COVID: Considerations with Cancer
“Patients should talk with their oncologists and health care teams to discuss their options to protect themselves from infection.”
-Merry Jennifer Markham, MD, FACP, FASCO, Cancer.Net
At a glance
People with cancer can continue to receive care during the pandemic, though changes such as more virtual visits with your doctor/team, changes in the clinic/healthcare environment, and scheduling to reduce your risk of exposure to COVID have become common. Your treatment will be prioritized if it is considered essential to improving your survival. Other treatments may be delayed, for your safety, if a delay will not negatively affect your outcomes. Since the pandemic began, many people with cancer have been safely ushered through their treatment and follow-up care.
Some people with cancer are at greater risk for more serious problems from COVID-19 infection:
- Those whose immune systems are compromised (immunocompromised) by either cancer or treatment
- Those with additional health conditions such as diabetes, obesity or heart disease
- Those who smoke
- Older adults
But not all people with cancer are at increased risk of a serious case of COVID-19.
Before the pandemic, many who have had cancer were already used to precautions such as wearing a mask, staying away from large crowds of people, and good handwashing. These precautions continue to be a mainstay for reducing your risk of exposure to COVID.
Major oncology care organizations, as well as the CDC, strongly recommend COVID vaccination for most people with cancer as a way to reduce a serious COVID infection. Integrative medicine specialists as well as oncology associations such as the American Society for Clinical Oncology (ASCO) further recommend self-care and healthy lifestyle practices as well as certain complementary therapies for strengthening health and resilience.
Cancer care during the pandemic
Cancer treatment should not be discontinued or delayed if it can affect overall survival. A review and meta-analysis in late 2020 confirmed that delaying cancer treatment increases the risk of dying.1 Acquiring COVID-19 can also have serious impacts on cancer treatment.2
Cancer treatment centers and other healthcare providers have had to make continual changes such as in physical space and other safety measures, as well as treatment and testing schedules, to make care delivery as safe as possible for both patients and staff. These accommodations are subject to frequent change based on surges in infections, new virus variants as well as COVID testing, vaccination, and treatment guidelines. Whether you’re on the giving or receiving end of treatment and follow-up care during the pandemic, you, by now, have experienced the head-spinning speed with which these changes have occurred. If you ever have questions about what you need to do and/or what your oncology team is doing to keep you safe while receiving care, don’t hesitate to ask your doctors and nurses.
Immune compromise from cancer
People with cancer often have weakened immune systems, known as immunocompromise. Certain cancers such as blood cancers and myeloma can compromise the immune system. In general, immunocompromise is usually due to treatment for cancer, such as a bone marrow transplant for blood cancer or intensive chemotherapy for certain types of leukemia. Some less intensive chemotherapy regimens can still cause immunosuppression.
Immunocompromise can also come from intense radiation therapy or surgery. Immunocompromise means the body is less effective fighting diseases, so people with cancer and their family members need to follow steps to protect themselves. Precautions include COVID vaccinations, frequent handwashing, physical distancing, and masks.
Having a history of cancer may increase your risk of severe illness from COVID-19. A study found that breakthrough infections in fully vaccinated people were more severe among those with cancer than in healthy people. People with blood cancers and/or low lymphocyte counts were at highest risk for serious and sometimes fatal breakthrough infections.3
Emerging evidence indicates that people with hematological malignancies, including leukemia, lymphoma, and multiple myeloma, have a greater risk of infection and complications than patients with other cancer diagnoses. People with progressing cancer when they are diagnosed with COVID-19 may be at higher risk of death or serious health complications compared with those with disease in remission.4 Among people at higher risk, even mild symptoms of COVID warrant medical attention.
However, not all people with cancer are at increased risk of a serious case of COVID-19. Cancer authorities recommend you speak with your doctor if you have concerns about your risks for developing COVID-19 or for serious disease as a result of current or past cancer treatment.5
- CancerNet: Coronavirus and COVID-19: What People With Cancer Need to Know
- American Cancer Society: Common Questions about the COVID-19 Outbreak
Guidelines for people with cancer
Some of the major professional oncology organizations provide guidance related to cancer care during the pandemic. Main points for people with cancer are summarized here.
Guidelines for health professionals are in Are you a health professional?
- Stay at home as much as possible and avoid areas where people gather.
- Continue to wear a mask and keep your distance from others.
- Follow other practices for preventing infection, such as frequent hand washing, cleaning objects and surfaces that are frequently touched, and not touching your eyes, nose, or mouth.
- Follow guidance on travel restrictions issued by the CDC or the World Health Organization (WHO).
- Some cancer appointments, especially pre-treatment meetings and follow-up appointments, may move online to minimize contact with others.
- You may not be able to have a family member or friend accompany you to your hospital or clinic for treatment.
