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These recommendations should be used as guidance for prioritising the various aspects of cancer care in order to mitigate the negative effects of the COVID-19 pandemic on the management of cancer patients. The situation is evolving, and pragmatic actions may be required to deal with the challenges of treating patients, while ensuring their rights, safety and wellbeing.

So far, no systematic reports are available regarding a higher incidence of COVID-19 or SARS-CoV2 asymptomatic infections in patients with cancer. Recent limited data from China, and more recently from Italy and the US, do however seem to confirm a higher risk.

Available data indicate that older people are more vulnerable, with underlying health conditions such as chronic respiratory, cardio-vascular or chronic kidney disease, diabetes, active cancer and more generally severe chronic diseases.

Therefore, during the COVID-19 pandemic, the Benefit/Risk ratio of cancer treatment may need to be reconsidered in certain patients.

Two groups of patients have been identified: “patients off therapy” (A) who have completed a treatment or have disease under control (off therapy); and patients under treatment (neoadjuvant or adjuvant curative treatment or treatment for metastatic disease) (B). Patients with “active disease” can be eligible for surgery, chemotherapy and/or radiotherapy, biological therapy, endocrine therapy and immunotherapy (either in the adjuvant or in in the metastatic setting). For all patients (A and B) it is mandatory to provide health education: a) Avoid crowded places; b) Wear PPE when you attend hospital for visits and treatments; c) Correctly wash your hands according to World Health Organization (WHO) indications; d) Do not have contacts with friends and relatives with COVID-19 symptoms or living in endemic zones; e) Guarantee social distancing with all people: protect yourself to protect others.

For patients receiving active treatment (B), living in epidemic zones or not, hospitals should identify specific pathways in order to guarantee timing of treatment with curative intent and, when possible, also for patients with metastatic disease. Outpatient visits for cancer patients should be reduced to the safest and most feasible level without jeopardising patient care. For patients receiving oral treatment for which monitoring can be done remotely, drug supply should be provided for at least 3 courses to reduce access to the hospital. Blood monitoring for those patients can be done in local labs close to home. We suggest implementation of telemedicine services. We advise to delay all follow-up visits. More intensive surveillance should be used during treatment for patients with lung cancer or who received previous lung surgery, and for older patients or those patients with other comorbidities. Intensive measures should be undertaken to avoid nosocomial spread. There should be strict and safe triaging procedures to assess any COVID-19 symptoms and the urgency and necessity of hospitalisation. In order to regulate access to the “Cancer Hubs”, establish “checkpoint areas” screening for early detection of potentially infectious persons. Clinical staff responsible for the checkpoint area should be trained and wear PPE. Individuals who meet criteria for highly communicable diseases requiring isolation, such as novel COVID-19 or other emerging infections, must be placed in a private exam room as soon as possible, as per the infectious control guidance found on the WHO and CDC websites. They should be tested and transferred to COVID-19 dedicated areas.

In cancer patients, categories at risk include:

  • Patients receiving chemotherapy, or who have received chemotherapy in the last 3 months
  • Patients receiving extensive radiotherapy
  • People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppressive drugs
  • People with some types of blood or lymphatic system cancer which damage the immune system, even if they have not needed treatment (for example, chronic leukaemia, lymphoma or myeloma).

Specific risk groups are cancer patients with an impaired immune system such as:

  • Leukocytopaenia
  • Low immunoglobulin levels
  • Long lasting immunosuppression (steroids, antibodies)

Special attention should be considered in case of recent new symptoms such as:

  • Fever
  • Coughing
  • Sore throat
  • Difficulty breathing
  • Muscle pain
  • Tiredness
  • Anosmia
  • Dysgeusia

In such situations, recommendations include:

