Cancer Care During the COVID-19 Pandemic: An ESMO Guide for Patients

COVID-19 is short for ‘Coronavirus Disease 2019’. It is an illness that is caused by a new, fast-spreading coronavirus called SARS-CoV-2.

Coronaviruses are a family of viruses that cause disease in mammals and birds but can occasionally evolve to affect humans. In December 2019, the first human cases of COVID-19 caused by SARS-CoV-2 were reported in Wuhan, China. In this guide, SARS-CoV-2 will be referred to simply as ‘coronavirus’.

Coronaviruses are spherical in shape and have protein spikes protruding from their surface. The spikes can latch onto human cells, allowing the viral particle to join with the human cell. Genes from the virus can then enter the human cell and reproduce themselves in order to produce more viruses.

Coronaviruses cause respiratory tract infections in humans. The new coronavirus (SARS-CoV-2) has spread rapidly around the world and the resulting disease, COVID-19, can cause serious and life-threatening infections, particularly in older people (e.g. over 65 years) and those with other underlying health conditions.

Who is most at risk from COVID-19?

The data available so far indicate that older people are more vulnerable to complications from COVID-19, particularly when there have underlying health conditions such as chronic lung disease, cardiovascular disease, diabetes, chronic kidney disease and active cancer.

If you have cancer, you may be at higher risk of severe illness from COVID-19 if you:

• Are having chemotherapy or have received chemotherapy in the last 3 months
• Are receiving extensive radiotherapy
• Have had a bone marrow transplant or stem cell transplant in the last 6 months, or are still taking immunosuppressive drugs 
• Have a type of blood or lymphatic system cancer which damages the immune system, even if you have not received treatment (for example, chronic leukaemia, lymphoma or myeloma)

This is because some cancer treatments, and some cancers themselves, can suppress your immune system, which means you may not be able to fight the infection as well as someone without cancer. However, in some patients, continuing cancer treatment is essential to fight the disease even if this is associated with an increased risk of severe illness from COVID-19. As such, careful consideration of the risk versus benefit of any cancer treatment must be carefully considered for each individual patient.

If you fall into any of the categories listed above, your doctor will instruct you to take steps to protect yourself from infection with coronavirus.

Transmission of coronaviruses from person to person is thought to mostly occur via the droplets generated when we sneeze and cough. The new coronavirus that causes COVID-19 seems to be very contagious, with each infected person typically passing the virus on to another two people.

Good hygiene measures, such as washing your hands regularly and covering your mouth when you cough or sneeze, are very important under normal circumstances. However, they must be even more strictly observed during the COVID-19 pandemic, as these simple measures can greatly reduce your risk of becoming infected and passing the infection onto other people.

Preventative strategies for avoiding COVID-19 are outlined below.

Washing hands

Hands should be washed regularly with warm soapy water for at least 20 seconds. Special care should be taken to wash hands after being outside, after touching anything that has come into your house from outside (e.g. mail and groceries) and before cooking or eating. You should also try not to touch your face, especially your nose, eyes and mouth, to avoid transferring the coronavirus from your hands to areas where the virus could get inside your body.

Nail hygiene is also important. Nails should be kept short and be brushed whilst washing hands.

Face masks

Face masks should only be worn if you are ill with symptoms of COVID-19 or if you are looking after someone with COVID-19. Disposable face masks should only be worn once. However, you can also consider wearing a face mask if you are at high risk of serious consequences from COVID-19 and are unable to effectively self-isolate (for example, if other members of your household are unable to self-isolate with you and coming into contact with them is unavoidable). If you are not considered as being at high risk of serious consequences from COVID-19 and choose to leave the house for exercise and groceries, you may also choose to wear a face mask. However, a face mask alone should not be relied upon to protect you from infection. You should also observe the social distancing rules outlined below and make sure you wash your hands thoroughly as soon as you return home.

Social distancing

Many countries now have social distancing rules in place. Social distancing includes measures to minimise your contact with people outside your household (including friends and family). For example, social gatherings, including parties and weddings, are not currently permitted in many areas. Schools, universities, restaurants and shops are also closed. People are being encouraged to only leave their house when absolutely necessary to shop for food, collect medication and to go to work if there is no way to work from home. Leaving the house for exercise may also be permitted; however, you must remain distant (more than 2 metres away) from anyone you see. For essential travel on public transport, people are being asked to stay 2 metres away from each other wherever possible. Patients with cancer should avoid using public transport if at all possible.

The social distancing rules are designed to keep people a safe distant apart in order to reduce the risk of the coronavirus spreading through social contact.

Self-isolation

Self-isolation is recommended for people at high risk of serious consequences from COVID-19. Some patients who are being treated for cancer are believed to be at high risk of severe illness from COVID-19 (see section ‘Who is most at risk from COVID-19?’) and should remain in self-isolation while the pandemic is ongoing. Your doctor will let you know if you should be self-isolating. Self-isolation means that you should stay inside your home at all times and have no contact at all with anyone outside your household. For self-isolation to be effective, other members of your household should be isolated with you. If this is not possible then you should try to isolate within an area of your household (e.g. your bedroom), preferably with your own bathroom, and try to keep at least 2 metres away from other members of your household. When in self-isolation, you must not leave your home for any reason. As such, you will need to organise for your shopping and medication to be delivered to the outside of your home. This can be done using remote technology such as the phone, internet or social media.