- CDC: Travel
- World Health Organization (WHO): Travel advice
Preparing for COVID
- Keep enough essential medications, both prescription and over-the-counter, to last for at least 1 month.
- Have your health care wishes in writing, in case you are too sick to make decisions for yourself. Make sure the person who will speak for you has a copy.
If you think you have COVID
- Contact your oncologist as soon as possible if you are in active treatment or your family doctor if you aren’t in active cancer treatment and/or not seeing your oncologist regularly.
- Get tested for the virus.
- As far as possible, stay connected to your support system. Connect with your family and friends virtually, through video chats or phone calls.
- Consult your oncologist about the benefits and risks of continuing or delaying treatment.
- Severe symptoms could be a medical emergency, and you may need to call 911 (in the US). If you or your loved one has symptoms such as trouble breathing, persistent pain or pressure in your chest, new confusion, or bluish lips, you should seek medical attention immediately.
- Patients with cancer and survivors of cancer can be vaccinated against COVID-19 as long the person isn’t allergic to the ingredients in the vaccine. Major professional oncology organizations recommend the vaccine for people with cancer, since many are at higher risk of severe COVID.6 7
- Even people who have tested positive for COVID in the past should be vaccinated, unless your doctor recommends against vaccination for a medical reason.
People in active treatment (chemotherapy or radiotherapy) may do better being vaccinated between or after treatment has ended. You may need to delay your vaccine if you’re undergoing some treatments, such as bone marrow/stem cell transplant or CAR T-cell therapy. Talk with your oncologist about timing your vaccination.
- Information about both vaccination and COVID treatment may change over time. Check with your oncology team or Cancer.Net for updated information.
- Preparing to Be Vaccinated: An Integrative Approach (blog)
- American Society for Clinical Oncology (ASCO) Cancer.Net: COVID-19 Resources for People with Cancer
- National Cancer Institute: COVID-19: What People with Cancer Should Know Guidance for those with cancer about getting vaccinated and boosted
- National Comprehensive Cancer Network (NCCN): NCCN COVID-19 Vaccination Guide for People with Cancer
- European Medical Society for Oncology (EMSO): Cancer Care during the COVID-19 Pandemic: An ESMO Guide For Patients
- Institute for Functional Medicine: COVID-19 Vaccine Updates and Latest Information
December 2021: CancerChoices advisor Jen Green, ND, FABNO, offers advice on reducing risks of severe COVID-19. These excerpts pertain especially to people with cancer. Read her full document: Integrative Immune Support.
Melatonin is mentioned as a coronavirus treatment in some studies and recommended by some physicians. However, melatonin is not advised for people with blood cancers. Speak to your physician or primary care professional about dosing and appropriateness for you.
Vitamin A deficiency is more common in people with autoimmune conditions, inflammatory bowel disease, people who take statin drugs and people with cancer. If you are at risk of being deficient, fasting serum retinol is a blood test that can tell you your level.
Both deficient and excess vitamin A can suppress immunity so please be very mindful with dosing. Vitamin A supplementation is very important for people who are deficient in it, but in children with normal levels, high dose vitamin A can make their respiratory infections worse. ((Chen H, Zhuo Q, Yuan W, Wang J, Wu T. Vitamin A for preventing acute lower respiratory tract infections in children up to seven years of age. Cochrane Database of Systematic Reviews. 2008 Jan 23;(1):CD006090; Stephensen CB, Franchi LM et al. Adverse effects of high-dose vitamin A supplements in children hospitalized with pneumonia. Pediatrics. 1998 May;101(5):E3.)) High dose Vitamin A is also not safe for pregnant women.
Zinc deficiency is more common with vegans/vegetarians, people with chronic diarrhea, and cancer patients.
In an observational study in New York City, the addition of 50mg elemental zinc twice daily for five days to hydroxychloroquine and azithromycin did not impact ICU duration, but did increase the frequency of patients being discharged home, decreased the need for ventilation, decreased admission to the ICU, and lowered mortality or transfer to hospice. ((Carlucci PM, Ahuja T et al. Zinc sulfate in combination with a zinc ionophore may improve outcomes in hospitalized COVID-19 patients. Journal of Medical Microbiology. 2020 Oct;69(10):1228-1234.))
- As an adult, do not take more than 80mg zinc daily for more than a brief period because high doses of zinc can become immune suppressive. ((Johnson AR, Munoz A, Gottlieb JL, Jarrard DF. High dose zinc increases hospital admissions due to genitourinary complications. Journal of Urology. 2007 Feb;177(2):639-43; Wellinghausen N, Rink L. The significance of zinc for leukocyte biology. Journal of Leukocyte Biology. 1998 Nov;64(5):571-7.))
- Always take zinc with food because it can cause nausea on an empty stomach.
- Zinc interacts with some antibiotics such as cipro and doxycycline.
