Taking care of older patients with cancer in the context of COVID-19 pandemic

In their Comment in The Lancet Oncology, Benoit You and colleagues¹ recommend prevention of coronavirus disease 2019 (COVID-19) in patients with cancer through barrier measures and limitation of hospital admissions by all means, and caution before initiating or continuing treatment because of excess risk of COVID-19-related death in patients with cancer. We, the Société Francophone d'Onco-Gériatrie (SoFOG) and the French cooperative group for clinical research in geriatric oncology DIALOG (GERICO-UCOG), would like to endorse these guidelines and stress further important points for older patients with cancer.

Indeed, older patients (ie, >70 years) have cumulative excess risks related to both cancer and ageing. Prevention with intensified barrier measures is required; however, facing an unprecedented health crisis, the choice between pursuing the standard treatments for these patients (often based on little data in the literature) and a cautious so-called primum non nocere approach, raises many concerns and ethical questions.² Highly committed to an individualised health-care approach, we think highlighting the following points is essential. First, in light of the potential for patients with cancer to be infected with SARS-CoV-2 during this pandemic treatment decision making should take into account cancer type, disease extent, prognosis, and treatment opportunities irrespective of a patient's age, but acknowledge the excess risks associated with viral infection in older patients. Second, evaluation of life expectancy should be part of treatment decision making. Finally, as much as possible, alternatives to standard therapy that have few side-effects on the immune system (eg, endocrine therapy vs chemotherapy) should be favoured, and are preferred to no treatment, which might lead ultimately, long after the epidemic, to excess cancer-related deaths.

Barrier measures and confinement, supportive care, and adjustment of treatment schedules (eg, increased intervals between treatments, dose reductions, and alternative radiotherapy fractionation) should be widely used, as in younger patients when appropriate.

In our community, stressing these points seems to be essential because older patients with cancer might be exposed to excess risk from both COVID-19 and under-treatment of cancer. To avoid serious ethical issues and preserve the highest standards of care and treatment for older patients with cancer, sharing treatment decision making with a geriatrician team remains the best strategy, whenever possible. Through this process, we can indeed avoid under-treatment, often and wrongly influenced by a patient's age alone, and hopefully reach the balanced and appropriate decisions our patients deserve.

Of course, in critical situations related to COVID-19, referral physicians remain at the forefront to prioritise patients and treatments, relying on their own clinical judgment. When possible, practitioners should have institutional support from ethics committees to help them find a balance between unreasonable obstinacy and the principle of beneficence.