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Dr Gary Lyman: Pandemic Barriers Led to More Late-Stage Cancer Presentations


Gary Lyman, MD, MPH, an oncologist and hematologist, discusses how doctors are managing patients who present with later-stage cancers as a result of barriers to screening measures imposed by the pandemic.

Gary Lyman, MD, MPH, is an oncologist, hematologist, and public health researcher who has long been an advocate for biosimilars. He has also developed guidelines in support of using biosimilars in the oncology space.


What are your thoughts about patients presenting with advanced cancers because of health care interruption during COVID-19?

Lyman: Yeah, well that's kind of a 2-pronged question. I think there's no question that COVID-19 has had a dramatic impact on the care of patients in general and cancer patients in particular. They're a particularly vulnerable population to COVID-19, as well as the serious life-threatening complications and mortality associated with COVID-19. So, it has been a very much at the forefront of our concerns.

And early in the pandemic, I would say for the first 3 to 6 months when we did not know how long this was going to go on, a lot of institutions and practices took the policy of perhaps delaying treatment, modifying treatment to less myelosuppressive and less immunosuppressive therapies. But it quickly became that this has gone on now for well over a year. It could go on, unfortunately, for several more months. And delaying patients for even more than a few weeks, in some cases, could be catastrophic, in terms of disease control, particularly for rapidly growing tumors.

So, after a few months, practices began to say, "Well, we just need to treat these patients and we need just need to make sure they're safe and protected as optimally as possible." Even today, in most practices, there's still strict with masking, handwashing, and social distancing where it's possible, but patient screening and treatment care is proceeding ahead.

The unfortunate thing is, and I've written and spoken a lot about this is that the pivotal trials for the 3 vaccines that we have approved in the US from Pfizer, from Moderna, and from Johnson and Johnson. Those trials had few, in some cases, no patients with active cancer or receiving cancer therapy in those trials. And that was done deliberately because those patients were thought to be immunosuppressed and perhaps not a fair test of a new vaccine technology for treating or preventing COVID-19. But what it did is that left us at the end of these very large, pivotal trials for these 3 vaccines with almost no data about how effective these vaccines are in patients with cancer, again, particularly those on active treatment or recently treated or with an actively progressive cancer.

Subsequent data has been reported largely from observational studies, including the largest national registry, the COVID-19 Cancer Consortium that I've been involved with from the beginning. And we've seen that in fact, yes, COVID-19 unduly impacts on the cancer population, again, primarily those who have been treated within the last few months or are on active treatment, and exceptionally in those that are not necessarily responding to treatment and the types of treatments that impact on that risk while they vary somewhat, myelosuppressive chemotherapy is particularly a risk factor. But things like checkpoint inhibitors, targeted therapies like anti CD20 therapies may further increase the risk in the spaces.

So, the cancer population is particularly vulnerable to getting the infection to suffering from the infection. And while we have far less than optimal data on vaccine efficacy, and we know from some early studies over the last few weeks that their serologic response, or antibody response, with active disease, particularly in hematologic malignancies is blunted after the first dose. It does improve after the second dose and a patient with solid tumor may be have a fairly vigorous response. My group, ASCO [American Society of Clinical Oncology], NCCN [National Comprehensive Cancer Network], ESMO [European Society for Medical Oncology], AACR [American Association for Cancer Research] have all said cancer patients must be prioritized for vaccination at the earliest possible time. And we feel most of our patients are getting prioritized for vaccination at this time but, unfortunately, that wasn't the case for several months.

At this point, my main message, because the level of protection afforded by the vaccine and cancer patients remains somewhat unclear and will vary from cancer type to cancer type and across cancer treatments, is that even after vaccination, cancer patients and their providers need to provide all the precautions that we're asking the general unvaccinated population to follow. And that is to wear your mask in public places, social distance, and all these precautions. Just assume that you're not fully and perhaps not adequately protected, despite being vaccinated and until the level of infection throughout the community is down to very low levels, one should continue to be very cautious but, on the other hand, you should not forego your cancer treatment. Because that, again, in many cases, is his life's journey.

So, it's been complicated. It's been a rocky road for many patients. But I think we fully understand now these patients need to be vaccinated. I strongly encourage health care providers, at all levels, be vaccinated to care for these patients and they should speak to [patients'] family members. Patient family members should be vaccinated if at all possible, just to optimize the protection of our patients, who remain vulnerable in many instances.

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