The therapeutic approach to cancer patients is changing rapidly due to the COVID-19 pandemic. In discussing with colleagues from several different countries, a few themes emerge.

Patient visits, surgery, and treatment that is not essential is being deferred. The benefit/risk that we each consider for individual patient decisions must now include risk of hospitalization and thus COVID-19 exposure in the risk assessment. How specific regimens including chemotherapy and IO impact risk of virus infection and subsequent outcome is largely unknown. A recent Lancet article suggested higher mortality in cancer patients, albeit the number of cancer patients were very small (n=18). My opinion is that curative/essential anti-cancer therapy should still be given, but all attempts to de-intensify therapy should be made e.g. deferring start of therapy, holding therapy in patients with disease control etc.

Specifically for TCC, given the small benefit of neoadjuvant chemo, I would be tempted to forego and consider adjuvant therapy pending pathology results. For RCC, I would try to defer the start of systemic therapy for metastatic disease, especially with more intense regimens like Ipi/nivo given the onset of toxicity would be in the next 1-3 months when the COVID-19 virus is likely to peak. Holding ongoing therapy in patients with disease control should always be considered, more so now. 

We have a series of Uromigos podcasts devoted to coronavirus and implications in Oncology.

Excellent comments and answer by @Brian I. Rini! Cancer is also a big threat to many patients. It is very hard to make hard & fast decisions in these situations; it is usually a case by case approach, balancing very carefully risks vs benefits, and discussing rationale, data, logistics, details of each option. Personally, I would still consider neoadjuvant cisplatin based chemotherapy in resectable MIBC considering level I evidence in fit patients, use strict precautions, and discuss in detail with each patient. There is a big challenge with potential postponing of definitive surgery, while radiation would also entail daily trips to Cancer Center; therefore the challenges are not only with the use of systemic therapy. The impact of IO agents to COVID-19 infection is also unknown. It may also be challenging to keep accruing in some clinical trials, based on available personnel, resources, infrastructure, policies and local requirements, in the current situation. 

This is very hard and we need to document very carefully the decision making process with each patient. Will use much more telemedicine when appropriate, e.g. follow up (surveillance) visits off therapy. Answers may change rapidly in this environment. It is critical to develop clinical trials, surveys, databases & registries in real time, so we can learn from each other and share emerging data. 

Stay safe everyone, keep the very strict social distancing, hand washing, etc!

Disclosure:
prior consulting with Genentech/Roche, BMS, Merck & Co., AstraZeneca, EMD Serono, Pfizer, ClovisOncology, Seattle Genetics, Driver, QED Therapeutics, Heron Therapeutics, Janssen, Foundation Medicine, Mirati Therapeutics, Genzyme, Bayer, GlaxoSmithKline, Exelixis