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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, Panagiotis Balermpas4, Thomas Berg5*, Anna Berghoff6*, Ilaria Betella7*, Jean-Yves Blay8, Davide Giovanni Bosetti9, Paolo Bossi10, Hasna Bouchaab11, Juliane Brandt12, Christian Buske13, Augusto Caraceni14*, Fatima Cardoso15*, Joan Carles16*, Silvia Catanese17, Nathan Cherny18, Ilaria Colombo19*, Nicoletta Colombo19,20, Javier Cortes16,21*, Carmen Criscitiello22*, Giuseppe Curigliano22,23, Evandro de Azambuja24*, Suzette Delaloge25*, Maria Del Grande9*, Maria De Santis26* Jean-Yves Douillard27*, Reinhard Dummer28, Rafal Dziadziuszko29*, Bernard Escudier25*, Karim Fizazi25*, Tania Fleitas30,31, Enrico Franceschi32*, Christoph Hoeller33*, Silke Gillessen18,34,35,36, Antonio Gonzalez Martin37*, Richard Gralla38*, Alexandru Grigorescu39*, Alessandro Gronchi40, Azza Hassan41*, David Hui42*, Mats Jerkeman43, Robin Jones44*, Karin Jordan12, Ulrich Keilholz45, Gudrun Kreye46*, Jonathan Ledermann47*, Sibylle Loibl48*, Florian Lordick49*, Paul Lorigan50*, Yohann Loriot25*, Jean-Pascal Machiels51*,Javier Martin Broto52*, Ulrich Mey53, Olivier Michielin54, Masanori Mori55*, Francesco Multinu7*, Shani Paluch-Shimon56*, Chris Parker57*, Antonio Passaro58, George Pentheroudakis59*, Solange Peters11, Cesare Piazza60, Camillo Porta61,62*, Thomas Powles63, Matthias Preusser6, Martin Reck64*, Carla Ripamonti65*, Maryna Rubach66*, Tamari Rukhadze67*, Manuela Schmidinger6*, Elzbieta Senkus-Konefka68*, Cristiana Sessa9, Adir Shaulov69*, Silvia Stacchiotti70, Anna-Marie Stevens71*, Sebastian Stintzing72*, Petr Szturz73, Dario Trapani22, Alexander van Akkooi74, Loredana Vecchione73,75, Florian van Bömmel5, Ursula Vogl9, Christophe Von Garnier76,77, Michael Weller78, Jayne Wood79*, Eleonora Zaccarelli7*, Camilla Zimmermann80,81*

*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

4Department for Radiation Oncology, University Hospital Zürich, Zürich, Switzerland

5Division of Hepatology, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectiology, Leipzig University Medical Center, Germany

6Medizinische Universität Wien, Klinik für Innere Medizin I, Klinische Abteilung für Onkologie, Vienna, Austria

7Department of Gynecologic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

8Medical Oncology Department, Centre Léon Bérard, Lyon, France

9Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland

10Medical Oncology, University of Brescia, ASST-Spedali Civili, Brescia, Italy

11Department of Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland

12Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Germany

13Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany

14Palliative Care, National Cancer Institute, Milan, Italy

15Breast Unit, Champalimaud Clinical Center-Champalimaud Foundation, Lisbon, Portugal

16Vall d´Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona, Spain

17Unit of Medical Oncology, Pisa University Hospital, Pisa, Italy

18Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

19Gynecology Program, European Institute of Oncology, 20141 Milan, Italy

20School of Medicine and Surgery, University Milan Bicocca, 20126 Milan, Italy

21Medical Oncology Department, IOB Institute of Oncology, Quirosalud Group, Madrid & Barcelona, Spain

22New Drugs and Early Drug Development for Innovative Therapies Division, IEO, European Institute of Oncology IRCCS, Milan, Italy

23Department of Oncology and Hematology, Universita degli Studi di Milano, Milan, Italy

24Department of Medical Oncology, Institut Jules Bordet and Université Libre de Bruxelles (ULB), Brussels, Belgium

25Department of Cancer Medicine, Gustave Roussy, Villejuif, France

26Department of Urology, Charité University Hospital, Berlin, Germany

27Chief Medical Officer, ESMO, Lugano, Switzerland

28Department of Dermatology, University and University Hospital Zürich, Zürich, Switzerland

29Department of Oncology and Radiology, Medical University of Gdańsk, Gdańsk, Poland

30Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain

31Instituto de Salud Carlos III, CIBERONC, Madrid, Spain

32Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy

33Department of Dermatology, Medical University of Vienna, Austria

34Universita della Svizzera Italiana, Lugano, Switzerland; Cantonal Hospital, St. Gallen, Switzerland

35University of Bern, Bern, Switzerland

36Division of Cancer Science, University of Manchester, Manchester, UK

37Medical Oncology, Clinica Universidad de Navarra, Madrid, Madrid, Spain

38Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, New York, USA

39Department of Medical Oncology, Institute of Oncology, Bucharest, Romania

40Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

41Supportive & Palliative Care Section, Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar

42Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

43Department of Oncology, Skåne University Hospital, Lund University, Lund, Sweden

44Sarcoma Unit, Royal Marsden NHS Foundation Trust/Institute of Cancer Research, Chelsea, London, UK

45Charité Comprehensive Cancer Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany

46Palliative Care Unit, Department of Internal Medicine II, University Hospital Krems, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria

47University College London Cancer Institute, and University College London Hospitals, London, UK

48German Breast Group, Neu-Isenburg, Germany

49University Cancer Center Leipzig, University Hospital Leipzig, Leipzig, Germany

50The Christie NHS Trust,  Manchester, UK; The University of Manchester, Manchester, UK

51Service 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

52Medical Oncology Department, University Hospital Virgen del Rocio, Sevilla, Spain

53Department of Oncology and Haematology, Kantonsspital Graubünden, Chur, Switzerland

54Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland

55Palliative Care Team, Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan

56epartment of Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

57Royal Marsden Hospital and Institute of Cancer Research, Sutton, UK

58Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

59Department of Medical Oncology, University of Ioannina, Ioannina, Greece

60Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, ASST-Spedali Civili, Brescia, Italy

61Department of Internal Medicine, University of Pavia, Italy

62Division of Translational Oncology, I.R.C.C.S. Istituti Clinici Scientifici Maugeri, Pavia, Italy

63Barts' Cancer institute, Queen Mary University of London, London, UK

64LungenClinic, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany

65Supportive Care Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy

66Centrum Onkologii-Instytut im. Marii Sklodowskiej-Curie, Warsaw, Poland

67Faculty of Medicine, Iv, Javakhishvili Tbilisi State University, Tbilisi, Georgia

68Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland

69Department of Hematology, Hadassah-Hebrew University Medical center, Jerusalem, Israel

70Cancer Medicine Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Nazionale Tumori, Milan, Italy

71Nurse Consultant Symptom Control and Palliative Care, The Royal Marsden NHS Foundation Trust, London

72Department of Hematology, Oncology and Tumor Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany

73Medical Oncology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland

74Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands

75Charitè Comprehensive Cancer Center, Berlin, Germany

76Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland

77Department of Pulmonary Medicine, University Hospital of Bern, Bern, Switzerland

78Department of Neurology, University Hospital and University of Zürich, Zürich, Switzerland

79Palliative Care, The Royal Marsden, London, UK

80Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada

81Divisions of Palliative Medicine and Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada

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