People who are showing any symptoms of COVID-19 (see section ‘What are the symptoms of COVID19?’) should also go into self-isolation to ensure they don’t pass the coronavirus on to anyone else.

Additional prevention measures for patients with cancer

Some patients who are being treated for cancer may be at high risk of serious illness from COVID-19. This is because cancer can suppress your immune system, which means you may not be able to fight the infection as well as someone without cancer. Some cancer treatments also suppress the immune system so it is very important to listen to the advice of your doctor on the steps you can take to prevent infection. Your doctor or your local authorities may instruct you to take more stringent measures than the general population; for example, you may be required to self-isolate, even from other members of your household, to ensure that you are protected from any risk of infection and therefore serious illness. You should also use telephone or online services for all outside contact, including contact with your doctor, nurse or family doctor, and to arrange delivery of your shopping and medication. Maintaining good hygiene, including washing your hands regularly, is also important.

If you are not sure if you are at higher risk of severe illness from COVID-19 and the steps you need to take to protect yourself, you should contact your doctor, nurse or GP, for further information and advice.

Additional prevention measures in hospitals and health centres

Hospitals and other places that provide healthcare have incorporated new measures to minimise the risk of infection to patients and staff. For example, non-essential appointments may be cancelled or conducted over the phone. If you have an essential appointment, you may not be permitted to take anyone with you. Waiting areas may be closed and you might be asked to wait outside until you receive a call or text to let you know that your appointment is beginning. There may be screens or barriers in front of sign-in desks to prevent the virus passing from staff to patients and vice versa. You might also be asked to use private transport to get to your appointment rather than travelling on public transport.

Many hospitals have now separated their medical teams into those caring for COVID-19 patients and those caring for other patients, including cancer patients. These separate teams do not come into contact with each other at any time, professionally or personally, to prevent transmission from the COVID-19 team to the cancer team. In some areas, cancer care is being relocated away from general hospitals to specialist cancer centres, again to reduce the risk of transmission between the general hospital population and patients with cancer. Some hospitals may not permit visitors during the pandemic.

It is important that you can recognise the symptoms of COVID-19. They are:

• Fever.
• Coughing.
• Sore throat.
• Difficulty breathing.
• Muscle pain.
• Fatigue.
• Loss of taste and smell.
• Symptoms in the gastrointestinal system, e.g. diarrhoea.

Patients with cancer might experience differences in symptoms compared with the general population; for example, if your immune system is suppressed due to cancer treatment, you may experience fewer early symptoms. It is also important to note that some COVID-19 symptoms overlap with symptoms experienced during cancer treatment, including fatigue and fever.

The time from when a person is exposed to the new coronavirus and when symptoms first appear is typically 4–6 days, although this may range from 2–14 days. It is thought that most COVID-19 cases are spread from people who have symptoms. However, some patients may be infectious before their symptoms develop.

You should contact your doctor if you experience symptoms of COVID-19. It is very important that you do not go directly to your doctor or hospital in order to avoid potential spread of the infection. Contact them first, either online or by telephone, and follow the instructions they give to you. If your symptoms are mild, you will probably be asked to isolate yourself at home to avoid spreading the infection. If your symptoms are severe, you may be asked to go into hospital for further assessment, but you will not be seen in your usual oncology department. This is because it is crucial that patients with symptoms of COVID-19 are kept separate from other departments, especially those treating patients with cancer.

An antigen test is already available that is used to detect whether a person currently has COVID-19. An antigen is a structure within a virus that triggers the body’s immune system to fight off the infection. This antigen test involves taking a swab from the nose or throat which is then sent to a laboratory for testing. Depending on the situation (e.g. the location of the laboratory and the number of tests ordered), it may take several days for the laboratory to run the test and tell the person the result. The availability of the antigen test and guidance on who should be tested varies between countries.

An antibody test is being developed that could be used to detect whether a person has had past exposure to COVID-19 and has since recovered, regardless of the presence of symptoms. Antibodies are generated by the blood in response to the presence of a specific antigen. Once generated, these antibodies attach onto the virus in order to destroy it. It can take several days for the body to generate antibodies to a virus, but once formed, they remain in the blood ready to protect us if we encounter the same virus again. An antibody test involves taking a small amount of blood using a device that pricks your finger and could potentially give a result within 15 minutes. However, as it takes time for the body to generate antibodies, an antibody test should not be used to see if a person currently has COVID-19.

Various antibody tests for COVID-19 are being checked to make sure they are reliable, and one test has already been authorised for use in the United States. However, once they are widely available, they will become an important test to find out how many people have had COVID-19 and to determine the full impact of this pandemic.

Healthcare staff

Healthcare workers may be tested for COVID-19 in order to minimise the risk of transmission between healthcare staff and patients. However, the availability of the test and who should be tested varies between countries. In some areas, all healthcare workers may be tested for COVID-19 regardless of symptoms, or this may be restricted to only those showing symptoms of COVID-19. In other areas, healthcare workers with mild symptoms may not be tested but instructed to self-isolate for 14 days instead.

Patients

If you have mild symptoms, you may or may not be tested for COVID-19 as testing procedures and guidelines vary between countries and may change as the pandemic continues and more tests become available. Currently, tests are mainly being carried out on patients who are hospitalised with severe symptoms.

