Introduction
Dear Editor,
Regarding COVID-19, which is now accepted as a
pandemic, many questions have been generated about
how to manage and postpone the treatment of cancer
patients, especially for the patients in geriatric age. It
was determined that the incidence of lymphopenia increased
in COVID-19 and there was a significant relationship
between lymphopenia, age and mortality.
This can be accepted as an unsolved problem in how
to maintain radiotherapy that cause lymphopenia. In
radiation oncology, which is comprised of the majority
of geriatric patients, treatment decisions, the application
of the treatment and the continuation of the
treatment are particularly important. It is essential not
to ignore this geriatric population in the COVID-19
pandemic, which concerns the whole society. This letter
was written for taking attention of professional staff
that are responsible for geriatric cancer patients diagnosed
with COVID-19.
A virus-related infection called 2019 novel coronavirus
disease (COVID-19), which is now accepted
as a pandemic, has negatively affected daily life in all
countries, and has become a significant cause of death
globally.[] After detection of an atypical viral pneumonia
case cluster in late 2019, a new coronavirus was
isolated from these cases in Wuhan, China in January
2020 which was named severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) and was reported
to cause a serious pneumonia.[] Every single country
faced to fight with COVID-19 to prevent its spread as
if they were all in a real war.
In the light of the current data, although 81% of
patients with COVID-19 develop a milder form of disease, 14% have a severe illness requiring hospitalization
and additional oxygen, and the remaining 5% develop
respiratory failure, septic shock, and/or multi-organ
dysfunction. Again, the current data show that
COVID-19 case death rates are approximately 2%, and
it rises to 15% in patients aged 80 and over.[] Cancer
patients have a higher risk of developing COVID-19
and a higher risk of mortality as well.[] Immune suppression
that arises from the tumor and its treatment is
also a plausible contributory factor [], which suggests
that oncologists should carefully weigh the benefits
of treatment offered to their patients against the risks
posed by COVID-19.
Radiotherapy (RT) is an essential part of cancer
treatment. The bone marrow suppression effect of
RT has been shown, and this includes depletion of
circulating lymphocytes.[,] Pre-treatment lymphopenia,
which has been identified as a poor prognostic
factor in many malignancies, is probably a
reflection of tumor-induced immune suppression.
[] Low lymphocyte count was reported to be associated
with increased disease severity in COVID-19,
and patients who died of COVID-19 had significantly
lower lymphocyte counts than survivors. As a result,
this RT-induced lymphopenia is considered to be an
important prognostic laboratory marker both for infected
COVID-19 and mortality due to COVID-19.[]
Deferring treatment in patients with good prognostic
tumors with a low risk of progression, such as lowand
intermediate-risk prostate cancer, has also been
recommended.[] Since, shown a positive correlation
between age and lymphopenia rate exists, we should
evaluate our geriatric cancer patients before RT start.
Additionally, limited access to food supply and fear of
contacting the disease in a public area may alter their
nutrition and depress their immunity. Lymphopenia
can be a real problem for the geriatric population due
to this depressed immunity.[] Rui et al. published
their clinical investigation in geriatric patients with
COVID-19.[] All the evaluated patients had lymphopenia,
and they concluded that lymphopenia could be
an unfavorable factor for mortality due to COVID-19
pneumonia. Similarly, An et al. reported that lymphopenia
frequently occurs in COVID-19 patients, manifested
as the decrease of total T cells, CD4+T cells and
CD8+T cells in the peripheral blood; with the degree
of decline related to the severity of the disease. Compared
with patients with mild symptoms, a higher
proportion of severe or deceased patients had lymphopenia,
which is similar to the observation during
SARS-CoV infection.[]
What about RT for geriatric cancer patients? We
do not have chance to leave these populations with
their unexpected faith. We should try to look at the
new COVID-19 pandemic process from the geriatric
cancer patients" window. We could not delay RT at
least for palliative necessities and definitive purposes.
On the other hand, we all agree that it is necessary to
consider benefit versus the risk in using RT to geriatric
cancer patients in the reality of COVID-19 pandemia.
However, we should not fear to use palliative RT when
there is a certain indication. Additionally, we should
learn not only the reasons for lymphopenia but also
the management of it.