  • Test for confirmation if not already done
  • RT-PCR SRAS-CoV-2 testing should be proposed to all patients undergoing surgery, radiotherapy, chemotherapy or immunotherapy, if feasible and ideally before each treatment/cycle
    • It should also be proposed to patients in follow-up or cancer survivors if they present with symptoms suggestive of COVID-19 infection
    • Serology (if available) should be proposed to identify previous COVID-19 infection in all cancer patients
    • If capacity is limited, RT-PCR SRAS-CoV-2 testing should be proposed to all patients with suggestive symptoms of COVID-19 infection, being in active treatment, in follow-up phase or a survivor
    • If serology is limited, it should be proposed to all patients undergoing surgery, radiotherapy, chemotherapy or immunotherapy, or any active anti-cancer treatment
  • Assess severity by clinical, radiological, lung function and biological tests
  • Evaluate the need for patients in terms of hospitalisation in dedicated units
  • Communication, discussion with other professionals and with patients preferably by phone rather than face-to-face is strongly recommended
  • Decisions for treatment initiation or continuation must be discussed for both uninfected patients and SARS-CoV2-positive patients if they are a- or pauci-symptomatic, still fit to be treated and willing to do so after proper risk/benefit explanation
  • Discuss the benefits and risks of present cancer therapy in the setting of the COVID-19 pandemic: treatment setting, disease prognosis, patient comorbidities, patient preferences, probability and risks from COVID-19 infection.
    • If local treatment for early stage (surgery or radiation) is planned, explore possibilities of postponing using a “wait and see” approach (like in some prostate cancer) or prioritise treatment balancing the cost/benefit ratio according to age, comorbidities and impact on outcome of the surgical procedure.
    • If an intravenous treatment is ongoing, possibly switch temporarily to an oral treatment, if available, to improve disease control
    • Prioritise adjuvant therapies in patients with resected high-risk disease who are expected to derive a significant absolute survival benefit.
    • Similarly, discuss the benefits and risks of palliative therapies and the options of “therapy holidays” “Stop and Go”, maintenance, switch to oral drugs, if available, during the pandemic.
    • Envisage other optional regimens and schedules to reduce hospital visits
    • For patients under oral treatments, prefer telephonic or web-technology contacts for consultation and prescription renewal.
    • If needed, favour telephone or web-technology contacts also for toxicity evaluation, dose adaptation and supportive care recommendation
    • Discuss shorter/accelerated or hypo-fractionated radiation schemes with radiation oncologists, where scientifically justified and appropriate for the patient. 
  • Cancer patients with fever
    • Must not be evaluated in oncology day centres
    • Initial evaluation outside of the area with high concentration of cancer patients or oncology staff
    • Possibility of coronavirus must be considered and evaluated
    • Stable patients should be treated with outpatient oral antibiotic therapy

The tiered approach of ESMO in delivering a guidance for cancer patients during the COVID-19 pandemic is designed across three levels of priorities, namely: tier 1 (high priority intervention), 2 (medium priority) and 3 (low priority) – defined according to the criteria of the Cancer Care Ontario, Huntsman Cancer Institute and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS), incorporating the information on the value-based prioritisation and clinical cogency of the interventions

  • High priority: Patient's condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g. significant overall survival [OS] gain and/or substantial improvement in quality of life [QoL]);
  • Medium priority: Patient's situation is non-critical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority;
  • Low priority: Patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is non-priority based on the magnitude of benefit (e.g. no survival gain with no change nor reduced QoL).

