COMMENTARY

COVID-19 Mortality Risk 'Profoundly Disturbing'

Mark A. Lewis, MD

Disclosures

March 18, 2020

This transcript has been edited for clarity.

Hello. This is Mark Lewis for Medscape. I am the director of gastrointestinal oncology at Intermountain Healthcare in Salt Lake City, Utah.

I'm recording this video on March 11, 2020. It's important to time-stamp this recording because I'm addressing an issue that is literally changing by the day, and that is, of course, the coronavirus and the disease it causes, COVID-19.

This is truly an issue of global concern. Earlier today, the World Health Organization officially declared it a pandemic, meaning that this is a viral illness that we may not be able to contain. We may simply have to mitigate its spread and the effects on patients.

I'd also like to give my profound thanks to colleagues in the global healthcare community, especially those in China and Italy who have been so brave and gracious in sharing with us all that they've seen in their clinical settings. The on-the-ground reporting, whether through social media or through traditional journals, has been absolutely remarkable, and harrowing, in its detail.

In particular, some of the work out of China that was published almost contemporaneously in the New England Journal of Medicine really gives us a perspective into the first several thousand cases that they had seen there and the outcomes thereof.

But why is an oncologist talking about coronavirus? Well, first of all, as I've stated, this is an issue of universal concern. Second, cancer patients and others with significant comorbidities are particularly at risk for the effects of COVID-19.

One of the analyses published in The Lancet Oncology from our Chinese colleagues showed that cancer patients are fivefold more likely to suffer severe effects from coronavirus compared with the average member of the population. I suspect that's because, either intrinsically or through the after-effects of treatment, cancer can create immunocompromise.

Although I tend to see patients at their peak when they're coming back for their next chemotherapy treatment, there's no doubt that chemotherapy can be cyclic in its effects on the immune system. Patients at their nadir after treatments may be particularly vulnerable to infection.

I'm also discussing this because I've heard many dismissive statistics around the coronavirus, and in particular, the case fatality rate. I'd like to talk about that for a second. Case fatality rate, or CFR, is a fraction. The denominator is the number of affected people. The numerator—and I cannot state this more starkly—is the number of people that have died. We cannot rest until the numerator is as close to zero as we can possibly make it.

When we say things like the case fatality rate is only 3% or is only in the low single digits, I think we're dramatically minimizing the impact on the population scale. If you take a tiny coefficient and multiply it by a massive number, you can still end up with a very substantial number [of fatalities].

Dr Anthony Fauci, who's done a marvelous job communicating to the American public about this disease, estimated today that tens of millions of Americans will be affected by the illness. If you take that sum and multiply it by even a tiny fraction, that is thousands and thousands of people dying.

Some say that it is "only the flu." First of all, this is an emerging disease and we're still learning its characteristics relative to other viruses. In fact, its novelty is both unsettling intellectually and troubling biologically because we don't have immunity to it. Second, our best current estimate is that its mortality risk is likely 10-fold that of seasonal influenza. This is not something to be taken lightly or joked about.

The reason I take this so personally is that 3 years ago I had a cancer surgery on my pancreas, the Whipple operation, for which I was cited a 3% mortality rate. I remember at the time I was consenting for the procedure that that number seemed low. However, the night before the operation, I couldn't sleep because that number loomed large.

I had a dark night of the soul. I thought, Well, when I wake up in the morning, I have a 1 in 33 chance of dying, which was profoundly disturbing, to say the least. My heart goes out to everybody who is thinking about this, dealing with this, or contemplating their own mortality.

I'd also remind everyone that we have an ethical obligation to protect the most vulnerable among us. You might think that you're young, healthy, and not at risk. You might be right about that. Maybe the silver lining of this disease is that it seems to leave children relatively unaffected.

Let's not forget that it's also highly transmissible through surface contact and respiratory droplets. We really owe it to those among us who are sicker, who have cancer, and who are elderly to protect them. We have to band together to protect them.

We can get through this together—not by an individualistic mindset of panic-buying and hoarding, but through the best kind of group thinking of how we can address this threat collectively.

I'd like to close with a line of poetry from Philip Larkin that I think really resonates with me at this moment in time: We should be careful/Of each other, we should be kind/While there is still time.

For Medscape, this is Mark Lewis, and I truly wish all of you the best of health.

Mark A. Lewis, MD, is director of gastrointestinal oncology at Intermountain Healthcare in Salt Lake City, Utah. He has an interest in neuroendocrine tumors, hereditary cancer syndromes, and patient-physician communication.

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