Reports from Wuhan—China — the city of originated for the virus, indicate that patients with cancer may be at an increased risk of COVID-19 compared with the general population due to frequent hospital visits. Oncology practices are following strict protocols to ensure their patients’ safety during this time, and many have made the switch to using telehealth as much as possible in lieu of patients coming into the hospitals and putting themselves more at risk.
“Undoubtedly, healthcare providers have had to rapidly alter care delivery models while simultaneously acknowledging the crucial unknowns of how these changes may affect clinical outcomes. This special feature reviews strategies on how to mitigate transmission of COVID-19 in an effort to reduce morbidity and mortality associated with the disease for patients with cancer without infection, for patients with cancer with COVID-19 infection, and for the healthcare workers caring for them, while continuing to provide the best possible cancer care,” wrote Pelin Cinar, MD, MS, of the University of California San Francisco, et al.
In response to the pandemic, social distancing has been recommended across the globe. However, this is particularly challenging to control in the hospital setting. The use of telemedicine plays an important role in the treatment of patients with cancer during this challenging time. Through telemedicine physicians have the ability to see and check in on patients, limiting the risk of in-person visits. However, not every visit can be done virtually, and some patients require therapy that cannot be interrupted or altered.
Managing Patient Care in Amidst COVID-19 Pandemic
The NCCN recommends patients be prescreened for symptoms and potential exposure history via phone calls or telehealth platforms before any hospital visits. Separate screening clinics can be used to evaluate and test patients with symptoms in a dedicated unit for COVID-19.
In most cancer centers, prescreening is done 1 to 2 days prior to a patient’s visit. Symptoms they are screened for include a new or worsening cough within the past 14 days, shortness of breath, muscle aches, or fever. Patients should also be asked about their travel history or any contact they may have had with an individual who tested positive for the virus. Should patients have any concerning symptoms, the institution should determine if the patient needs to be evaluated, monitored at home, or referred to an emergency department.
Any upcoming in-person visits that can be converted to virtual visits should be at this point, according to the NCCN. The institutions and staff must determine what is considered an “essential visit” to limit the number of patients coming in. Hospitals should put in place a limited or no visitor policy, and surgeries or procedures that are not essential, urgent, or emergent should be postponed to a later date.
For patients who require a diagnostic biopsy via aerosol-producing procedures, such as endoscopies, endoscopic ultrasounds, or bronchoscopies, CT-guided biopsies can be done if possible. In addition, molecular testing and liquid biopsies can also be considered in certain circumstances.
For patients who test positive for COVID-19 and must come in for treatment, most centers have established separate units for treating these patients. Grouping COVID-19-positive patients together helps to control the risk of exposure to others and provides patients with cancer the ability to receive their treatment.
Alternative dosing schedules for patients receiving systemic therapy should be considered to limit the number of in-person visits to the hospital, and physicians should also consider switching therapy to oral agents if an equivalent formulation of infusion therapy is available for those receiving infusion treatments. Some therapies may also be administered at home via home care nurses. Patients receiving radiation therapy can be evaluated for short-course or hypofractionated radiation therapy if appropriate.
Wherever possible, care at home can replace outpatient care for some patients. The time between scans can be increased or physicians can use biochemical markers in lieu of scans. Overall, centers should make every effort to keep a limited number of patients coming into the clinic by utilizing telehealth.
In the event of treating patients with hematologic malignancies, the NCCN does not recommend therapies of curative intent be delayed or considered elective. Asymptomatic patients receiving chemotherapy that could result in significant immunosuppression should be testing for COVID-19 before the start of therapy.
The urgency of the use of stem cell transplantation, which is unique to patients with hematologic malignancies, should also be considered, and physicians should note that processes for obtaining donor stem cells have been modified due to the pandemic and travel restrictions. All transplant centers are required by the National Marrow Donor Program to receive and cryopreserve unrelated donor products ahead of administering conditioning chemotherapy to the patient.
“Additionally, because many centers have limited nonemergent surgical procedures, peripheral blood mobilized stem cell products are preferred over bone marrow grafts requiring surgical harvest, except in circumstances where data supports improved survival with the use of bone marrow graft over peripheral blood graft,” Cinar et al wrote.