Matti Aapro1*, Alfredo Addeo2, Paolo Acierto3, Igor Aurer4, Panagiotis Balermpas5, Thomas Berg6*, Anna Berghoff7*, Ilaria Betella8*, Jean-Yves Blay9, Davide Giovanni Bosetti10, Paolo Bossi11, Hasna Bouchaab12, Juliane Brandt13, Christian Buske14, Augusto Caraceni15*, Fatima Cardoso16*, Joan Carles17*, Silvia Catanese18, Nathan Cherny19, Ilaria Colombo20*, Nicoletta Colombo20,21, Javier Cortes21,22*, Carmen Criscitiello23*, Giuseppe Curigliano23,24, Evandro de Azambuja25*, Suzette Delaloge26*, Maria Del Grande10*, Maria De Santis27* Jean-Yves Douillard28*, Martin Dreyling29,Reinhard Dummer30, Rafal Dziadziuszko31*, Bernard Escudier26*, Massimo Federico27, Karim Fizazi26*, Tania Fleitas33,34, Enrico Franceschi35*, Christoph Hoeller36*, Silke Gillessen19,37,38,39, Antonio Gonzalez Martin40*, Richard Gralla41*, Alexandru Grigorescu42*, Alessandro Gronchi43, Azza Hassan44*, David Hui45*, Mats Jerkeman46, Robin Jones47*, Karin Jordan13, Ulrich Keilholz48, Marie José Kersten49, Gudrun Kreye50*, Jonathan Ledermann51*, Kim Linton52, Sibylle Loibl53*, Florian Lordick54*, Paul Lorigan55*, Yohann Loriot26*, Jean-Pascal Machiels56*, Javier Martin Broto57*, Ulrich Mey58, Olivier Michielin59, Masanori Mori60*, Francesco Multinu8*, Shani Paluch-Shimon61*, Chris Parker62*, Antonio Passaro63, George Pentheroudakis64*, Solange Peters12, Cesare Piazza65, Camillo Porta66,67*, Thomas Powles68, Matthias Preusser7, Martin Reck69*, Carla Ripamonti70*, Maryna Rubach71*, Tamari Rukhadze72*, Manuela Schmidinger7*, Elzbieta Senkus-Konefka73*, Cristiana Sessa10, Adir Shaulov74*, Silvia Stacchiotti75, Anna-Marie Stevens76*, Sebastian Stintzing77*, Petr Szturz78, Hervé Tilly79, Dario Trapani23, Alexander van Akkooi80, Loredana Vecchione78,81, Florian van Bömmel6, Ursula Vogl10, Christophe Von Garnier82,83, Michael Weller84, Jayne Wood85*, Eleonora Zaccarelli8*, Camilla Zimmermann86,87*

*acted as reviewer

1Cancer Center, Clinique de Genolier, Genolier, Vaud, Switzerland

2Department of Oncology, University Hospital of Geneva, Geneva, Switzerland

3Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy

4University Hospital Centre Zagreb and Medical School, Zagreb, Croatia

5Department for Radiation Oncology, University Hospital Zürich, Zürich, Switzerland

6Division of Hepatology, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectiology, Leipzig University Medical Center, Germany

7Medizinische Universität Wien, Klinik für Innere Medizin I, Klinische Abteilung für Onkologie, Vienna, Austria

8Department of Gynecologic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

9Medical Oncology Department, Centre Léon Bérard, Lyon, France

10Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland

11Medical Oncology, University of Brescia, ASST-Spedali Civili, Brescia, Italy

12Department of Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland

13Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Germany

14Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany

15Palliative Care, National Cancer Institute, Milan, Italy

16Breast Unit, Champalimaud Clinical Center-Champalimaud Foundation, Lisbon, Portugal

17Vall d´Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona, Spain

18Unit of Medical Oncology, Pisa University Hospital, Pisa, Italy

19Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

20Gynecology Program, European Institute of Oncology, 20141 Milan, Italy

21School of Medicine and Surgery, University Milan Bicocca, 20126 Milan, Italy

22Medical Oncology Department, IOB Institute of Oncology, Quirosalud Group, Madrid & Barcelona, Spain

23New Drugs and Early Drug Development for Innovative Therapies Division, IEO, European Institute of Oncology IRCCS, Milan, Italy

24Department of Oncology and Hematology, Universita degli Studi di Milano, Milan, Italy

25Department of Medical Oncology, Institut Jules Bordet and Université Libre de Bruxelles (ULB), Brussels, Belgium

26Department of Cancer Medicine, Gustave Roussy, Villejuif, France

27Medical Oncology, CHIMOMO Department, University of Modena and Reggio Emilia, Modena, Italy