There are no specific treatments for COVID-19 yet, so the infection is managed by treating the symptoms. Mild cases can be treated at home by getting plenty of rest, drinking lots of water and taking paracetamol to reduce fever. Patients with severe symptoms might need to be treated for complications such as pneumonia in hospital.

Various existing drugs, including antivirals and drugs that modify the immune response, are being tested to see if they might help to treat patients with COVID-19. Among these, chloroquine and hydroxychloroquine are anti-malaria drugs that are being evaluated in clinical trials for patients with COVID-19. So far, data from two small studies suggest that they may provide some benefit in hospitalised patients. However, emerging data from additional studies do not all show the same results. The United States drug regulator has approved chloroquine and hydroxychloroquine for use in hospitalised patients with COVID-19, and these drugs have also been added to COVID-19 treatment guidelines in some countries, including China and the United States. However, the European drug regulator has advised that these drugs should only be used in clinical trials or emergency use programmes.

Other drugs currently being tested in clinical trials as potential treatments for COVID-19 include remdesivir, lopinavir/ritonavir (currently used to treat HIV infection) and interferon beta (currently used to treat diseases such as multiple sclerosis).

It is important to note that firm data are needed to show the efficacy and safety of any drug that is being considered for use in patients with COVID-19. Chloroquine and hydroxychloroquine, as well as other drugs mentioned in recent news stories, are not currently supported by strong clinical trial data. As such, self-medication should be avoided as some drugs may cause serious side effects or interfere with other medications. Your doctor will be able to advise you on the best way to treat your individual symptoms.

Vaccine development

There is currently no vaccine for the new coronavirus but scientists around the world are working hard to develop one. Vaccine development usually takes 12–18 months, but volunteers are already being screened to take part in clinical trials for coronavirus vaccines. Initial studies will look at the safety of the vaccines and whether they produce an immune response.

If you develop symptoms of COVID-19, the medical priority will be to isolate you and treat the COVID-19 infection rather than your cancer. Your cancer treatment will resume once you have recovered sufficiently from COVID-19.

Attending hospital during the COVID-19 pandemic can put you at risk of infection. Therefore, to keep you safe, your cancer care may be adapted while the pandemic is ongoing. The aim is to reduce your time spent in a hospital setting whilst still providing the care that you need.

To minimise face-to-face contact, you will be offered telephone or video consultations, particularly for pre-treatment meetings and follow-up appointments. If you usually have blood tests done at a hospital, these may be relocated to a local centre instead. Medication may be delivered to you, or a drive-through pick-up point may be arranged. Repeat or electronic prescription periods are also being extended in many areas to allow patients to access their home-based cancer treatment (e.g. oral treatments) without the need for additional prescribing appointments during the pandemic.

If you have an essential hospital appointment, you will find that special measures have been put in place to protect patients and staff (see section ‘Additional prevention measures in hospitals and health centres’). In addition, you may be contacted via telephone the day before your scheduled appointment to check that you have not developed any symptoms of COVID-19. Any patients showing signs of infection will not be permitted to attend their appointment and may be redirected to a department specialising in COVID-19, depending on the severity of symptoms.

Some types of treatment may be delayed in order to protect you from risk of infection. It is important to understand that in many cases it is perfectly safe to delay treatment slightly, and your doctor will only suggest this if it is in your best interests. Keep in close contact with your doctor or nurse via telephone and email so they can advise you of any changes to your care plan.

The scenarios outlined below are for guidance only and should not replace your doctor’s advice. Your doctor knows your full medical history and will advise on the best approach for you.

Impact of COVID-19 on cancer screening

It is likely that routine screening appointments, for example cervical screening tests and mammograms, will be cancelled or postponed for the foreseeable future.  

Impact of COVID-19 on diagnostic and staging procedures 

Tests to diagnose or stage cancer might be delayed if the risk of infection with coronavirus outweighs the benefits of the tests. This might apply to patients who have shown signs of a cancer that has a low risk of rapid progression, such as minor suspicious findings on mammography. This will be discussed on a case-by-case basis. In some patients, staging procedures may be limited to those that are the most crucial to guide treatment.

Impact of COVID-19 on cancer treatment

Your cancer treatment plan may be adapted in order to minimise the risks to your health resulting from the COVID-19 pandemic. The adaptation strategy may differ depending on the therapeutic goal; for example, curative treatment is more likely to continue as planned to ensure the best chance of remission, whereas the risks of COVID-19 in patients undergoing palliative therapy may outweigh any potential benefits of treatment.

ESMO is applying a tiered approach to guidance on the management of patients with cancer during the COVID-19 pandemic. This approach considers the patient’s condition, the urgency of the planned cancer treatment and its anticipated benefit in light of the potential risk of COVID-19 associated with the logistics of receiving treatment, as well as the available resources to safely provide treatment. Using this approach, patients can be grouped into the following tiers:

Tier 1: High priority. This group includes patients whose condition is life threatening or clinically unstable and/or where the planned treatment is likely to result in a significant benefit (e.g. prolonging life or improving quality of life), making treatment a high priority.

Tier 2: Medium priority. This group includes patients whose condition is serious but not immediately life threatening and where a short delay in treatment can be considered. However, a delay of longer than 6–8 weeks could potentially impact on outcome and/or the amount of benefit derived, making treatment a medium priority.