Additionally, in terms of patient care, support services like palliative care, dietitian services, and psycho-oncology should also be delivered through telehealth to ensure patients continue receiving comprehensive care.
Because patients with cancer who are still receiving therapy are at higher risk of developing COVID-19, they should limit their exposure to their family members and others. While caregivers of patients may not be at a higher risk themselves, close proximity can put the patient at a greater risk. The NCCN recommends telephone or video communication between caregivers and patients with cancer whenever possible to include caregiver support in the patient’s visits and treatments.
There is no clear answer on when to resume therapy in a patient with cancer who is tested positive for COVID-19. The Centers for Disease Control (CDC) recommends a test-based strategy, which includes 2 consecutive negative nasopharyngeal swabs collected ≥ 24 hours apart and resolution of fever and respiratory symptoms, but testing guidance is based on limited information at this time and remains subject to change. However, this is the preferred method among most cancer centers. A non-test based strategy for centers that do not have access to testing would be at least 3 days since the resolution of symptoms and at least 7 days since the initial appearance of symptoms.
For patients with cancer receiving therapy that cannot be interrupted, such as radiation therapy, physicians should manage these patients carefully should they test positive for the virus. These patients should wear a mask, be treated separately from other patients, and have minimal contact with staff members.
Recommendations for the Safety of Healthcare Providers
Frontline healthcare providers are also considered a high-risk population, and these individuals are faced with the challenge of a worldwide shortage of PPE. The CDC has recommend use of an N95 or higher respirator when providing care for patients with known or suspected COVID-19, but facemasks are an acceptable alternative if unavailable. Every institution is addressing the PPE shortage based on local public health jurisdiction and supply.
To maximize the use of PPE for healthcare providers, The World Health Organization (WHO) recommends the use of telemedicine for initial evaluation, only essential healthcare providers entering patient rooms, and minimizing the number of times a room is entered by grouping activities together.
Screening clinics are also valuable in conserving PPE by providing a dedicated area for evaluation of patients who may potentially have COVID-19. In response to the PPE shortage, the FDA approved Emergency Use Authorization for the Battelle CCDS Critical Care Decontamination System, allowing for the decontamination of compatible N95 or N95-equivalent respirators.
A PPE burn rate calculator has also been developed by the CDC to help healthcare providers optimize their use of PPE. The CDC has not shared any recommendations on the extended or universal use of surgical masks, but they recommended the use of cloth face coverings in public settings where social distancing may be difficult to maintain. This policy has been implemented in most cancer centers because of the difficulty in keeping 6 feet from individuals in the clinical care setting.
The NCCN also recommends any healthcare providers with concerning symptoms or potential exposure to COVID-19 should self-isolate themselves as opposed to reporting to work. COVID-19 hotlines should be developed to triage symptomatic healthcare providers for rapid testing.
Telecommuting is recommended and encouraged for all employees to limit the number of staff members on site. “Remote work tools” should be made available to all employees at institutions participating in telecommuting.
For healthcare providers with either suspected or confirmed COVID-19, both the test-based strategy and non-test-based strategy can be used to determine when they are cleared to return to work, similar to procedures recommended for resuming treatment in patients with cancer.
Overall, institutions should be sure to keep all lines of communication open between staff, as well as with patients.
“Regularly updated internal websites with guidelines and policies regarding COVID-19 and information on wellness, childcare, PPE, workflows, and clinical algorithms will be an invaluable resource for healthcare workers,” Cinar et al wrote. “Developing and distributing a document with frequently asked questions will also provide patients and their families with a sense of ease.”
While these are extraordinary times, oncology practices as a whole should take precautions to ensure the safety of both their staff and patients with cancer. It is important to remain committed to the patients with compassionate care but to not sacrifice the health and safety of healthcare providers as well.
“The distressing global experience with COVID-19 limited and in some cases devastated the healthcare delivery systems we have relied on to provide safe and effective care to our patients. Nonetheless, our healthcare community remains dedicated, resilient and adaptable,” Cinar et al concluded.
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Cinar P, Kubal T, Freifeld A, et al. Safety at the Time of the COVID-19 Pandemic: How to Keep our Oncology Patients and Healthcare Workers Safe [Published Online April 3, 2020]. JNCCN. DOI: 10.6004/jccn.2020.7572.