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Protecting Medical Staff to Ensure Cancer Patients Can Safely Receive Care During the Pandemic

With Antonio Passaro, European Institute of Oncology (IEO), Milan, Italy
06 Apr 2020
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As the proportion of healthcare workers with COVID-19 has rapidly increased in many countries since the beginning of the outbreak, implementing efficient measures to protect medical teams has become a top priority globally, with clear benefits for the quality of care in oncology too. According to Antonio Passaro, from the European Institute of Oncology (IEO) in Milan, Italy, protecting medical oncologists from contracting the virus is key to ensuring that continuity of care is maintained and that cancer patients can safely attend visits and receive treatment in due time.

What is the current policy for COVID-19 testing in Italy?

In the Lombardy region, ISS, the leading technical-scientific body of Italy’s National Health Service, does not recommend performing the diagnostic swab in asymptomatic individuals, except in the specific context of an epidemiological strategy to track all the possible contacts linked to an infection cluster. Doctors are responsible for prescribing the swab in subjects who show symptoms of an acute respiratory infection and who meet the criteria issued by the Ministry of Health. These criteria include contact with a probable or confirmed case of COVID-19, living in or coming from areas with community transmission, hospitalisation and the absence of other causes that fully explain the clinical picture.

Discussions are in progress at the level of the regional governments to evaluate the possibility to broaden the population to be tested. In particular, this includes new strategies to test healthcare providers who are at higher risk of being exposed to the infection. The governments of the Piemonte and Veneto regions have been among the first in recent days to extend the test to family doctors and healthcare workers. I am confident that this approach will help doctors, but especially patients during this health emergency.

How has the daily routine of medical oncologists changed since the COVID-19 pandemic outbreak?

At IEO, we have made every effort to improve our setting and better protect our patients since the early stages of the pandemic. All IEO staff and patients have their temperature checked every time they enter the institute. Carers are granted entry only when accompanying patients who are not self-sufficient. For patients who are hospitalised we now allow just one visitor, and only in the evening.

Each day, we additionally perform a phone check to triage all the patients scheduled for a visit the following day: we call them to ask how they are feeling, whether they have new symptoms to report or are experiencing a significant modification of pre-existing cancer-related symptoms.

We are also reaching out to all of our patients, be it over the phone or via social media, to advise them to avoid crowds and practice social distancing, to wash their hands following WHO guidelines, to use personal protective equipment (PPE) in accordance with national recommendations and when coming to the hospital, to avoid contact with friends and relatives who have COVID-19 symptoms or live in endemic zones.

What strategies have been planned at IEO to ensure the continuity of treatments and follow-up visits for cancer patients?

We have prepared a dedicated unit for the hospitalization of patients with a suspected or detected SARS-CoV-2 infection in our institution. These individuals are temporarily taken out of the path of cancer treatment, and receive all the support and care necessary for recovery from COVID-19.

Differentiated approaches have been established for three distinct groups of COVID-negative patients: individuals who are off treatment, those with early-stage cancer who are due to receive therapy with curative intent, and finally patients with metastatic disease.

For patients who are off treatment and in the absence of recurring active disease, we are delaying visits and follow-up appointments. We contact people by phone ahead of their scheduled follow-up visit and provide evaluations of their examination reports via email. Imaging results may also be transmitted by regular mail.

To treat patients in a curative setting, we have implemented specific pathways to guarantee the timing of their therapy unfolds as planned. This is associated with close monitoring for potential toxicity and for COVID-19 symptoms, which are very similar to the baseline symptoms observed in lung cancer.

Patients suffering from metastatic disease have their chemotherapy or immunotherapy delayed where possible. Every single case is discussed in a Division meeting, where we evaluate the person’s prognosis and disease characteristics, as well as their clinical condition, taking into account factors such as comorbidities, performance status and concomitant medication.

Are treatment doses reduced, to the extent that it could impact the quality of care?

There is no reason to reduce the doses for any patients able to receive their cancer treatment as planned by visiting the cancer centre or because they are under oral therapy. In the case of patients receiving oral therapy such as tyrosine kinase inhibitors, we provide them with a supply for two months and make use of telemedicine where applicable to ensure appropriate toxicity management.

We are also able to deliver drugs directly to patients’ homes in certain circumstances, for instance when they have a poor performance status or live outside of our region. The drugs are provided by the hospital pharmacy service based on prescriptions from the doctor and pharmacist, in agreement with the local health company which takes care of home dispensation to the most fragile patients. With the support of the pharmaceutical industry sponsor, we are even able to home-deliver oral drugs to patients involved in some ongoing clinical trials. This allows us to ensure continuity of care even in the most complex situations.

How do you, personally, deal with not being able to care for your patients who become infected with COVID-19?

The adage “primum non nocere” applies particularly well here. Cancer patients, in particular lung cancer patients, must be protected and not exposed to additional risks. Those who test positive for COVID-19 need to be protected from any problems that anti-cancer treatments can cause if they are asymptomatic. When they do show symptoms, they must be hospitalised immediately and receive the necessary treatment for the infection as a top priority, thus delaying the administration of anti-cancer therapies. Reducing concomitant medication potentially harmful to a COVID-19 infection is a key precaution to take.

At the same time, it is more important than ever to be even closer to our patients in this critical period, as during this pandemic they are confronted with new levels of uncertainty in their fight against cancer.

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