop COVID-19 from that exposure. An exception may be made for patients receiving low-risk therapies, such as hormonal treatments. (See 'Cancer treatment in uninfected patients' above.)
●Cancer patients with COVID-19
•Risk factors – Most studies suggest a higher risk of severe COVID-19 in adult patients with active cancer, although data are mixed. In particular, hematologic malignancies, lung cancer, advanced or progressive cancer, active chemotherapy, older age, and comorbid conditions are risk factors for severe COVID-19. Prior cancer is also a risk factor, but the risk is lower compared with active cancer. (See 'COVID-19 outcomes among cancer patients and survivors' above.)
•Management of COVID-19 – Overall, COVID-19 management for patients with cancer is similar to the management used for the general population. However, cancer is considered to be a risk factor for progression to severe COVID-19 (table 1), which influences available treatment options. (See 'Management of COVID-19' above.)
•Cancer therapy in infected patients – For most cancer patients with COVID-19, chemotherapy or immunotherapy should be interrupted, whether patients are symptomatic from COVID-19 or not. We typically resume cancer treatment once transmission-based precautions can be discontinued; the duration of such precautions is often determined by regional and institutional protocol. (See 'Cancer therapy in infected patients' above.)
●COVID-19 vaccination
•Vaccination in cancer patients – All individuals with active or prior cancer should receive up to date COVID-19 vaccination to prevent SARS-CoV-2 infection. (See "COVID-19: Vaccines", section on 'Immunocompromised individuals' and "COVID-19: Vaccines", section on 'Dose and interval (for immunocompetent individuals)'.)
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