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Ask the Experts: Common questions about kidney cancer and COVID-19
You may have heard that the risks of complications and death from COVID-19 are much greater if you have other medical conditions such as heart disease, chronic kidney disease or cancer. It is only natural for the kidney cancer community to wonder how COVID-19 might affect us given the fact many of us, or our loved ones, have both a history of cancer or kidney disease.
We’ve gathered some quotes from some of the top kidney cancer experts to help answer patients’ questions about how kidney cancer and the novel coronavirus COVID-19 impact each other. This content is quoted and originally found on the Kidney Cancer Association Website and the Uromigos podcast The KCA has gathered some great resources, you should check it out if you’re looking for more understanding on this topic
This page will be updated as more information becomes available. Last update: 6/10/20.
Q: Does where a person is on their kidney cancer journey – the stage, when they’ve had surgery and how long ago, if they have no evidence of disease (NED), etc. – impact their risk of infection with COVID-19? How?
Dr. Brian Rini: This is not entirely known but it is likely that patients with an active cancer (i.e. not NED) and undergoing active therapy are likely at higher risk of infection.
Dr. Toni Choueiri: I would think advanced aged and presence of comorbidities would matter irrespective. Someone who had surgery and is not on active therapy would be at lower risk. [Nobody’s] risk is zero!
Q: Can the risk of getting COVID-19 be lessened or reduced?
Dr. Brian Rini: Yes, in the sense that we are trying to keep patients away from the hospital/medical center as much as possible with telehealth visits, shipping study drug when possible, possibly holding treatments or spacing out infusions. These are individual decisions that need to be discussed between the patient and the provider.
Dr. Toni Choueiri: All the data so far points toward social distancing, masks, proper hygiene: all playing an important role. Studies are coming and there is a flurry of research… Just today I saw a Nature Medicine paper about randomized controlled trials of masks vs non-masks. It shows masks reduce transmissions!
Q: How does where a person is on their kidney cancer journey impact the risk of becoming seriously ill if they become infected with COVID-19?
Dr. Brian Rini: This is not known. At Vanderbilt, we have created a national registry, called CCC-19, that is collecting data on patients with active cancer and COVID-19 infection to understand how the cancer affects COVID-19 infection and vice-versa.
Dr. Toni Choueiri: Older age, heart and lung comorbidities, and immunosuppression are all [some of the] risk factors. In the context of renal cell carcinoma (RCC) – already people with RCC [may] have these risk factors based on the average population of patients. Add to that any immunosuppression that can happen. An example is the use of corticosteroids, sometimes for a prolonged period of time, in patients with advanced disease who receive immune checkpoint inhibitors and develop immune-related side effects.
Q: Does the risk of serious illness change a lot among individual kidney cancer patients (as opposed to cancer patients as a group)?
Dr. Toni Choueiri: Adjusted for all underlying conditions, stage, comorbidities, medications, chemotherapy/systemic therapy, I do not think RCC is different here.
Q: Can the risk of serious illness in cancer patients who become infected be lessened or reduced?
Dr. Brian Rini: There are numerous approaches to treating COVID-19 infection, both serious and less serious infections. No approach at present is proven to help. It is important to note that most patients with COVID-19 infection (95%) will get better and 85% total do not require hospitalization.
Dr. Toni Choueiri: Clinical trials are being conducted at a rapid pace. Consortiums are being formed to study COVID-19 in cancer patients (for example, The COVID-19 & Cancer Consortium [CCC19]; for more information please check the journal article The COVID-19 & Cancer Consortium (CCC19): a collaborative effort to understand the effects of COVID-19 on patients with cancer.) Strategies to clear the virus in patients with no symptoms may not be the same strategies or treatments in patients with severe COVID-19. A large randomized trial published in the New England Journal of Medicine showed the antiviral drug Remdesivir was superior to a placebo in shortening the time to recovery (but not overall survival) by 4 days in adults hospitalized with COVID-19 and evidence of lower respiratory tract infection.
