CDC. Post-COVID conditions. Available at: Accessed August 13, 2021.

Disclosures: Borno, Markham, Nekhlyudov and Santhosh report no relevant financial disclosures.
August 16, 2021
7 min read

Long-term effects of COVID-19 and cancer create population of ‘dual survivors’


CDC. Post-COVID conditions. Available at: Accessed August 13, 2021.

Disclosures: Borno, Markham, Nekhlyudov and Santhosh report no relevant financial disclosures.
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The late effects of cancer and its treatment are well documented and may extend years beyond active treatment.

Depending on the type of cancer, these late effects may include cardiovascular, pulmonary, neurological, orthopedic and mental health complications.

Quote from Larissa Nekhlyudov, MD, MPH

Although much less is known about the long-term effects of COVID-19, the virus has been associated with long-term, post-acute sequelae known as “long COVID.” Symptoms of long COVID may include difficulty breathing or shortness of breath, fatigue, cough, chest or stomach pain, headache, heart palpitations and joint or muscle pain.

Additionally, the CDC has identified multiorgan effects or autoimmune issues that occur over a longer period, potentially extending weeks or months after COVID-19 sickness.

These complications can occur in most, if not all, body systems, including heart, lung, kidney, skin and brain functions.

For survivors of cancer, who may experience late effects in these same body systems due to their cancer and its treatment, infection with COVID-19 may leave them with intensified, potentially indistinguishable long-term symptoms.

“Clinicians are still learning so much about the COVID long-haulers — how to approach them, how to evaluate them and how to manage them,” Larissa Nekhlyudov, MD, MPH, clinical director of internal medicine for cancer survivors at Dana-Farber Cancer Institute and professor of medicine at Harvard Medical School, said in an interview with Healio. “We really know nothing about the dual survivors — the COVID-plus-cancer survivor.”

A unique set of risks

When assessing the potential long-term complications of a dual cancer and COVID-19 survivor, there is a need for specificity in understanding the individual’s cancer type and treatment history.

Hala Borno, MD
Hala Borno

“Each patient’s treatment exposure imbues a unique set of risks,” Hala Borno, MD, assistant clinical professor in the division of hematology/oncology at University of California, San Francisco and co-medical director of the genitourinary medical oncology clinic at Helen Diller Family Comprehensive Cancer Center, said in an interview with Healio. “So, for example, if a patient received prior radiation to the lungs, which has compromised some lung tissue in a long-term fashion, that would potentially put them at greater risk for pulmonary complications if they were to become infected with COVID-19.”

Nekhlyudov noted that surgery, radiation, chemotherapy and immunotherapy can all have long-term multiorgan effects similar to those of long COVID.

“We don’t know whether long-term cancer survivors are more likely to have a greater disease burden, and we don’t know how to manage cancer survivors who may have long COVID,” Nekhlyudov said. “All of that is yet to be determined.”

Nekhlyudov and her colleagues are exploring the possible connections and interactive effects of both diseases.

“We’re looking at the literature and drawing the corollaries between the two entities,” she said. “Then we’re also trying to figure out if there is a shared path forward for rehabilitation. We know that cancer survivors often do not receive the rehabilitation that they need for their long-term and late effects. Right now, many long-haul clinics are opening. We’re wondering: is there an opportunity to learn from these kinds of rehab facilities that may potentially advance our care for cancer survivors?”

Borno said it is important for clinicians to be as focused and specific as possible when following dual survivors over the long term.

“There’s a degree of precision where we monitor patients and counsel them on their risks,” Borno said. “We also think that, for survivors, there is a need to talk to their oncologists about any risks that may be attributed to their prior treatments. In general, we think the minimum advice for survivors is to follow the CDC guidelines, but depending on the details of what has happened to their body, there may be some additional precautions that are important.”

Nekhlyudov also emphasized the need for in-depth studies that look specifically at the long-term effects of COVID-19 in the cancer survivor population.

“One of the problems we have in the COVID-related literature is that there has not been a real effort to tease out the cancer survivor population,” she said. “The studies might specify ‘cancer survivor: yes or no,’ or ‘history of cancer: yes or no.’ Few studies have included long-term survivors. We need to delve further into the kind of cancer, the kind of treatment exposures and time since treatment so we can better assess patient outcomes. We know that cancer survivors may have worsened effects with COVID-19, but without the granularity of the information, it’s not very helpful.”

A ’one-stop shop’

Long-term cancer survivorship care can be challenging; not all cancer centers have designated survivorship clinics, and in some cases, survivorship is handled almost entirely by a survivor’s primary care clinician. In addition to disrupting the continuity of care, this approach can often cause important survivorship information to become lost in the shuffle of routine primary care.