Tier 3: Low priority. This group includes patients whose condition is stable enough that any treatment can be safely delayed for the duration of the COVID-19 pandemic. It also includes patients who’s planned treatment is unlikely to provide a significant benefit (e.g. unlikely to prolong life or improve quality of life), making treatment a low priority.

A multidisciplinary team will review each individual patient in order to decide if any changes to treatment are needed. It is therefore very important to keep in contact with your doctor or nurse via telephone or email to ensure you understand if, how and why your treatment plan might be modified.

Below are some examples of adaptations to treatment that might happen in your country.

Adaptations to surgery plans 

In most countries, non-essential surgery is being postponed for the duration of the COVID-19 pandemic. For patients with cancer, the potential risk of disease progression following a delay in surgery has to be balanced against the potential exposure to coronavirus and risk of serious complications from COVID-19. If the surgery requires post-operative intensive care, the current availability of intensive care units will be considered as part of the decision-making process.

In some situations where neoadjuvant therapy (treatment given before surgery) is available but not routinely used (e.g. early-stage breast cancer), your doctor may offer neoadjuvant therapy as an alternative to upfront surgery (which could result in exposure to coronavirus) in order to delay your surgery. However, it’s important to note that neoadjuvant therapy that is immunosuppressive or that requires clinic visits is also associated with a risk of infection and serious complications of COVID-19. Therefore, your doctor will discuss all of the options with you to ensure optimal outcomes whilst minimising the risk of coronavirus infection.

Adaptations to chemotherapy

A decision to delay, modify or interrupt your chemotherapy will only be taken after weighing up the potential harm that could result from delaying or interrupting chemotherapy versus the potential benefits of preventing COVID-19. The clinical decision will be made on a case-by-case basis, taking into account the risk of cancer recurrence if chemotherapy is delayed or interrupted, the number of cycles of chemotherapy already completed and how well you are coping with treatment.

• Your doctor might recommend a chemotherapy ‘holiday’ if you are on maintenance therapy and are in established remission. This might be timed to coincide with when the pandemic is at its peak in your region.
• Delaying or modifying adjuvant treatment (treatment given after surgery) may be recommended in some cases. If you are undergoing adjuvant treatment for resected high-risk disease, then your chemotherapy is likely to continue as planned. However, if the benefit of adjuvant chemotherapy is thought to be relatively small and non-immunosuppressive options are available, your doctor may suggest using an alternative treatment to reduce your risk of complications from COVID-19.
• There may be an opportunity to switch to a chemotherapy regimen that requires less frequent infusions; for example, every 2/3 weeks rather than weekly. In some cases, the chemotherapy infusion may even be possible at home depending on the infrastructure in your area.
• You may be able to switch from an intravenous chemotherapy to an oral therapy, thus reducing the frequency of hospital visits.
• If you continue to receive chemotherapy, your doctor may recommend that you take prophylactic growth factors to help boost your immune system and antibiotics to fight off any infections in order to make you less vulnerable to serious complications of COVID-19.

Adaptations to radiotherapy

If you have a rapidly progressing, potentially curable tumour, the risks of delaying radiotherapy may outweigh the risks associated with COVID-19 and so your radiotherapy is likely to go ahead. To reduce your visits to the hospital, your doctor might consider accelerated or hypo-fractionated radiotherapy schedules. This means that the total dose of radiotherapy is given over a shorter period of time or in fewer doses compared with standard radiotherapy.

If you are at high risk of harm from an altered radiotherapy schedule or if you are receiving radiotherapy for symptom control, then your radiotherapy visits could potentially be delayed and alternative treatments may be discussed.

A decision to alter or delay radiotherapy will only be made when medically justified and appropriate for you. Your doctor will be able to discuss all of the options available to you.

Adaptations to endocrine therapy

Endocrine therapy does not suppress the immune system; therefore, it does not increase your risk of severe COVID-19. This means it is usually safe to continue taking endocrine therapy during the pandemic.

However, if you receive your endocrine therapy as an injection, your doctor may decide to change your treatment schedule so that you don’t have to visit the hospital or healthcare centre as frequently. For example, if you usually have an injection every 3 months, you may start having one every 6 months instead.

Adaptations to immunotherapy

If you are receiving immunotherapy, your doctor might adjust your treatment schedule to reduce the frequency of hospital visits. It is important to note that immunotherapies can cause serious immune-related side effects; treatment-related pneumonitis is a particular concern as it may increase the risk of serious complications if you develop COVID-19. Any changes to your therapy will be made following individual assessment and discussion with you.

Adaptations to stem cell transplant

If you are at high risk of serious complications from COVID-19, your doctor may recommend delaying your planned stem cell transplant, particularly if your cancer is well controlled with other treatments. If your stem cell transplant goes ahead, you may not be able to have any visitors while you remain in hospital.

There is currently no evidence to suggest that the new coronavirus is transmitted via blood transfusions, but in some areas potential stem cell donors may be tested for COVID-19 before stem cell collection. There may also be fewer stem cell donors available due to COVID-19 infection or logistical reasons (e.g. travel restrictions). Stem cell transplants could therefore be delayed until the hospital is able to confirm that they have received the stem cells. In these cases, the stem cells would be frozen until your appointment can be rescheduled.

