Should Older Cancer Patients be Tested for Coronavirus-19 Disease Before Treatment: Recommendation of the International Geriatric Radiotherapy Group

During the coronavirus 19 disease (COVID-19) pandemic, older patients are disproportionately affected with a higher death rate compared to younger patients because of the presence of co-morbidity. The likelihood of dying is even higher among older cancer patients who get infected [1]. As COVID-19 patients may be asymptomatic, inadvertent surgery for cancer has been reported [2]. Thus, it raises a serious issue whether older cancer patients should be tested for COVID-19 before any type of treatment such as chemotherapy or radiotherapy which may further depress their immune system and may accelerate their demise. This issue is particularly important as resources of most countries are limited. Older cancer

patients may not be candidates for intensive care unit (ICU) admission and artificial ventilation if the hospital system is overwhelmed with infected patients [3]. As the prevalence of cancer in the US is 8.8 times higher among Americans who are 65-year-old or older compared to younger ones, physicians need to develop a policy on how to manage those patients who are likely to be affected by this pandemic [4]. Currently, the Center for Disease Control and Prevention (CDC) guidelines do not advocate testing for asymptomatic patients because of the shortages of diagnostic testing kits and personal protective equipment (PPE). However, a special case should be considered for older cancer patients to be tested for COVID-19 before considering any type of treatment, not only because of their high mortality risk but also to protect their health care workers (HCW) who may get infected during a routine endoscopic procedure or a surgical operation. Those procedures have been reported to increase the risk of infection through aerosolization of infected droplets which requires a respiratory mask instead of a surgical mask [5]. Deaths of HCW has been reported in many countries secondary to their exposure to infected patients without adequate protection [6]. Inadvertent and prolonged contact with asymptomatic infected cancer patients is one of those situations. As an international organization devoted to the care of older cancer patients who are frequently excluded from clinical trials because of their chronological age (http://www.igrg.org), we believe that older cancer patients should be tested for COVID-19 before treatment [7]. If infected, they should be quarantined and be enrolled in clinical trials for infected COVID-19 patients to test their efficacy and toxicity. In our opinion, it would be more cost effective and potentially lifesaving to perform a diagnostic test than to admit an infected cancer patient after a surgical procedure or following inadvertent chemotherapy.

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