28Department of Urology, Charité University Hospital, Berlin, Germany

29Chief Medical Officer, ESMO, Lugano, Switzerland

30Department of Medicine III, LMU Hospital, Munich, Germany

31Department of Dermatology, University and University Hospital Zürich, Zürich, Switzerland

32Department of Oncology and Radiology, Medical University of Gdańsk, Gdańsk, Poland

33Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain

34Instituto de Salud Carlos III, CIBERONC, Madrid, Spain

35Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy

36Department of Dermatology, Medical University of Vienna, Austria

37Universita della Svizzera Italiana, Lugano, Switzerland; Cantonal Hospital, St. Gallen, Switzerland

38University of Bern, Bern, Switzerland

39Division of Cancer Science, University of Manchester, Manchester, UK

40Medical Oncology, Clinica Universidad de Navarra, Madrid, Madrid, Spain

41Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, New York, USA

42Department of Medical Oncology, Institute of Oncology, Bucharest, Romania

43Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

44Supportive & Palliative Care Section, Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar

45Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

46Department of Oncology, Skåne University Hospital, Lund University, Lund, Sweden

47Sarcoma Unit, Royal Marsden NHS Foundation Trust/Institute of Cancer Research, Chelsea, London, UK

48Charité Comprehensive Cancer Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany

49Department of Hematology, Amsterdam UMC, the Netherlands

50Palliative Care Unit, Department of Internal Medicine II, University Hospital Krems, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria

51University College London Cancer Institute, and University College London Hospitals, London, UK

52Manchester Cancer Research Centre, University of Manchester, United Kingdom

53German Breast Group, Neu-Isenburg, Germany

54University Cancer Center Leipzig, University Hospital Leipzig, Leipzig, Germany

55The Christie NHS Trust, Manchester, UK; The University of Manchester, Manchester, UK

56Service d’Oncologie Médicale, Institut Roi Albert II, Cliniques universitaires Saint-Luc and Institut de Recherche Clinique et Expérimentale, Université catholique de Louvain (UCLouvain), Brussels, Belgium

57Medical Oncology Department, University Hospital Virgen del Rocio, Sevilla, Spain

58Department of Oncology and Haematology, Kantonsspital Graubünden, Chur, Switzerland

59Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland

60Palliative Care Team, Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan

61Department of Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

62Royal Marsden Hospital and Institute of Cancer Research, Sutton, UK

63Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

64Department of Medical Oncology, University of Ioannina, Ioannina, Greece

65Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, ASST-Spedali Civili, Brescia, Italy

66Department of Internal Medicine, University of Pavia, Italy

67Division of Translational Oncology, I.R.C.C.S. Istituti Clinici Scientifici Maugeri, Pavia, Italy

68Barts' Cancer institute, Queen Mary University of London, London, UK

69LungenClinic, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany

70Supportive Care Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy

71Centrum Onkologii-Instytut im. Marii Sklodowskiej-Curie, Warsaw, Poland

72Faculty of Medicine, Iv, Javakhishvili Tbilisi State University, Tbilisi, Georgia

73Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland

74Department of Hematology, Hadassah-Hebrew University Medical center, Jerusalem, Israel

75Cancer Medicine Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Nazionale Tumori, Milan, Italy

76Nurse Consultant Symptom Control and Palliative Care, The Royal Marsden NHS Foundation Trust, London

77Department of Hematology, Oncology and Tumor Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany

78Medical Oncology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland

79Department of Hematology, Centre Henri Becquerel, University of Rouen, France

80Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands

81Charitè Comprehensive Cancer Center, Berlin, Germany

82Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland

83Department of Pulmonary Medicine, University Hospital of Bern, Bern, Switzerland

84Department of Neurology, University Hospital and University of Zürich, Zürich, Switzerland

85Palliative Care, The Royal Marsden, London, UK

86Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada

87Divisions of Palliative Medicine and Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada

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