If you have upcoming hospital appointments as part of your care plan, some of these appointments may go ahead as planned, be changed to telephone appointments, or be delayed. In order to carefully balance the urgency of care versus the potential risk of COVID-19 infection to all patients, ESMO has provided tiered guidance by prioritising different types of clinical situations and hospital visits as follows:

High priority: These appointments will likely go ahead as planned

High/medium priority: These appointments will be conducted via telephone where possible, or could be relocated to a local healthcare centre or cancer clinic

Medium priority: These appointments may be conducted via telephone (where possible), relocated to a local healthcare centre or cancer clinic, or may be delayed for a short time (no more than 6–8 weeks)

Low priority: These appointments may be conducted via telephone or delayed for the duration of the COVID-19 pandemic

The information below provides further guidance on the prioritisation of different types of treatments and hospital visits so that you can better understand how your care plan might be changed. However, this is intended as guidance only and should not replace your doctor’s advice. Your doctor knows your full medical history and will advise on the best approach for you. Treatment decisions will be made on a case-by-case basis with your doctor. Therefore, it is important that you keep in close contact with your doctor or nurse via telephone and email so they can advise you of any changes to your care plan.

You should also follow any specific guidance from your local healthcare authorities based on the situation in your own country.

Adaptations for Tumour Types

Adaptations to Urothelial Bladder Cancer Management

Adaptations to Primary Brain Tumour Management

Adaptations to Breast Cancer Management

Adaptations to Cervical Cancer Management

Adaptations to Colorectal Cancer Management

Adaptations to Endometrial Cancer Management

Adaptations to Gastro-Oesophageal Cancer Management

Adaptations to Hepatocellular Carcinoma Management

Adaptations to Lung Cancer Management

Adaptations to Aggressive Lymphoma (DLBCL, MCL, TCL) Management

Adaptations to Hodgkin Lymphoma Management

Adaptations to B-cell non-Hodgkin Lymphoma Management

Adaptations to Melanoma Management

Adaptations to Multiple Myeloma Management

Adaptations to Ovarian Cancer Management

Adaptations to Pancreatic Cancer Management

Adaptations to Prostate Cancer Management

Adaptations to Renal Cell Carcinoma Management

Adaptations to Sarcoma Management

It is very important that you continue to report any side effects from your cancer treatment to your doctor or nurse. It is likely that your usual face-to-face appointments will be replaced with telephone or video consultations, but you will still have ample opportunity to discuss any new or troubling side effects, and your doctor or nurse will still be able to help you to manage them. If you need medication to treat side effects, you might be able to have it delivered to your home.

Your doctor may take extra precautions during this time to minimise hospital visits related to the management of side effects. For example, if you are at a relatively low risk of febrile neutropenia and don’t usually take growth factors, your doctor may prescribe a prophylactic growth factor during the COVID-19 pandemic to minimise the potential need for emergency care and thus exposure to coronavirus. If you show symptoms of febrile neutropenia but are clinically stable (as determined by phone or video consultation), your doctor might prescribe antibiotics without you having to attend an appointment. If your doctor anticipates that you are at risk of serious treatment-related anaemia, they may prescribe an erythropoietin-stimulating agent to lower the risk of a subsequent hospital-based transfusion.

It is important to note that some COVID-19 symptoms overlap with the side effects of cancer treatment, for example fatigue and fever. It is therefore crucial that you stay in close contact with your doctor or nurse and report any new symptoms or side effects to them.

If you have upcoming hospital appointments as part of your care plan, some of these appointments may go ahead as planned, be changed to telephone appointments, or be delayed. In order to carefully balance the urgency of care versus the potential risk of COVID-19 to all patients, ESMO has provided tiered guidance by prioritising different types of clinical situations and hospital visits as follows:

High priority: These appointments will likely go ahead as planned

High/medium priority: These appointments will be conducted via telephone where possible, or could be relocated to a local healthcare centre or cancer clinic

Medium priority: These appointments may be conducted via telephone (where possible), relocated to a local healthcare centre or cancer clinic, or may be delayed for a short time (no more than 6–8 weeks)

Low priority: These appointments may be conducted via telephone or delayed for the duration of the COVID-19 pandemic

The information below provides further guidance on the prioritisation of different types of treatments and hospital visits so that you can better understand how your care plan might be changed. However, this is intended as guidance only and should not replace your doctor’s advice. Your doctor knows your full medical history and will advise on the best approach for you. Treatment decisions will be made on a case-by-case basis with your doctor. Therefore, it is important that you keep in close contact with your doctor or nurse via telephone and email so they can advise you of any changes to your care plan. You should also follow any specific guidance from your local healthcare authorities based on the situation in your own country.

