The coronavirus 2019 (COVID-19) pandemic has challenged many health care systems and put them under unprecedented pressure. Maintaining adequate nutrition helps bolster the patient's immune system and subsequently helps the body fight against COVID-19 infection. Maintaining adequate nutrition becomes more pertinent in patients with cancer who are already immunocompromised because of their disease and cancer therapy. In this editorial, we focus on the challenges of maintaining adequate nutrition in addition to providing comprehensive cancer care during the COVID-19 pandemic.
Almost all nations and their citizens have been deeply affected by various aspects of this pandemic, from emotional breakdown to loss of life. As of April 30, 2020, there were 3,261,473 confirmed cases of COVID-19 with 230,381 deaths across the globe.[1] With this high disease burden, it is important to ensure that the most vulnerable subset of the population is receiving adequate attention, guidance, and care.[2] Nutrition constitutes an important but not prioritized aspect of cancer treatment. From the oncology perspective, COVID-19 has affected almost every aspect of cancer care.
On the basis of the current literature, the elderly, people with multiple comorbidities, pregnant women, those with weaker immune systems (eg, people with HIV), and patients with cancer fall into the category of the COVID-19–susceptible population.[3,4] Missing crucial chemotherapy cycles, running out of prescription medication, canceling oncology-related surgeries, and risking becoming infected with COVID-19 are just a few of the many top concerns of patients with cancer. Unfortunately, patients and even the treating oncologists often tend to overlook the importance of maintaining adequate nutritional status during this pandemic.
When it comes to the nutritional needs of patients with cancer, oncology dietitians are the professionals who make sure that a tailored nutrition regimen is provided to every patient with cancer and is constructed with the cancer site, stage of the tumor, treatment plan, and patient's acceptability in mind. The Commission on Cancer now recognizes nutrition services as standard of care in oncology and states that nutrition services must be provided by a registered dietitian nutritionist.[5] COVID-19 infection is testing the expertise of oncology dietitians who help the treating oncologists provide comprehensive cancer care during this pandemic (Figure 1), which has made good nutrition and hydration even more critical. In oncology nutrition, there are several concerns that relate to managing coronavirus.
Figure 1.
Schema describing the interactive and collaborative effort required to provide a comprehensive cancer care.
Currently, there is no definitive antiviral agent or specific vaccine against COVID-19, which means that COVID-19 treatment regimens vary widely in hospitals across the world. Treatment options include, for example, remdesivir, hydroxychloroquine, azithromycin, and plasma therapy. In addition to these drugs, adjunctive therapies such as vitamin C, vitamin D, zinc, and melatonin are joining the treatment protocol for patients with COVID-19.
Regarding patients with cancer, a major concern is the overuse of supplements, specifically antioxidants, which are currently being promoted to prevent and treat coronavirus infections. The American Institute for Cancer Research does not recommend using supplements for cancer prevention.[6] For patients receiving active chemotherapy and radiation, the use of vitamins, herbal and traditional medications, and mineral supplements is controversial. In some cases, such supplements may interfere with chemotherapy or radiation.[7,8] Bairati et al[8] studied 540 patients with head and neck cancer (HNC) who were undergoing radiation treatment. They found a significantly higher death rate among patients who were prescribed vitamin E supplements (400 IU once per day) compared with placebo.
High doses of vitamin C are currently being studied in patients with COVID-19,[9] based on data from previous randomized controlled trials, which showed reduced mortality with high doses of intravenous vitamin C in sepsis-related acute respiratory distress syndrome.[10] However, high-dose vitamin C can be contraindicated in some anticancer treatment regimens, including those that use doxorubicin, mitomycin, and bleomycin.[11] The American Cancer Society has recommended that oncologists and patients use caution and avoid antioxidant dietary supplements during treatment.[12] Although it may be worthwhile to try high doses of vitamin C in patients with COVID-19 who do not have cancer, the current literature regarding patients with COVID-19 who do have cancer is neither for nor against its use.
A subset of patients with cancer might require a feeding tube to ensure that they get the proper nutrition during cancer treatment,[13] specifically those in the HNC population.[14] The American Dietetics Association Oncology Evidence-Based Nutrition Practice Guideline indicates strong imperative evidence for using enteral nutrition to increase calorie and protein intake for outpatients with stage III to IV HNC who are undergoing intensive radiation treatment. Maintenance of nutrition status by enteral nutrition during radiation therapy may improve tolerance to that therapy and promote better outcomes. For the same reason, it is our practice for patients with stage III to IV HNC who receive concurrent chemotherapy and radiation to traditionally get a feeding tube placed prophylactically before treatment starts. Placement of a percutaneous endoscopic gastrostomy tube may be considered an elective procedure, so we are facing difficulties placing those tubes because most elective surgeries such as this one are currently on hold because of the COVID-19 pandemic.
For now, we are using a watch-and-wait approach rather than a prophylactic approach regarding placement of feeding tubes. However, we are concerned that this might compromise the nutrition and hydration of our patients and might ultimately lead to more emergency room visits and hospitalization. We are trying to avoid any unnecessary office visits for our patients with cancer unless they are mandatory. We are motivated to use and are encouraging our patients to use telemedicine venues such as Skype, Zoom, and other portals to share information and answer non-urgent questions. But from a practical standpoint, we are finding it difficult to connect with some patients who are not answering their phones.
There is always a concern about food safety and security for our patients with cancer. Some of our patients have limited access to grocery stores, they may ignore expiration dates in an effort to make food last longer, which puts them at risk for foodborne illnesses, and the quality of food might not be good because many patients are not buying much fresh food and instead are choosing more comfort food and unhealthy food.
So far, during this COVID-19 pandemic, the nutrition of patients with cancer is still an under-recognized aspect of care that needs immediate attention by world health care organizations. Malnutrition will likely make recovering from COVID-19 more difficult and will further weaken the patient's immune system. We hope that the messages of self-care, healthy lifestyle, and balanced nutrition for patients with cancer during the COVID-19 crisis will now be taken seriously.
J Oncol Pract. 2020;16(10):621-623. © 2020 American Society of Clinical Oncology