The future, I believe, is a vaccine and to be ready and have clear systems in place for pandemics. Early results from a vaccine produced by Moderna was a good first step (still in the research domain). We have to continue simple measures of self-distancing, and face masks to prevent the spread as much as possibly, taking into account a very slow and careful consideration when/how we are all back together.
Q: Does having a partial nephrectomy increase the risk of getting or becoming seriously ill from COVID-19? Does having only one functioning kidney increase the risk of getting or becoming seriously ill from COVID-19?
Dr. Elizabeth Plimack: For all these questions, the number of kidneys or surgical history do not matter. What is relevant is renal function. If a patient’s renal function is normal or near normal, they should not be at any increased risk. If a patient’s renal function is abnormal, they should ask their nephrologist about their particular level of risk in light of their renal function as the information on this is rapidly evolving as we learn more about COVID-19.
Dr. Chung-Han Lee: Does having a partial nephrectomy increase the risk of getting COVID-19? Having a prior partial nephrectomy should not increase the risk of getting COVID-19. We would ask that you just take routine precautions in order to minimize your exposure risk. As the recommendations in terms of sheltering and social distancing are rapidly changing, I would recommend that you keep up to date regarding the recommendations in your area. It is also quite important to discuss with your medical oncologist re: how to best balance the risks related to COVID-19 and the risk related to your cancer. Depending on your specific situation, it may involve altering the frequency of infusions or altering the frequency of imaging; however, there are many factors that need to be considered in order to make this decision.
Does having a partial nephrectomy increase the risk of becoming seriously ill from COVID-19? The data for the risk of severe illness related to COVID infection for cancer patients remains quite limited. Much of the information comes from small series or are from non-peer reviewed sources. In the very small series from China, a both a history of treated/cured and active cancer was associated with an increased incidence of severe illness from COVID-19. However, given the limited data, is hard to know whether this universally applies to all types of cancer and also whether other comorbidities may account for the increased severity.
Does having only one functioning kidney increase the risk of getting COVID-19? Having a prior radical nephrectomy should not increase the risk of getting COVID-19. We would ask that you just take routine precautions in order to minimize your exposure risk. As the recommendations in terms of sheltering and social distancing are rapidly changing, I would recommend that you keep up to date regarding the recommendations in your area. It is also quite important to discuss with your medical oncologist re: how to best balance the risks related to COVID-19 and the risk related to your cancer. Depending on your specific situation, it may involve altering the frequency of infusions or altering the frequency of imaging; however, there are many factors that need to be considered in order to make this decision.
Does having only one functioning kidney increase the risk of becoming seriously ill from COVID-19? After a radical nephrectomy, patients often a decreased in kidney function. It is currently unknown whether surgical loss of kidney function conveys the same risk as loss of kidney function due to chronic disease. The data for the risk of severe illness related to COVID-19 infection for cancer patients remains quite limited. Much of the information comes from small series or are from non-peer reviewed sources. In the very small series from China, a both a history of treated/cured and active cancer was associated with an increased incidence of severe illness from COVID-19. However, given the limited data, is hard to know whether this universally applies to all types of cancer and also whether other comorbidities may account for the increased severity. Anecdotally, we have seen kidney cancer patients who have experienced the entire spectrum of symptoms from very mild to fatal symptoms. We currently still do not have sufficient numbers to determine how the distribution of severity changes. Also of note there is also overlap between some of the symptoms of mild COVID-19 illness and the side effects of RCC TKI and immunotherapy.
Q: If someone has only undergone surgery (partial or total nephrectomy but no other treatments) what is the risk of getting COVID-19? The risk of becoming seriously ill from COVID-19?
Dr. Christopher Wood: Patients who have undergone renal surgery are at no increased risk of contracting COVID-19 or becoming seriously ill from COVID-19 than the general population. Like everyone else, kidney cancer survivors should practice social distancing and frequent hand washing. Face masks and gloves can also be employed.