Adaptations to supportive care strategies by symptoms

Acute cerebellar syndrome

• Very high doses of cytarabine may be avoided, especially if you have impaired kidney function

Anaemia

• Anaemia may be treated according to the level of symptoms rather than specific haemoglobin thresholds during the COVID-19 pandemic
• Erythropoiesis-stimulating agents may be given if you have symptomatic anaemia and are receiving chemotherapy in order to reduce your number of hospital visits. In these cases, long-acting erythropoiesis-stimulating agents may be preferred
• If you have severe anaemia-related symptoms, you may receive a red blood cell transfusion

Bone complications

• Treatment with bone-targeted agents by injection/infusion may be avoided during the COVID-19 pandemic. If needed, your doctor may administer this during an already-planned hospital visit in order to minimise your total number of hospital visits. You may also be able to take an oral bone-targeted agent instead
• If you have not received treatment with a bone-targeted agent before, you should have a dental examination first and complete any required dental treatment prior to starting treatment. However, this may be challenging in some countries/regions as dental services may be limited
• If you are receiving bisphosphonates for metastatic cancer, this can be safely switched to a 3-monthly administration
• If you are receiving denosumab, this may be administered at your local healthcare centre in order to reduce your number of hospital visits
• If you are receiving treatment with a bone-targeted agent, you will likely also receive vitamin D and calcium supplements

Cytokine release syndrome (CRS)

• CRS is a common side effect of CAR T-cell therapy which, if severe, can result in intensive care treatment. Given the need for additional intensive care beds due to the COVID-19 pandemic, your doctor may decide to delay CAR T-cell therapy or select an alternative treatment approach

Diarrhoea

• If you are experiencing severe diarrhoea, you should contact your doctor or nurse immediately as you may require hospital treatment. A hospital visit for severe diarrhoea should not be avoided or delayed during the COVID-19 pandemic
• If you are receiving a cancer treatment that is known to cause diarrhoea, your doctor or nurse will advise you of basic measures to be used, if needed, such as drinking lots of water and taking loperamide

Fatigue

• Exercise is an essential component to help manage cancer-related fatigue. Although this might be challenging during the COVID-19 pandemic due to local restrictions on outdoor exercise and/or group activities, try to incorporate some daily exercise wherever possible by walking in your garden or following an online exercise programme

Febrile neutropenia

• As febrile neutropenia can result in the need for emergency hospital treatment, your doctor may change your care plan and choose an alternative anticancer treatment with a lower risk of febrile neutropenia. This is for your own safety and to ensure you receive effective anticancer treatment whilst minimising your risk of COVID-19 and potentially severe complications
• You may also receive additional/prolonged growth factor support and/or antibiotics after chemotherapy to reduce your risk of developing febrile neutropenia
• If you are receiving or are scheduled to receive a steroid, this may avoided or given at a lower dose

Hypogammaglobulinaemia

• If you are at risk of developing hypogammaglobulinaemia, your doctor may prescribe immunoglobulin replacement therapy to help protect you against infections

Nausea and vomiting

• If you are receiving a cancer treatment that is known to cause nausea and vomiting, your doctor or nurse may prescribe you with antiemetic medications for prophylactic use

Chemotherapy-induced peripheral neurotoxicity (CIPN)

• Unfortunately, there is no treatment for CIPN, but it often goes away once chemotherapy is completed
• If you experience CIPN, you should speak to your nurse about practical ways to manage this. Strategies can include using a walking stick if your gait is unsteady and/or the removal of trip hazards from your home

Pulmonary (lung) toxicity

• As people with lung conditions may be at greater risk of serious complications following COVID-19, some cancer treatments that are known to cause pulmonary toxicity may be avoided
• If you are receiving a cancer treatment that is associated with a risk of pulmonary toxicity, you may be monitored more closely. However, if you develop any pulmonary symptoms, you should contact your doctor or nurse immediately. You may need to go to hospital for a computed tomography scan and further investigations make sure that your pulmonary symptoms are treatment-related and not linked to COVID-19

Thromboembolic events

• If you are receiving prophylactic treatment for thromboembolic events, this is likely to continue as planned with no changes
• If you develop COVID-19 and require hospitalisation, your prophylactic treatment for thromboembolic events may be changed to a low molecular weight heparin since this is less likely to interfere with any other medications you might receive

If you have upcoming hospital appointments as part of your care plan, some of these appointments may go ahead as planned, be changed to telephone appointments, or be delayed. In order to carefully balance the urgency of care versus the potential risk of COVID-19 to all patients, ESMO has provided tiered guidance by prioritising different types of clinical situations and hospital visits as follows:

High priority: These appointments will likely go ahead as planned

High/medium priority: These appointments will be conducted via telephone where possible, or could be relocated to a local healthcare centre or cancer clinic

Medium priority: These appointments may be conducted via telephone (where possible), relocated to a local healthcare centre or cancer clinic, or may be delayed for a short time (no more than 6–8 weeks)

Low priority: These appointments may be conducted via telephone or delayed for the duration of the COVID-19 pandemic

The information below provides further guidance on the prioritisation of different types of treatments and hospital visits so that you can better understand how your care plan might be changed. However, this is intended as guidance only and should not replace your doctor’s advice. Your doctor knows your full medical history and will advise on the best approach for you. Treatment decisions will be made on a case-by-case basis with your doctor. Therefore, it is important that you keep in close contact with your doctor or nurse via telephone and email so they can advise you of any changes to your care plan. You should also follow any specific guidance from your local healthcare authorities based on the situation in your own country.

