Cancer Patient Management During the COVID-19 Pandemic

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, Igor Aurer⁴, Panagiotis Balermpas⁵, Thomas Berg⁶*, Anna Berghoff⁷*, Ilaria Betella⁸*, Jean-Yves Blay⁹, Davide Giovanni Bosetti¹⁰, Paolo Bossi¹¹, Hasna Bouchaab¹², Juliane Brandt¹³, Christian Buske¹⁴, Augusto Caraceni¹⁵*, Fatima Cardoso¹⁶*, Joan Carles¹⁷*, Silvia Catanese¹⁸, Nathan Cherny¹⁹, Ilaria Colombo²⁰*, Nicoletta Colombo^20,21, Javier Cortes^21,22*, Carmen Criscitiello²³*, Giuseppe Curigliano^23,24, Evandro de Azambuja²⁵*, Suzette Delaloge²⁶*, Maria Del Grande¹⁰*, Maria De Santis²⁷* Jean-Yves Douillard²⁸*, Martin Dreyling²⁹,Reinhard Dummer³⁰, Rafal Dziadziuszko³¹*, Bernard Escudier²⁶*, Massimo Federico²⁷, Karim Fizazi²⁶*, Tania Fleitas^33,34, Enrico Franceschi³⁵*, Christoph Hoeller³⁶*, Silke Gillessen^19,37,38,39, Antonio Gonzalez Martin⁴⁰*, Richard Gralla⁴¹*, Alexandru Grigorescu⁴²*, Alessandro Gronchi⁴³, Azza Hassan⁴⁴*, David Hui⁴⁵*, Mats Jerkeman⁴⁶, Robin Jones⁴⁷*, Karin Jordan¹³, Ulrich Keilholz⁴⁸, Marie José Kersten⁴⁹, Gudrun Kreye⁵⁰*, Jonathan Ledermann⁵¹*, Kim Linton⁵², Sibylle Loibl⁵³*, Florian Lordick⁵⁴*, Paul Lorigan⁵⁵*, Yohann Loriot²⁶*, Jean-Pascal Machiels⁵⁶*, Javier Martin Broto⁵⁷*, Ulrich Mey⁵⁸, Olivier Michielin⁵⁹, Masanori Mori⁶⁰*, Francesco Multinu⁸*, Shani Paluch-Shimon⁶¹*, Chris Parker⁶²*, Antonio Passaro⁶³, George Pentheroudakis⁶⁴*, Solange Peters¹², Cesare Piazza⁶⁵, Camillo Porta^66,67*, Thomas Powles⁶⁸, Matthias Preusser⁷, Martin Reck⁶⁹*, Carla Ripamonti⁷⁰*, Maryna Rubach⁷¹*, Tamari Rukhadze⁷²*, Manuela Schmidinger⁷*, Elzbieta Senkus-Konefka⁷³*, Cristiana Sessa¹⁰, Adir Shaulov⁷⁴*, Silvia Stacchiotti⁷⁵, Anna-Marie Stevens⁷⁶*, Sebastian Stintzing⁷⁷*, Petr Szturz⁷⁸, Hervé Tilly⁷⁹, Dario Trapani²³, Alexander van Akkooi⁸⁰, Loredana Vecchione^78,81, Florian van Bömmel⁶, Ursula Vogl¹⁰, Christophe Von Garnier^82,83, Michael Weller⁸⁴, Jayne Wood⁸⁵*, Eleonora Zaccarelli⁸*, Camilla Zimmermann^86,87*

*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

⁴University Hospital Centre Zagreb and Medical School, Zagreb, Croatia

⁵Department for Radiation Oncology, University Hospital Zürich, Zürich, Switzerland

⁶Division of Hepatology, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectiology, Leipzig University Medical Center, Germany

⁷Medizinische Universität Wien, Klinik für Innere Medizin I, Klinische Abteilung für Onkologie, Vienna, Austria

⁸Department of Gynecologic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

⁹Medical Oncology Department, Centre Léon Bérard, Lyon, France

¹⁰Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland

¹¹Medical Oncology, University of Brescia, ASST-Spedali Civili, Brescia, Italy

¹²Department of Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne University, Lausanne, Switzerland

¹³Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Germany

¹⁴Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany

¹⁵Palliative Care, National Cancer Institute, Milan, Italy

¹⁶Breast Unit, Champalimaud Clinical Center-Champalimaud Foundation, Lisbon, Portugal

¹⁷Vall d´Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona, Spain

¹⁸Unit of Medical Oncology, Pisa University Hospital, Pisa, Italy

¹⁹Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

²⁰Gynecology Program, European Institute of Oncology, 20141 Milan, Italy

²¹School of Medicine and Surgery, University Milan Bicocca, 20126 Milan, Italy

²²Medical Oncology Department, IOB Institute of Oncology, Quirosalud Group, Madrid & Barcelona, Spain

²³New Drugs and Early Drug Development for Innovative Therapies Division, IEO, European Institute of Oncology IRCCS, Milan, Italy

