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Cancer Patient Management During the COVID-19 Pandemic

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, Thomas Berg4*, Anna Berghoff5*, Ilaria Betella6*, Jean-Yves Blay7, Davide Giovanni Bosetti8, Hasna Bouchaab9, Juliane Brandt10, Christian Buske11, Augusto Caraceni12*, Fatima Cardoso13*, Joan Carles14*, Silvia Catanese15, Nathan Cherny16, Ilaria Colombo17*, Nicoletta Colombo17,18, Javier Cortes14,19*, Carmen Criscitiello20*, Giuseppe Curigliano20,21, Evandro de Azambuja22*, Suzette Delaloge23*, Maria Del Grande8*, Maria De Santis24* Jean-Yves Douillard25*, Reinhard Dummer26, Rafal Dziadziuszko27*, Bernard Escudier23*, Karim Fizazi23*, Tania Fleitas28,29, Enrico Franceschi30*, Christoph Hoeller31*, Silke Gillessen16,32,33,34, Antonio Gonzalez Martin35*, Richard Gralla36*, Alexandru Grigorescu37*, Alessandro Gronchi38, Azza Hassan39*, David Hui40*, Mats Jerkeman41, Robin Jones42*, Karin Jordan10, Ulrich Keilholz43, Gudrun Kreye44*, Jonathan Ledermann45*, Sibylle Loibl46*, Florian Lordick47*, Paul Lorigan48*, Yohann Loriot23*, Javier Martin Broto49*, Ulrich Mey50, Olivier Michielin51, Masanori Mori52*, Francesco Multinu6*, Shani Paluch-Shimon53*, Chris Parker54*, Antonio Passaro55, George Pentheroudakis56*, Solange Peters9, Camillo Porta57,58*, Thomas Powles59,  Matthias Preusser5, Martin Reck60*, Carla Ripamonti61*, Maryna Rubach62*, Tamari Rukhadze63*, Manuela Schmidinger5*, Elzbieta Senkus-Konefka64*, Cristiana Sessa8, Adir Shaulov65*, Silvia Stacchiotti66, Anna-Marie Stevens67*, Sebastian Stintzing68*, Dario Trapani20, Alexander van Akkooi69, Loredana Vecchione68,70, Florian van Bömmel4, Ursula Vogl8, Christophe Von Garnier71,72, Michael Weller73, Jayne Wood74*, Eleonora Zaccarelli6*, Camilla Zimmermann75,76*

*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

4Division of Hepatology, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectiology, Leipzig University Medical Center, Germany

5Medizinische Universität Wien, Klinik für Innere Medizin I, Klinische Abteilung für Onkologie, Vienna, Austria

6Department of Gynecologic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

7Medical Oncology Department, Centre Léon Bérard, Lyon, France

8Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland

9Department of Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland

10Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Germany

12Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany

12Palliative Care, National Cancer Institute, Milan, Italy

13Breast Unit, Champalimaud Clinical Center-Champalimaud Foundation, Lisbon, Portugal

14Vall d´Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona, Spain

15Unit of Medical Oncology, Pisa University Hospital, Pisa, Italy

16Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

17Gynecology Program, European Institute of Oncology, 20141 Milan, Italy

18School of Medicine and Surgery, University Milan Bicocca, 20126 Milan, Italy

19Medical Oncology Department, IOB Institute of Oncology, Quirosalud Group, Madrid & Barcelona, Spain

20New Drugs and Early Drug Development for Innovative Therapies Division, IEO, European Institute of Oncology IRCCS, Milan, Italy

21Department of Oncology and Hematology, Universita degli Studi di Milano, Milan, Italy

22Department of Medical Oncology, Institut Jules Bordet and Université Libre de Bruxelles (ULB), Brussels, Belgium

23Department of Cancer Medicine, Gustave Roussy, Villejuif, France

24Department of Urology, Charité University Hospital, Berlin, Germany

25Chief Medical Officer, ESMO, Lugano, Switzerland

26Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland

27Department of Oncology and Radiology, Medical University of Gdańsk, Gdańsk, Poland

28Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain

29Instituto de Salud Carlos III, CIBERONC, Madrid, Spain

30Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy

31Department of Dermatology, Medical University of Vienna, Austria

32Universita della Svizzera Italiana, Lugano, Switzerland; Cantonal Hospital, St. Gallen, Switzerland

33University of Bern, Bern, Switzerland

34Division of Cancer Science, University of Manchester, Manchester, UK

35Medical Oncology, Clinica Universidad de Navarra, Madrid, Madrid, Spain

36Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, New York, USA

37Department of Medical Oncology, Institute of Oncology, Bucharest, Romania

38Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

39Supportive & Palliative Care Section, Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar

40Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

41Department of Oncology, Skåne University Hospital, Lund University, Lund, Sweden

42Sarcoma Unit, Royal Marsden NHS Foundation Trust/Institute of Cancer Research, Chelsea, London, UK

43Charité Comprehensive Cancer Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany

44Palliative Care Unit, Department of Internal Medicine II, University Hospital Krems, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria

45University College London Cancer Institute, and University College London Hospitals, London, UK

46German Breast Group, Neu-Isenburg, Germany

47University Cancer Center Leipzig, University Hospital Leipzig, Leipzig, Germany

48The Christie NHS Trust,  Manchester, UK; The University of Manchester, Manchester, UK

49Medical Oncology Department, University Hospital Virgen del Rocio, Sevilla, Spain

50Department of Oncology and Haematology, Kantonsspital Graubünden, Chur, Switzerland

51Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland

52Palliative Care Team, Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan

53Department of Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

54Royal Marsden Hospital and Institute of Cancer Research, Sutton, UK

55Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

56Department of Medical Oncology, University of Ioannina, Ioannina, Greece

57Department of Internal Medicine, University of Pavia, Italy

58Division of Translational Oncology, I.R.C.C.S. Istituti Clinici Scientifici Maugeri, Pavia, Italy

59Barts' Cancer institute, Queen Mary University of London, London, UK

60LungenClinic, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany

61Supportive Care Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy

62Centrum Onkologii-Instytut im. Marii Sklodowskiej-Curie, Warsaw, Poland

63Faculty of Medicine, Iv, Javakhishvili Tbilisi State University, Tbilisi, Georgia

64Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland

65Department of Hematology, Hadassah-Hebrew University Medical center, Jerusalem, Israel

66Cancer Medicine Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Nazionale Tumori, Milan, Italy

67Nurse Consultant Symptom Control and Palliative Care, The Royal Marsden NHS Foundation Trust, London

68Department of Hematology, Oncology and Tumor Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany

69Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands

70Charitè Comprehensive Cancer Center, Berlin, Germany

71Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland

72Department of Pulmonary Medicine, University Hospital of Bern, Bern, Switzerland

73Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland

74Palliative Care, The Royal Marsden, London, UK

75Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada

76Divisions of Palliative Medicine and Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada

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