Q: How are kidney cancer survivors, particularly after nephrectomy, compromised when it comes to COVID-infection?
Dr. Christopher Wood: Survivors are not compromised in any way. This virus infects through the respiratory tract and can impact pulmonary and cardiovascular function. There is no direct impact of the virus on renal function to my knowledge.
Q: How can people with kidney cancer keep up with appointments for scans, infusions, or general check-ups if they can’t go to the appointment in person?
Dr. Scott Haake: Many institutions have been rapidly increasing the utilization of telephone and video conferencing for routine appointments. For patients not actively receiving therapy and are otherwise feeling well, this makes a lot of sense. As for patients who are actively receiving therapy, if they are stable on their medicine and not actively having side effects, you may discuss with your provider about whether getting labs and scans without face-to-face clinic appointments is an option.
Q: What is the best way for patients to prepare for a telemedicine appointment?
Dr. David Braun: I think that there are a few ways that patients can prepare for telemedicine visits, both technically and mentally.
On the technical and practical side, if it is possible to review the televisit instructions and test out the connection before the actual appointment, that can save time and stress for patients. I want to emphasize that physicians should ALWAYS be understanding and patient, as these are unusual times that are new for everyone. Still, I’ve had patients who struggle to connect on the day of the visit, and I can feel their stress building up as they are struggling to connecting as soon as possible to discuss scan results (and I feel terrible about it!). I would suggest getting clear instructions from the physician’s office, and if possible, asking if there is even a way to test the connection before the appointment itself.
With respect to mentally preparing, it can be really difficult for patients to not see the physician in person, and missing that human connection. With that being said, it is important that you really do approach this as a typical visit, and that means advocating for yourself. I think it is natural for some patients to think that these telemedicine appointments are temporary, and a few patients might even hold off on bringing up specific questions or discussing certain symptoms until things “return to normal”. I would suggest the opposite – you should be asking the same questions and bringing up new or concerning symptoms in the exact same way as before. If something needs to be evaluated in person, almost all physician offices have the ability to that. If you need extra support, physicians, nurses, social workers, and support groups are figuring out ways to connect virtually. With this in mind, telemedicine hopefully won’t be a barrier to getting the care you need.
Q: Should people living with kidney cancer delay or stop their immunosuppressive therapy, immune checkpoint inhibitors, and/or stem cell transplantation?
Dr. Brian Shuch: With anything, one must weigh risks and benefits. Safety of visiting the hospital should depend on regional statistics of COVID-19. Regions greatly impacted would be higher risk. Patients with multiple comorbidities would be at greater risk. For individuals stable on the current therapy, it may be safer to perhaps delay treatment than someone who is initiating therapy. Of course, individuals should speak to their treating provider.
Q: How long of a break in immunotherapy treatment is safe to take for the immunotherapy to still be effective? Are there studies that indicate how long is too long without immunotherapy treatment?
Dr. Nizar Tannir: We know that several immune checkpoint inhibitors have a long half-life and therefore they can stay on the receptors of the immune cells for several weeks. We also know that patients with renal cell carcinoma (RCC) who developed toxicity during nivolumab and ipilimumab and discontinued therapy but were progression-free at the time of discontinuation did not have an inferior survival compared with patients who continued therapy. We still do not know about the optimal duration of immune checkpoint inhibitors in patients who are progression-free and tolerating treatment well. Although some trials have allowed therapy to be stopped after 2 years, some investigators recommend continuation of therapy beyond 2 years if the patient is tolerating therapy well. So, if a patient skips one or two infusions, they can hopefully make up later when travel is safe. It is always essential to discuss your care with your treating oncologist.
Q: Is it ok to stop or pause infusion treatments if patients are concerned about leaving their house to go to the clinic?
Dr. Nizar Tannir: It depends on the status of the response to therapy (if someone has already achieved a complete or a deep partial response or stable disease). The patient can pause for few weeks if they have already achieved a response. Of course, they can pause if they are experiencing some side effects, which will be a good time to take a break.
