Coronavirus: what are the implications for cancer patients?

Grandstand. With the coronavirus, we are living much more than a health crisis. It is also a test of resistance for our health systems, even for the countries considered as “best ranked” by the various evaluation institutes or bodies. The indicators used, such as economic performance criteria, minimization of the cost of production, satisfaction of a standard of equity specific to each company, now appear to be poorly calibrated and insufficient in the face of such an epidemic crisis. As this pandemic progresses, we understand less the absence of indicators relating to the conditions of practice of those who provide care and to their dedication.

The fight against Covid-19 goes beyond a fight against the epidemic. It is also a struggle to maintain care for other chronic or acute pathologies that have not disappeared during this epidemic period. No one can also conceal the social and economic consequences, possible obstacles to access to care for all. An estimated 3.5 million French people are affected by cancer in France and 382,000 new annual cases in 2018, i.e. around 1,450 new cases diagnosed every day of the week. The Minister of Solidarity and Health regretted that cancer screenings were no longer carried out, “Calling the French” to return to their doctor for these diagnostic procedures. This announcement is important but may not be sufficient or essential to avoid the potential serious consequences of delayed or unannounced diagnoses, treatments degraded by necessity, renunciations of care or the interruption of inclusions in therapeutic trials.

A national strategy to be implemented

It would now be necessary to quickly implement a coordinated national strategy with a coherent territorial variation adapted to the local epidemiological and health situation, even when efforts are made to limit the spread of the virus by containment and barrier measures. The paradox of our society overdone with inflationary regulations and saturated with organizations of all kinds, but which ultimately finds it very difficult to organize or impose cooperation in this unprecedented context. Yet we have entered a period when things that once seemed impossible are inevitable.

Read also “My confinement started in January, when the pain put me in bed”

Since the epidemic crisis and the post-containment period are expected to last several months, the fear of the medical community with which I associate and of the nursing staff of my establishment specialized in the fight against cancer is that we are faced with a first “wave” of more serious cases than before linked to deferred care. After this period of crisis, the duration of which no one can seriously determine, health facilities that have been under tension for many years may find it difficult, especially if they have been considered as “Covid-19 hospitals”, to be absorbed into reasonable times the care of patients awaiting treatment as well as the flow of patients with newly diagnosed cancer reintegrating a course of care. It will most certainly take months to restore optimal organization. In addition, even if the epidemic crisis ends, the deterioration of the economy could accentuate inequalities with all its consequences on access to healthcare, particularly in the case of cancer.

Towards an increase in mortality?

For breast cancer, the most frequent cancer in women, whose annual number of new cases is estimated at 54,000 in France, the surgical management of patients with favorable prognostic criteria has been postponed, in accordance with the opinion of the High Council of Public Health available from mid-March and on the recommendations of learned societies. Even if these are remarkable recommendations which are unanimous during this period, it should not be forgotten that these are expert agreements for degraded care which should not last, at the risk a loss of luck for patients with even cancer said to have a good prognosis. Other examples could be taken, such as pancreatic cancer, the incidence of which has more than doubled over the past twenty years and whose unfavorable prognosis means that any delay in diagnosis by limiting access to radiology services, that any delay in surgical management due to the absence of an available operating theater or access to post-operative resuscitation could inevitably lead to an increase in mortality.

The Lombardy region of Italy, very affected as everyone knows by the pandemic, has managed to organize itself to maintain adequate care for cancer patients during this epidemic plague. Several platforms (HUB centers) have been set up, dedicated solely to the treatment of cancer patients (including the European Institute of Oncology and the National Cancer Institute in Milan). They receive newly diagnosed surgical candidates from area hospitals more dedicated to treating Covid-19 patients. These Covid-19-free cancer hospitals can continue to care for cancer patients even if they are small cancers with good prognosis.

This attention-grabbing pandemic should not make us lose our minds. After having wagered on economic performance for years, we suddenly moved on to the almost exclusive total fight against the Covid-19. It must be remembered that there is a middle way in everything that avoids extreme attitudes while preserving the future.

