- A systemic review (n = 52 studies with 18,650 cases) revealed that patients with cancer and COVID-19 infection had a higher mortality than the general infected population without cancer (mortality of 25.6 per 100 inhabitants). Cancer is an independent risk factor for mortality (especially hematologic malignancies and lung cancer). Other risk factors are age, the male gender, the black race, current smoking habit, and comorbidities ;
- A single-center, retrospective, observational study (n = 309 cases) showed that in patients with cancer who are COVID-19-positive, cytotoxic chemotherapy administered within 5 weeks of the diagnosis of viral infection does not significantly increase the rate of events which are serious or critical for COVID-19. In contrast, the presence of hematological neoplasms, lung cancer, lymphopenia at the time of diagnosis of COVID-19 infection, and initial neutropenia (14 to 90 days prior to diagnosis of this viral infection) are significantly associated with a higher rate of critical or serious events due to this infection ;
- A prospective observational study (n = 800 cases) showed that in cancer patients who test positive for COVID-19 (through RT-PCR in nose or throat smears), after adjusting for other risk factors, patients who underwent cytotoxic chemotherapy showed no significant effect on mortality versus cancer and COVID-19-positive patients who did not receive chemotherapy. It should be noted that neither adjuvant chemotherapy nor palliative chemotherapy showed any significantly higher mortality within 4 weeks of the infection diagnosis versus the group that received no treatment. When comparing recent first-line palliative chemotherapy versus second- or third-line chemotherapy, mortality did not vary significantly in cancer patients who were COVID-19-positive. There was also no significant difference in mortality with respect to immunological therapy, hormonal therapy, radiotherapy, and target therapies between the group that received early treatment versus those who did not ;
- The suspension or delay in cancer therapy during this pandemic, based on a supposed greater possibility of harm to the patient, is a reality. For example, in the previous study, treatment was interrupted due to the current pandemic situation in 22% of patients (n = 172 cases) . In a prospective study in COVID-19-negative lung cancer patients (n = 211 cases), it was determined that palliative chemotherapy was delayed in 39.7% of cases due to the pandemic, was interrupted in 14.9%, and was definitively stopped in 3% [4,5].
2. Comment Development
2.1. First Bullet
- Non-maleficence: understood as not causing harm voluntarily. Evidence shows that when chemotherapy is administered early in cancer patients who are COVID-19-positive, this does not increase the risk of severe morbidity from this infection, nor does it increase mortality. Therefore, it is malicious to delay adjuvant, neoadjuvant, or palliative treatment that has been shown to improve the quality of life and survival in cancer patients. We only increase the risk of increasing morbidity and mortality from the underlying neoplastic disease, managing to do harm by omission. It is understood that we are referring to treatments which have demonstrated clinical benefit. On the other hand, if, and only if, the chemotherapy in question does not improve the patient’s quality of life and survival with certainty versus placebo, then the suspension of the therapy would be legitimate. It must be emphasized that at the beginning of the pandemic, the behavior of the virus was unknown, and it was therefore legitimate to delay chemotherapy. However, now, in light of current knowledge, it is not. Additionally, lack of knowledge is not an excuse, because health practice essentially involves continuous training and study;
- Justice: understood as providing each person with what they are entitled or deserve, corresponding in equity or merit. Delaying or stopping chemotherapy which has been shown to be beneficial because of the pandemic only violates this principle. With justice, these patients must receive their treatment in a timely manner, without delay or suspension;
- Beneficence: understood as any action that seeks to do good. If effective therapy is suspended or delayed without justifiable scientific evidence (as we have previously shown), we violate this principle by omission without justification. Every bioethical decision must be supported by the evidence. Additionally, the evidence does not support suspending or delaying treatment which has a clinical benefit;
- Autonomy: related to the capacity of each person to decide freely. Any true choice must be based on solid information. Therefore, the oncologist must explain to the patient the benefits and risks of undergoing chemotherapy during this pandemic. The objective will be to listen to the patient, clarify their doubts, and dispel the unfounded myths regarding oncology, chemotherapy, and this infection. Only then will the patient be able to decide freely.
2.2. Second Bullet
- Utilitarian ethics: in public health, the R0 (basic reproductive ratio) measures the speed with which an infection spreads in a given population (R0 = transmission rate/recovery rate) . Additionally, in order to control this pandemic, it is necessary to reduce the effective R0, through herd immunity, by vaccinating at least 60% to 70% of the population. In fact, in view of the increased transmissibility of the infection, it may be necessary to vaccinate 80% to 85% of the population.
- Double-effect principle: known as a principle of practical reasoning that helps determine the lawfulness of an action that produces (or can produce) two effects, one good and the other bad .
- The purpose of the act to be pursued must be good: the action is the vaccination of the cancer population and its objective is to prevent symptomatic infection (beneficial objective);
- The intention of one who acts must be good and excludes (does not wish, but tolerates) the bad effect that will result from the action: without a doubt, the intention of the one who indicates and the one who proceeds to vaccinate is beneficial.
- The action itself must be good or indifferent: a systemic review and meta-analysis (n = 17 observational studies including 3268 cases) showed that cancer patients have a higher risk of dying from this viral infection (risk of 24.8 per 100 inhabitants versus 2.2 per 100 inhabitants in the general population). Within this group, the male sex, age over 65 years, comorbidities (especially high blood pressure and chronic obstructive pulmonary disease) and respiratory symptoms (dyspnea, cough and sputum) are described as risk factors for mortality . Furthermore, it is also known that severe or critical COVID-19 events are more frequent in cancer patients than in the general population. Thus, the action of vaccinating is essentially good because it seeks to prevent severe morbidity and increased mortality from COVID-19 infection in this higher-risk population;
- There must be a proportionally serious reason to accept the act, i.e., the benefit that is expected to be obtained from the action must be much greater than the damage that the action may produce.
- Absence of better actions that cause less damage: at present, neither hygienic measures nor physical isolation have been able to stop the advance of the pandemic. Physical isolation is not innocuous. The psychological/social damage to individuals families and the deterioration of the economy is significant. Therefore, there is no better alternative than vaccination.
- Due to it being un ethical to use an evil means to later obtain a good effect, the simultaneity of both effects resulting from the same action is a crucial point to be clarified. In our particular case, the vaccination of cancer patients has a beneficial effect (the potential decrease in morbidity and mortality from COVID-19) and a malefic effect (the potential adverse effect in this population), which are both simultaneous. The beneficial effect is not a consequence of the malefic effect;
- The problem of proximity describes the evil result that the action attempts and the anticipated negative consequences as indistinguishable. However, the motivation of the agent of the action has no intention of causing an evil effect, but anticipates it. It is only tolerated if the good obtained is proportionally greater than the evil that maybe produced.
- The determination of the proportionality relationship between the beneficial effect and the malefic effect;
- This principle considers the absence of alternatives actions that cause less damage.
- The efficacy of messenger RNA vaccines and Ad26.COV2.SCOVID-19 vaccine in cancer patients is not yet known;
- We do not know the percentage of protection from asymptomatic infection in the general population;
- The vaccines developed against the original virus have been found to be less effective against variant viral B.1.351 (this variant contains the E484K mutation that has caused so much concern in B.1.351. This mutation is thought to allow the virus to escape from some of the body’s immune response) .
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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