Resources on integrative medicine and COVID
Cancer tends to thrive in an inflamed body. Strategies that minimize inflammation to reduce cancer risk may also reduce risks of severe COVID-19. ((Five to Thrive Live. Critical Covid-19 Update. March 20, 2020. Viewed March 24, 2020.))
These resources are not specific to COVID with cancer, but they guide you in supporting an appropriate immune response in general. They recommend measures to strengthen resilience and health:
- Institute for Functional Medicine:
- Boosting Immunity: Functional Medicine Tips on Prevention & Optimizing Immune Function During the COVID-19 (Coronavirus) Outbreak
- COVID-19: Functional Medicine Resources
- Wayne Jonas, MD: Resources to Support a Healthy Immune System Right Now
- Cynthia Li, MD: How to Shield Yourself against COVID-19: Science-Based, Integrative Medicine Strategies for a Once-in-a-Century Pandemic (free e-book)
Are you a health professional?
American Society for Clinical Oncology (ASCO):
- COVID-19 Provider & Practice Information
- General Information About COVID-19 and Cancer
- Disease-specific information (includes information from other major medical oncology organizations as well as published research)
- Cancer Treatment and Supportive Care
- Cancer Screening, Diagnosis, Staging and Surveillance
Memorial Sloan Kettering Cancer Center: Recommendations for testing and treating outpatient cancer patients in the era of COVID-19
National Comprehensive Cancer Network (NCCN):
Society for Integrative Oncology: TCM and Integrative Oncology Practice in China During COVID-19
European Medical Society for Oncology (EMSO): Cancer patient management during the COVID-19 Pandemic
Korean Cancer Association: Guidelines for Cancer Care during the COVID-19 Pandemic in South Korea
Vaccination and cancer
Experts agree that the COVID-19 vaccine is recommended for people with cancer, cancer survivors, and those currently on cancer treatment, including chemotherapy and immunotherapy. The best available evidence suggests the odds of dying or experiencing severe complications from COVID-19 are roughly two times higher in a person with cancer than a person without cancer. The only people who should not be offered the vaccine are those who may have a harmful reaction, such as anaphylaxis, to a specific vaccine component”8
With regard to vaccine efficacy, patients treated for solid tumors mount a good serological response to the vaccine. However, in certain hematologic cancers, humoral responses to the vaccine are subdued. ASCO explains that there’s limited evidence available regarding vaccination of patients with cancer receiving active treatment, but they are not aware of any study that has shown any safety concern for such patients.9 Some of the guidelines listed below provide strategies for timing vaccinations when patients are in active treatment and/or receiving immune globulin treatment.
- National Comprehensive Cancer Network (NCCN): Recommendations of the National Comprehensive Cancer Network® (NCCN®) Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis
- American Society of Clinical Oncology (ASCO): COVID-19 Vaccines & Patients with Cancer
- European Medical Society for Oncology: COVID-19 vaccination in cancer patients: ESMO statements
- Herishanu Y, Avivi I et al. Efficacy of the BNT162b2 mRNA COVID-19 vaccine in patients with chronic lymphocytic leukemia. Blood. 2021 Jun 10;137(23):3165-3173.
- Oncology Association of Naturopathic Physicians: OncANP Statement in Support of COVID-19 Vaccination
General information and research on COVID and cancer
- Moss Reports: Cancer and Coronavirus
- Cancers: Blood cytokine analysis suggests that SARS-CoV-2 infection results in a sustained tumour promoting environment in cancer patients
- Nature Medicine: CD8+ T cells contribute to survival in patients with COVID-19 and hematologic cancer
Conventional cancer care and COVID
- American Society of Clinical Oncology (ASCO): COVID-19 Patient Care Information
- National Comprehensive Cancer Network: Coronavirus Disease 2019 (COVID-19) Resources for the Cancer Care Community
Integrative care and COVID
- Society for Integrative Oncology webinar: The New Now: Skills for Coping with Uncertainty during Challenging Times
- Block KI. Integrative cancer therapies: learning from COVID-19. Integrative Cancer Therapies. 2020 Jan-Dec;19:1534735420932652.
- The Andrew Weil Center for Integrative Medicine:
- Integrative Considerations during the COVID-19 Pandemic, authored by Lise Alschuler, Andrew Weil, Randy Horwitz, Paul Stamets, Ann Marie Chiasson, Robert Crocker and Victoria Maizes
- Integrative medicine considerations for convalescence from mild-to-moderate COVID-19 disease
COVID Vaccination and Cancer
- National Comprehensive Cancer Network: Cancer and COVID-19 Vaccination
- American Society of Hematology: COVID-19 and Indolent Lymphomas: Frequently Asked Questions (section “Should patients with indolent lymphoma receive a vaccine for SARS-CoV-2?”)
Written by Laura Pole, RN, MSN, OCNS, and Nancy Hepp, MS; most recent update on January 12 , 2022.