Emmanuel Barranger Surgeon oncologist, director general of the Center for the fight against cancer Antoine Lacassagne, Nice (Fédération Unicancer)


Diabetes, CVD linked to the worst prognosis for COVID-19 infection

The indications so far are that people with diabetes and other chronic medical conditions, such as cardiovascular disease (CVD), will have a worse prognosis if they become infected with COVID-19, the new coronavirus that has emerged from China.

There is also evidence that diabetes can increase the risk of COVID-19 infection two to three times, regardless of other medical problems, such as CVD.

Although more detailed analyzes are needed to show a clearly defined connection between conditions such as diabetes and a worse prognosis with COVID-19, statistics suggest that this virus affects the hardest among the most vulnerable, namely, the elderly and people with multiple medical problems, especially those with long-lasting diabetes that has not been well controlled.

“The message we want to emphasize is that emergencies unmask the vulnerabilities of diabetes. The old and the sick are the most vulnerable,” said Juliana C. N. Chan, MD, Medscape medical news in an interview.

Chan is director of the Hong Kong Institute of Diabetes and Obesity at the Chinese University of Hong Kong.

Chan and other experts therefore ask that diabetic patients, those with CVD and patients with other chronic medical conditions be more vigilant in their efforts to avoid contact with the virus, although they also note that individual responses vary widely.

In the past, epidemics of infectious diseases, including severe acute respiratory syndrome (SARS) and H1N1 flu, people with diabetes were at increased risk of serious disease and death.

“I don’t think it’s an exaggeration to say that people with diabetes … are at greater risk of developing COVID-19, because the data is suggestive,” Chan observed, although he warned that long-term research will give a lot more photos. clear.

Poor control of diabetes is a risk factor for infection

Chan was a senior coauthor of a study published in Diabetology, as reported by Medscape medical news, who found that mortality rates among people with diabetes in Hong Kong have plummeted in recent years, with the exception of young people, who may be more likely to have poorly controlled diabetes.

And – especially in the context of the COVID-19 epidemic – although in that study deaths from most conditions such as CVD and cancer decreased among people with diabetes, deaths from pneumonia among people with diabetes remained virtually unchanged. .

In severe cases of infection, the COVID-19 virus invades the cells that line the respiratory tract and lungs and enters the mucus, causing pneumonia. Severe lung damage from pneumonia can cause acute respiratory distress syndrome (ARDS), which in turn can cause septic shock.

ARDS and septic shock are the leading causes of death from COVID-19.

To date, Hong Kong has had only 70 confirmed cases of COVID-19, although the first Hong Kong resident to die from the virus was a 39-year-old man with diabetes. That death was soon followed by a second death – a 70-year-old man with diabetes and other medical problems, including hypertension and kidney disease.

“Our message is to ask people with diabetes to do things early to protect themselves and reduce the risk of having problems if something happens,” Chan told Medscape.

Although the mechanism for this increased susceptibility remains unclear, research suggests that high blood glucose levels can lead to impaired immune system function.

Not yet pandemic, but Virus has claimed many more lives than SARS

By February 25, COVID-19 had infected around 80,000 people and had caused nearly 2,500 deaths worldwide.

Although the vast majority of these infections and deaths have been in China, there are now pockets of infection in Iran, Italy, Japan and South Korea, as well as a handful of cases in many other countries.

The World Health Organization (WHO) yesterday stopped calling the epidemic a pandemic, but stressed that status could change at any time.

Although COVID-19 appears highly transmissible, only a small percentage of people seem to develop a serious disease and an even smaller number die from the infection.

A recent study of 44,672 confirmed cases of COVID-19 that had been reported until 11 February and which have been analyzed by the Chinese Centers for Disease Control and Prevention (CCDC) shows that 80.9% of people at who was diagnosed with COVID-19 had a mild illness.

So far, the overall case death rate (CFR) in China is 2.3%, lower than the previous coronavirus outbreaks caused by SARS (CFR: 9.6%) and Middle East respiratory syndrome (MERS) (CFR: 34.4%).

That being said, since COVID-19 has infected many more people than SARS or MERS, the latest coronavirus on the block has already caused many more lives.