As the United States continues to amass more and more COVID-19 survivors, multidisciplinary survivorship clinics have been established to address the similar long-term and late effects these patients will likely face. As has frequently been the case during the COVID-19 pandemic, these interventions born of necessity may prove a valuable model for other areas of medicine, including cancer survivorship.

Lekshmi Santhosh, MD, MAEd
Lekshmi Santhosh

“Our clinic, like many across the country, is devoted to providing a holistic-care approach to people recovering from COVID-19,” Lekshmi Santhosh, MD, MAEd, assistant professor of clinical medicine, pulmonary/critical care and hospital medicine and medical director of the University of California, San Francisco post-COVID OPTIMAL Clinic, said in an interview with Healio. “Basically, we take a multidisciplinary team approach where the patient is seen by a pulmonary physician like me, as well as by team members from pharmacy, physical therapy and psychiatry, and we have robust referral pathways for neurology, cardiology and integrative medicine. We’re trying to provide a sort of ‘one-stop shop’ for people in recovery after a serious infection with COVID-19.”

Based on her experiences with cancer survivors in her clinic, Santhosh said her biggest piece of advice for cancer survivors is a simple one: get vaccinated.

“I’ve seen [COVID-19] kill people with cancer. I’ve seen horrible cases of persistent symptoms in patients who have had cancer,” she said. “The vaccine is key to protecting people who have survived cancer or patients with cancer. That’s one thing I like to emphasize.”

Additionally, Santhosh warned dual survivors against making assumptions about any late effects they might experience.

“Many times, people who are recovering from cancer or other illnesses who have had COVID may erroneously attribute their symptoms to long COVID,” she said. “I’ve seen multiple situations where people have attributed symptoms like shortness of breath, headaches, bloody stool, etc. to long COVID, and I’ve had to say, ‘You know, thinking broadly as an internal medicine doctor, I’m worried this could be related to your cancer.’

Santhosh said she has seen the unfortunate results of these misunderstandings in dual survivors.

“I personally have diagnosed metastatic cancer in multiple people who thought they were dealing with long COVID,” she said. “Both patients and clinicians need to think broadly when someone comes to them with what they assume are long COVID symptoms. We can’t just assume that is what is going on.”

The delta variant: A lingering risk

As the threat of the COVID-19 virus had begun to recede because of increased vaccination rates, a new danger has emerged in the form of the delta variant and other potential variants.

The highly contagious delta strain may be associated with more severe illness and is affecting younger individuals. Patients and survivors of cancer, whose immune systems have been compromised both by their disease and its treatment, are especially vulnerable to this variant, to which experts have appended the phrase “younger, sicker, quicker.”

Especially concerned are clinicians who practice in states with lower rates of vaccination, such as Merry Jennifer Markham, MD, FACP, FASCO.

Merry Markham, MD, FACP, FASCO
Merry Markham

“I practice in Florida and, right now, our rates here are just skyrocketing,” Markham, who is associate director for medical affairs at University of Florida Health Cancer Center, chief of the division of hematology and oncology and professor in the department of medicine at University of Florida College of Medicine, said in an interview with Healio. “It doesn’t look like it’s going to go away anytime soon. And for immune compromised patients, the risk for getting very sick or dying is so much greater.”

With case rates trending upward and the delta variant representing the most common strain of COVID-19 in the U.S., clinicians like Markham have begun to change their precautionary recommendations for patients with cancer and survivors.

“Before the delta variant was really running rampant, I was advising my patients who are vaccinated against COVID-19 that it’s probably okay to dine in a restaurant, as long as they are just cautious in general,” Markham said. “Now, especially for the unvaccinated cancer survivors, the risk is so great that my guidance for patients is to treat it as if we were at the very beginning of the pandemic.”

Markham did clarify, however, that concerns about the delta variant should not generally be considered a reason to delay cancer treatment. She addressed the confusion that may have been caused by decisions to delay treatment early in the pandemic.

“We have learned a lot through the pandemic so far,” she said. “In the very beginning of the pandemic, we were concerned that the immune suppression associated with having someone on chemotherapy, for example, might increase COVID-19 risk. Now we know that not treating a cancer that needs to be treated is riskier.

“I know it can seem frustrating to the public because science has continued to change its mind, but this is what is expected with science,” she added. “As we learn more, we modify our recommendations.”


For more information:

Hala Borno, MD, can be reached at

Merry Jennifer Markham, MD, FACP, FASCO, can be reached at

Larissa Nekhlyudov, MD, MPH, can be reached at

Lekshmi Santhosh, MD, MAEd, can be reached at