Dr. Thomas Powles: It’s ok to do this – especially during the peak of the pandemic and for those that have been on treatment for a while.
I think most healthcare services are beyond the peak of the initial wave of this pandemic. Therefore we are treating patients following standard guidelines again. Immune therapy first then VEGF therapies. I hope we don’t have to stop or delay treatments again.
Q: Are there alternate ways to access infusion therapies at home if the patient is concerned about leaving the house to go to the clinic?
Dr. Nizar Tannir: Unfortunately, my answer is no as the patient has to be monitored closely during infusion of an immune checkpoint inhibitor. Additionally, I am not aware of any home health agency sending nurses to administer therapies in patients’ homes during this pandemic.
Dr. Thomas Powles: This is tough – usually no. Also patients on immune therapy need to be assessed – especially during the first 12 weeks.
Q: Are there criteria doctors are using to determine whether or not to defer scans, surgeries, and/or treatments? Are there guidelines for how long these may safely be deferred?
Dr. Brian Shuch: Every center has different criteria but in general most believe it should be based on risk. Active surveillance of small renal masses less than 4 cm has been shown to be incredibly safe. In the era where patients have significant health risks by contracting COVID-19, the risks of the infection far outweigh the benefits of treatment at this time. We should not do surgery for small renal masses right now. When resources permit, most centers are still doing surgery for larger or invasive kidney tumors.
Scans to document no evidence of disease may be safely delayed as there is no evidence that identification of an asymptomatic recurrence a few months earlier will have any impact on outcomes. If someone was on a system therapy for some time and doing well, it seems very reasonable to delay a restaging scan. If someone was having significant symptoms, scanning now would be advised as it may be important to document any progression of disease to perhaps switch therapy.
How long things should be delayed obviously depends on the course of this crisis.
Q: How long is it safe to wait for kidney cancer surgery
Dr. Gennady Bratslavsky: We have plenty of studies looking at active surveillance of small renal masses. Typically, renal tumors grow quite slowly (3 mm or 1/8th of an inch per year). So, if someone has a small tumor, less than 4 cm, it is certainly safe to wait 3-6 months in most cases. The surgery for larger tumors (up to 7 cm) is likely ok to wait for 3 months as well. At this time, the general consensus is to operate on large renal tumors, those that cause symptoms (pain or bleeding), or those with thrombi with involvement of the vessels (known as IVC thrombi). Now, with many hospitals reopening their ORs, many “back logged” patients are being brought in for surgery. Yet, if one must wait with a smaller tumor, it is usually quite safe.
Q: How can patients prepare to return to a more typical clinic schedule? What would be the most different in the short term and long term?
Dr. David Braun: While navigating these uncertain times, I think it is key to maintain flexibility. The need for flexibility applied when offices were transitioning to telemedicine, and will equally apply as offices transition back to more in-person visits. In the short term, that might mean more protections and restrictions – having to wearing masks in the office, limiting the number of people on elevators, and unfortunately, in some cases, limiting the number of visitors that can accompany a patient to the visit (though this places an enormous burden on patients, and should only be done in the extreme cases where patient safety is at risk). In the long term, I would not be surprised if telemedicine, to some extent, is here to stay. Each office will likely be different in how they incorporate telemedicine moving forward, and so it is worth having a conversation with your oncology office about their practices, and prepare to discuss what you feel most comfortable with. Finally, there is still a tremendous amount of uncertainty with respect to what will happen with the COVID-19 pandemic, and so flexibility is needed here as well – if there is a rise in cases, offices may need to re-implement restrictions quickly, and plans may need to change on short notice.
Q: How will doctors determine what kind of surgery would be elective?
Dr. Gennady Bratslavsky: Typically, if something is not life threatening within the next week or two, many surgeries can be postponed (certainly for smaller renal masses) and are considered elective. Many hospitals start to use the term “medically necessary and time sensitive”. Larger renal tumors belong to the latter category. Finally, small renal masses grow quite slowly, and in general, management of tumors up to 7 cm can be delayed for a few months.