This in turn raises the question: who is most at risk of serious disease and death from COVID-19?

Case mortality rates vary based on factors such as age, gender, basic medical conditions, and geography. Outside the Hubei province in China, the epicenter of the epidemic, the CFR can reach 0.4%, compared to 2.9% within the province.

The mortality rate for diabetes is high, but the interpretation is complicated

So far, for all age groups, the highest CFR is among people aged 80 or over, at 14.8%. CFRs were higher in people with other medical conditions than in healthy people.

CVD and diabetes are high on the list, in the event that mortality rates of 10.5% and 7.3%, respectively, compared to 0.9% for people without any previous disease, according to the latest CCDC report above.

Prior to the publication of this report, two relatively small case series of COVID-19 hospitalized patients in Wuhan also suggested that older men with underlying medical problems, especially CVD and diabetes, are more likely to develop disease. serious from the virus.

However, experts warn that for COVID-19 and similar infections, several factors can distort the data, making interpretation difficult.

“The identified cases tend to be in patients who have a more serious disease than younger and healthier individuals who stay at home and do not seek medical treatment,” said Preeti N. Malani, MD, an infectious disease and health specialist. principal officer of the University of Michigan medical school, Ann Arbor.

“This is also the case for individuals who are sick enough to be hospitalized. There are more people with more chronic conditions, including diabetes [among hospitalized individuals]”Malani told Medscape via email.

“Overall, diabetes can be an indicator of other chronic health conditions such as heart disease and obesity, which could contribute to an increased risk of infection,” added Malani.

“Diabetes is also much more common with age and will continue to be an indicator of poor results [all of] these reasons, “he said.

Every person with diabetes is different; Use common sense

All this makes it difficult to make fun of the individual contribution of diabetes to the risk of infection.

“The percentage in which each medical condition contributes to … the risk of infection is difficult to analyze,” explained Andrea Luk, MBChB, FHKCP, FHKAM.

Luk is an associate professor at the Chinese University of Hong Kong and is the other senior coauthor of the study Diabetology.

“Certainly a person with diabetes and cardiovascular disease would have more risks than a person with diabetes and good glucose control and without other comorbidities,” he continued.

But because every person with diabetes is different, it’s important to consider the whole package, he stressed.

If someone with diabetes succumbs to infections, it has a lot to do with glycemic control, the duration of diabetes and the comorbid conditions related to diabetes, such as heart disease, kidney disease and stroke, as well as their age, weight and if they smoke.

Chan further clarified: “We have to judge this case by case. It is not possible to apply it across the board to all people with diabetes. A person with well-controlled diabetes is very different from someone with poorly controlled diabetes. They have a different set of factors. of risk and complications “.

Pending more detailed analysis, Chan, Luk and Malani all suggest common sense measures for patients with diabetes, CVD and other chronic conditions: stay up to date with vaccinations, avoid large crowds, wash hands frequently, avoid touching the eyes or the mouth (the so-called T zone) and wearing facial masks in the areas where COVID-19 is prevalent.

People with symptoms should also wear a mask to avoid spreading the infection to others.

Even a bad year for the flu, difficult to distinguish between the two

Malani added: “Although there is a lot of attention and concern for COVID-19, this one has [also] it has been a terrible year for seasonal flu. I recommend flu shots, especially for … patients with diabetes. “

He also suggested being considerate of the trip.

“This may not be a good time for a non-essential trip to Asia as the situation is evolving. The COVID-19 risk is still low, depending on where you go, but the risk of an interrupted trip is real,” he said. observed.

Even without an emergency like COVID-19, Chan and Luk say they can’t emphasize enough the importance of optimal glucose control for people with diabetes.

“People with diabetes or other chronic conditions should be much more careful about protecting themselves from infections,” reiterated Luk.

They should also have a lower threshold for seeking treatment if they feel they are developing symptoms of infection, he noted.

“At first, it’s hard to tell if it’s flu or COVID-19 because it looks the same way,” he said.

Chan, Luk and Malani have not disclosed relevant financial reports.

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