Adaptations to palliative care

Key principles

• Treatment to relieve severe distress caused by cancer, as well as severe acute complications of cancer, remains a priority for all cancer patients
• However, many symptoms can be effectively managed by telephone consultations
• Home care services may also be arranged to ensure adequate palliative care to meet your needs 

Prioritisation

• You should receive urgent evaluation and management by your doctor or nurse if you experience a severe cancer-related complication, such as:
  • Spinal cord compression
  • A broken bone
  • Intestinal obstruction
  • Nausea
  • Vomiting
  • A blockage that prevents urine flow, leading to kidney failure
  • Severe shortness of breath
  • Blood clot formation in your circulatory system, especially if this causes a blockage in a blood vessel in your lungs
  • Severe anaemia
  • Severe thrombocytopaenia
  • Symptomatic pleural effusion, pericardial tamponade, tense ascites
  • Blockage in the superior vena cava
  • Brain metastases, especially if you are also experiencing seizures; problems with nerve, spinal cord or brain function; or cognitive impairment
  • Delirium
  • Pain and other severe symptoms not adequately controlled by optimal home management
  • Severe refractory symptoms that are not adequately controlled by optimal home management 

Practical suggestions

• Make sure you have enough medications at home to manage your cancer-related symptoms, including pain relief
• Keep in regular contact with your doctor or nurse so that they can help you to monitor symptoms and adjust medications as needed
• If you are receiving palliative radiotherapy, the number of treatment sessions may be reduced to minimise your number of hospital visits
• If you have advanced-stage disease, your doctor will try to ensure that most of your treatment is from home to minimise your risk of COVID-19
• If you have a pleural effusion or ascites that require frequent drainage, you may be fitted with a permanent indwelling catheter drainage system (e.g. PleurX) to reduce your number of hospital visits 

Palliative care

High priority

Your appointment may be a high priority if:

• You have increasing back, neck or radiating pain and you need an appointment to find out if you need treatment with either radiotherapy or surgery
• You have severe hip or leg pain when standing or walking
• You have severe pain of any cause, which is not being effectively managed by your current medications
• You have severe and increasing shortness of breath, except for known extensive lung metastases, as you may have a pleural effusion or pulmonary embolus that requires urgent treatment. If you experience recurrent effusions, you may be fitted with a permanent indwelling catheter drainage system to manage this effectively from home
• You experience symptoms of an intestinal obstruction such as abdominal pain or swelling, vomiting or constipation
• You have severe nausea and vomiting
• You have symptoms suggestive of superior vena cava compression such as face and arm swelling
• You have symptoms suggestive of brain metastases such as seizures; headache with confusion; or problems with nerve, spinal cord or brain function
• You have major bleeding: you are vomiting blood, coughing up blood, have blood in your sputum or rectal bleeding
• You have symptomatic anaemia (symptoms may include fatigue, shortness of breath, rapid heartbeat, pale skin, dizziness and difficulty concentrating)
• You have symptoms of biliary obstruction such as jaundice, dark urine or fever
• You have symptoms of a deep vein thrombosis such as leg or arm swelling with pain
• You have new onset agitated delirium
• You are experiencing severe emotional distress, including thoughts of suicide
• You have symptomatic brain metastases but are otherwise healthy. In these cases, you may be eligible to receive palliative radiotherapy

Medium priority

Your appointment may be a medium priority if:

• You have moderate back pain or back pain that is not effectively managed by your current medications
• You have extensive lung metastases and are experiencing increasing shortness of breath. In these cases, your doctor may be able to provide guidance by telephone appointment or you may need to be admitted to hospital if your current home care services are not adequate
• You are vomiting shortly after eating food. In these cases, you may need to see your doctor for further assessment and imaging. A stent or nasogastric tube may need to be fitted to help ensure adequate nutritional support
• You have asymptomatic anaemia
• You have increasing levels of anxiety and/or depression
• You have asymptomatic brain metastases. In these cases, you will likely be monitored and treatment may be delayed

Low priority

Your appointment may be a low priority if:

• You have mild back pain
• You have mild or moderate bone pain
• You have mild shortness of breath that is not getting any worse
• You are experiencing occasional vomiting or constipation
• You have a small amount of blood in your sputum or on the toilet paper
• You have a low haemoglobin level (less than 7 g/dL) and are terminally ill
• You have jaundice and known liver metastases
• You have mild arm swelling or swelling in both legs
• You have known extensive brain or liver metastases or advanced kidney failure and are experiencing confusion that is getting worse
• You have a mild or moderate level of anxiety and/or depression
• You have symptomatic brain metastases and are already very unwell, or close to end of life, because of your cancer. In these cases, your doctor may prescribe dexamethasone

The COVID-19 pandemic is likely to affect end of life treatment plans. Hospitals and hospices may restrict visitors during the pandemic; therefore, you might be given the option to be cared for at home by your family rather than in a healthcare setting, if possible. It is important to note that even when cared for at home, you will not be able to have visitors from outside your household under the current social distancing rules.

If it is not possible for you to receive end of life care at home, you will be fully supported by doctors and nurses in a hospital or hospice. You will not be alone at this time. Although you may not be able to have visitors, you can stay in touch with loved ones via telephone and video calls.

Your doctor or nurse will ensure that treatment for pain and discomfort is continued regardless of whether you are cared for at home or in a hospital/hospice. It is very important that you report any new pain or other symptoms so that your doctor can help you to manage them.