²⁴Department of Oncology and Hematology, Universita degli Studi di Milano, Milan, Italy

²⁵Department of Medical Oncology, Institut Jules Bordet and Université Libre de Bruxelles (ULB), Brussels, Belgium

²⁶Department of Cancer Medicine, Gustave Roussy, Villejuif, France

²⁷Medical Oncology, CHIMOMO Department, University of Modena and Reggio Emilia, Modena, Italy

²⁸Department of Urology, Charité University Hospital, Berlin, Germany

²⁹Chief Medical Officer, ESMO, Lugano, Switzerland

³⁰Department of Medicine III, LMU Hospital, Munich, Germany

³¹Department of Dermatology, University and University Hospital Zürich, Zürich, Switzerland

³²Department of Oncology and Radiology, Medical University of Gdańsk, Gdańsk, Poland

³³Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain

³⁴Instituto de Salud Carlos III, CIBERONC, Madrid, Spain

³⁵Department of Medical Oncology, Azienda USL/IRCCS Institute of Neurological Sciences, Bologna, Italy

³⁶Department of Dermatology, Medical University of Vienna, Austria

³⁷Universita della Svizzera Italiana, Lugano, Switzerland; Cantonal Hospital, St. Gallen, Switzerland

³⁸University of Bern, Bern, Switzerland

³⁹Division of Cancer Science, University of Manchester, Manchester, UK

⁴⁰Medical Oncology, Clinica Universidad de Navarra, Madrid, Madrid, Spain

⁴¹Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, New York, USA

⁴²Department of Medical Oncology, Institute of Oncology, Bucharest, Romania

⁴³Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

⁴⁴Supportive & Palliative Care Section, Medical Oncology Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar

⁴⁵Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

⁴⁶Department of Oncology, Skåne University Hospital, Lund University, Lund, Sweden

⁴⁷Sarcoma Unit, Royal Marsden NHS Foundation Trust/Institute of Cancer Research, Chelsea, London, UK

⁴⁸Charité Comprehensive Cancer Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany

⁴⁹Department of Hematology, Amsterdam UMC, the Netherlands

⁵⁰Palliative Care Unit, Department of Internal Medicine II, University Hospital Krems, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria

⁵¹University College London Cancer Institute, and University College London Hospitals, London, UK

⁵²Manchester Cancer Research Centre, University of Manchester, United Kingdom

⁵³German Breast Group, Neu-Isenburg, Germany

⁵⁴University Cancer Center Leipzig, University Hospital Leipzig, Leipzig, Germany

⁵⁵The Christie NHS Trust, Manchester, UK; The University of Manchester, Manchester, UK

⁵⁶Service 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

⁵⁷Medical Oncology Department, University Hospital Virgen del Rocio, Sevilla, Spain

⁵⁸Department of Oncology and Haematology, Kantonsspital Graubünden, Chur, Switzerland

⁵⁹Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland

⁶⁰Palliative Care Team, Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan

⁶¹Department of Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

⁶²Royal Marsden Hospital and Institute of Cancer Research, Sutton, UK

⁶³Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy

⁶⁴Department of Medical Oncology, University of Ioannina, Ioannina, Greece

⁶⁵Department of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, ASST-Spedali Civili, Brescia, Italy

⁶⁶Department of Internal Medicine, University of Pavia, Italy

⁶⁷Division of Translational Oncology, I.R.C.C.S. Istituti Clinici Scientifici Maugeri, Pavia, Italy

⁶⁸Barts' Cancer institute, Queen Mary University of London, London, UK

⁶⁹LungenClinic, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany

⁷⁰Supportive Care Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy

⁷¹Centrum Onkologii-Instytut im. Marii Sklodowskiej-Curie, Warsaw, Poland

⁷²Faculty of Medicine, Iv, Javakhishvili Tbilisi State University, Tbilisi, Georgia

⁷³Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland

⁷⁴Department of Hematology, Hadassah-Hebrew University Medical center, Jerusalem, Israel

⁷⁵Cancer Medicine Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Nazionale Tumori, Milan, Italy

⁷⁶Nurse Consultant Symptom Control and Palliative Care, The Royal Marsden NHS Foundation Trust, London

⁷⁷Department of Hematology, Oncology and Tumor Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany

⁷⁸Medical Oncology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland

⁷⁹Department of Hematology, Centre Henri Becquerel, University of Rouen, France

⁸⁰Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands

⁸¹Charitè Comprehensive Cancer Center, Berlin, Germany

⁸²Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland

⁸³Department of Pulmonary Medicine, University Hospital of Bern, Bern, Switzerland

⁸⁴Department of Neurology, University Hospital and University of Zürich, Zürich, Switzerland

⁸⁵Palliative Care, The Royal Marsden, London, UK

⁸⁶Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada

⁸⁷Divisions of Palliative Medicine and Medical Oncology, Department of Medicine, University of Toronto, Toronto, Canada