Q: What are some of the renal complications that might arise as a result of COVID-19 infection? Can these be avoided? How might such complications be managed?
Dr. Christopher Wood: COVID-19 infects through the respiratory tract and can primarily impact pulmonary and cardiovascular function. There is some data that the virus can also bind to cells of the kidney through blood born delivery, and potentially cause an inflammatory reaction that can impact kidney function adversely. For the most part, the greatest impact of the virus on renal function appears to be on patients that become critically ill from the virus which in turn results in a secondary impact on their renal function due to collateral damage from the primary effect of the virus (respiratory and cardiovascular).
Q: What are the best ways to stay safe around family members?
Dr. Scott Haake: Social distancing can be really tough, especially for cancer patients. Many of us have loved ones, friends, and family that live outside our home yet are important components of our support system. However, for family living outside our homes, social distancing is a critical tool in containing spread of the virus and keeping everyone healthy and safe. I encourage patients to use other methods of communication to stay in touch with family and friends outside the home, such as social media and smart phones.
As for family living within the kidney cancer patient’s home, if they are ill or exhibiting symptoms of COVID-19 infection, optimize social distancing and immediately seek medical attention.
Q: Is it safe to take walks or spend time outside if one is at increased risk of becoming seriously ill from COVID-19? What kinds of precautions could one take?
Dr. Scott Haake: During these stressful times, getting outdoors can be a great way to exercise and cope if this is possible/allowable in your area. However, the principles of social distancing still apply. Stay at least 6 feet apart from other people, do not gather in groups, avoid crowded spaces, don’t touch your face, wash hands often, and consider the use of a mask. The CDC has great resources on social distancing.
Who is at increased risk for COVID-19?
Certain groups of people have an increased risk of getting sick from a COVID-19 infection including older adults and people with serious underlying medical conditions like heart disease, lung disease, and diabetes.
Are people with cancer at increased risk? What about people with kidney cancer?
People with cancer are another group at high risk of serious illness from infection, according to the American Cancer Society (ACS) , and this can include COVID-19 infections. This is because cancer itself or cancer treatments can weaken the immune system.
Among people with kidney cancer, the average age at diagnosis is 64 years and most people are diagnosed between ages 65-74, according to the ACS.
In this Uromigos podcast episode called “COVID-19 and Renal Cancer: A Patient’s Perspective”, the hosts and guest discuss kidney cancer surgery and treatment in the context of COVID-19, what some of the unknown factors are (there are many), and what questions patients may want to ask their doctors.
What are the symptoms of COVID-19?
- Shortness of breath
Emergency warning signs for COVID-19 require medical attention immediately. They include :
- Difficulty breathing or shortness of breath
- Persistent pain or pressure in the chest
- New confusion or inability to arouse
- Bluish lips or face
According to the CDC, if you think you’ve been exposed to COVID-19 and develop a fever and symptoms, such as cough or difficulty breathing, call your healthcare provider for medical advice.
How does COVID-19 spread?
COVID-19 mainly spreads between people through respiratory droplets produced when someone coughs or sneezes, according to the CDC. It may also be possible for someone to get COVID-19 by touching something that has the virus on it and then touching their face (mouth, nose, and possibly eyes).
How can you prevent infection?
Good hygiene practices are among the best ways to lower the risk of any type of infection, though people at increased risk may need to ask their healthcare provider about additional steps.
- Wash your hands often with soap and water. If soap and water aren’t available, use a hand sanitizer with at least 60% alcohol.
- Avoid touching your face, especially the eyes, nose, and mouth.
- Cough or sneeze into your elbow or use a tissue to cover your face and throw it in the trash immediately.
- Clean and disinfect frequently touched surfaces and objects often.
- Avoid close contact with others, especially people who are sick and people at high risk of getting very sick.
- Stay home if you are sick.
Official COVID-19 guidance
Other COVID-19 Resources
These helpful information was copied from the KidneyCancerAssociation site.