This will be a distressing time for patients and families. However, you and your loved ones will still receive support from your healthcare providers via telephone, video calls and email. This will include support from your doctor and nurse as well as other healthcare providers such as a dietician, psychotherapist, counsellor or social worker, depending on your individual needs. Your doctor will discuss the options available in your area and you will be fully involved in the decision-making process.

Following treatment for cancer, there may be changes to your schedule of follow-up appointments to reduce the number of hospital visits. Routine blood tests may be carried out at local healthcare centres rather than in hospitals, and consultations with your doctor are likely to take place via telephone.

Essential imaging assessments to check on the progress of cancer (such as computed tomography scans) will still go ahead, but these may be reduced in frequency, especially if you are in remission or have stable or slowly-progressing cancer. In some areas, your imaging assessments may be relocated to a local cancer centre to avoid potential exposure to coronavirus in a general hospital.

As you may not see your doctor face-to-face during the pandemic, it is very important that you make full use of the telephone appointments to report any new symptoms, side effects or concerns that you may have.

It is very important that you continue to lead a healthy lifestyle during the COVID-19 pandemic; this will enable you to cope better during cancer treatment and the follow-up period.

It is crucial that you have a healthy diet so it’s important to make sure you can access the food that you need, such as fresh fruit and vegetables. If the shops in your area are experiencing shortages, there may be help available, for example:

• Some authorities are providing free food deliveries to vulnerable people
• Large supermarkets are prioritising delivery slots for vulnerable people
• Many stores have opening hours specially for vulnerable people

If you have trouble accessing the food you need, contact your local authority who will be able to help you. If you receive nutritional supplements and support from a dietician, these will continue throughout the pandemic.

To stay fit and healthy, you should take as much exercise as possible. This can be a challenge when confined to your home, but you can take walks in your garden, walk up and down stairs or follow online exercise classes. Any way you can move around will help you to stay strong and fit.

Remember to maintain your personal hygiene and contact your doctor or nurse if you have problems washing or bathing; they can provide you with advice to make these tasks easier.

It is very important to look after your mental health too during these challenging times. Stay in regular contact with friends and family via phone, email, social media and video calls. You should also contact your doctor or nurse if you feel you need additional emotional support from a psychotherapist or counsellor.

The COVID-19 pandemic has caused huge disruption to lives across the world, presenting challenges that we have not encountered before. It is a particularly worrying time for patients with cancer as well as their families and friends. However, it is important to remember that the pandemic will pass and the restrictions on social interaction will be lifted once it is safe to do so. Until then, it is crucial that you adhere to the current guidance to protect your health as far as possible.

In addition to medical support from your doctor or nurse, psychosocial support may be available, for example:

• Emotional support: You should contact your doctor or nurse if you need emotional support from a psychotherapist or counsellor. Your local healthcare centre may also be able to put you in touch with local services, and many areas now have networks of volunteers who can provide emotional support via telephone
• Financial support: Help is available in many countries to ensure you can manage your finances during the COVID-19 pandemic; this may include a guaranteed income if you are unable to work, as well as temporary holidays from mortgage or bill payments
• Logistical support: Help is frequently available for vulnerable people for the delivery of essential items such as food and medicines
• Social support: In many areas, provision is made for vulnerable people living on their own to ensure they have access to essential services, and help is also available for people who are unable to home-school their children during the school closures
• Government support: As a patient with cancer, you should be identified as a high-risk or vulnerable person during the pandemic, meaning you will be able to access the additional support services provided in your country

You might find that it helps to be part of an online community of patients who are facing the same worries as you. Local, national and international charities and patient support groups are available that can be excellent sources of emotional support and practical advice for patients as well as their families and carers. They may also provide information on the impact of the COVID-19 pandemic on your particular type of cancer.

Further information on patient support groups for different types of cancer can also be found in the ESMO Patient Guide series.

There is a high volume of information circulating in the media about the COVID-19 pandemic and its effects on patients with cancer. It is very important to understand that a significant number of these reports are not medically verified and can’t necessarily be trusted. You should ensure that you refer to reliable sources for accurate information.

Listed below are the key resources referred to when generating the information contained in this guide:

• American Society of Clinical Oncology. 2020. COVID19 patient care information. Accessed 31st March 2020.
• Cancer Council. 2020. Cancer and COVID-19. Accessed 2nd April 2020.
• Cancer Research UK. 2020. Coronavirus (COVID-19) and cancer. Accessed 2nd April 2020.
• European Cancer Patient Coalition. 2020. ECPC’s communication about cancer and COVID-19. Accessed 2nd April 2020.
• European Society for Medical Oncology. 2020. What should medical oncologists know about COVID19? Accessed 31st March 2020.
• Macmillan Cancer Support. 2020. Cancer and coronavirus (COVID-19). Accessed 2nd April 2020.
• National Health Service. 2020. Advice for everyone – coronavirus (COVID-19). Accessed 31st March 2020.
• National Institute for Health and Care Excellence. 2020. COVID19 rapid guideline: delivery of systemic anticancer treatments. Accessed 31st March 2020.
• Teenage Cancer Trust. 2020. Coronavirus advice. Accessed 2nd April 2020.
• You B, Ravaud A, Canivet A, et al. The official French guidelines to protect patients with cancer against SARS-CoV-2 infection. Lancet Oncol VOLUME 21, ISSUE 5, P619-621, MAY 01, 2020. Accessed online ahead of print, 25 March 2020.