Clinical guide for the management of cancer patients during the coronavirus pandemic

As doctors we all have general responsibilities in relation to coronavirus and for these we should seek and act on national and local guidelines. 
We also have a specific responsibility to ensure that essential cancer service care continues with the minimum burden healthcare 
Cancer services may not seem to be in the frontline with coronavirus but we do have a key role to play and this must be planned resources for the response to coronavirus.
The most vulnerable cancer patients some people with cancer are more at risk of becoming seriously ill if they contract the coronavirus infection:
• People with cancer who are undergoing active chemotherapy or radiotherapy
• People with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
• People having immunotherapy or other continuing antibody treatments for cancer
• People having other targeted cancer treatments .
• People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs.
In addition to immunosuppression, several factors/co-morbidities are likely to be linked with a poorer prognosis with coronavirus:
• age over 60
• pre-existing cardiovascular disease 
• pre-existing respiratory disease.
The more of these individual factors a cancer patient has, the more likely they are to develop a serious illness with coronavirus especially if treated with systemic anti-cancer therapies.
Clinicians may also need to prioritise treatment for those most in need. 
It is important that all decisions taken are done so with multidisciplinary team (MDT) input and clearly communicated with patients.
Surgical patients
Categorisation of patients
Priority level 1a
• Emergency: operation needed within 24 hours to save life 
Priority level 1b
• Urgent:operation needed with 72 hours
Based on: urgent/emergency surgery for life threatening conditions such as obstruction, bleeding and regional and/or localised infection permanent injury/clinical harm from progression of conditions such as spinal cord compression
Priority level 2
Elective surgery with the expectation of cure, prioritised according to:
• within 4 weeks to save life/progression of disease beyond operability based
General measures to consider
If appropriate, MDTs may consider non-surgical options, including prolongation of neoadjuvant treatment and non-surgical treatment if the outcomes are similar.
Systemic anti-cancer treatments
Treatment decisions will need to be made on a case-by-case basis 
General approach to prioritising patients on systemic anti-cancer therapy:
• Categorise patients by treatment intent and risk-benefit ratio associated with treatment.
• Consider alternative and less resource-intensive treatment regimes.
• Seek alternative methods to monitor and review patients receiving systemic
Clinicians will also need to consider the level of immunosuppression associated with an individual therapy and the condition itself, and patients’ other risk factors.
Categorisation of patients
This will differ according to tumour type, but it is suggested that clinicians begin to categorise patients into priority groups. If services are disrupted, patients can be prioritised for treatment accordingly.
Priority level 1
• Curative therapy with a high chance of success. 
• Palliative or non curative therapy can be delayed 
General measures to consider Medical Oncology 
Consider whether systemic therapies can be given in alternative regimens, different locations or via other modes of administration to minimise patient exposure and maximise resources.
1. Changing intravenous treatments to subcutaneous or oral if there are alternatives.
2. Selecting regimens that are shorter in duration.
3. Consider using 4-weekly or 6-weekly immunotherapy regimens rather than 2-weekly
and 3-weekly.
4. Dispensing longer periods or oral medications.
5. Consider deferring supportive therapies such as densoumab and zoledronic acid
treatments (except for hypercalcaemia).
6. Consider home delivery of oral medication where possible (but need to confirm the
resilience of home care providers).
7. Use of GCSF as primary prophylaxis to protect patients and reduce admission rates
8. Considering treatment breaks for long-term treatments when risk of coronavirus is high.
9. Consider what supportive services are required to deliver regimens safely.
Seek alternative methods to educate, monitor and review patients on systemic therapies. 
Identify alternative arrangements to minimise patient exposure. This could involve patients having blood tests locally or telephone/virtual appointments.
Radiation therapy
Categorisation of patients
Priority level 1
• Patients with category 1 (rapidly proliferating) tumours currently being treated with radical (chemo)radiotherapy with curative intent where there is little or no scope for compensation of gaps.
• Patients with category 1 tumours in whom combined External Beam Radiotherapy (EBRT) and subsequent brachytherapy is the management plan and the EBRT is already underway.
• Urgent palliative radiotherapy in patients with malignant spinal cord compression who have useful salvageable neurological function.
• Palliative radiotherapy where alleviation of symptoms such as haemoptysis.
General measures to consider Radiotherapy 
In all cases, the most clinically appropriate hypofractionated schedule be used, 
In some patients a short delay for treatment may be possible without compromising outcomes. 
General measures across all services to reduce patient contact and maximise workforce capacity
• Minimise face-to-face appointments
– Offer consultations via telephone or video consultation wherever possible.
– Cut non-essential follow-up visits.
– Accelerateadoptionofstratifiedfollow-upmodels.
– Home delivery of oral systemic agents where suitable/available.
• Reduce dwell time in services
– For those who do still need to attend, particularly for treatment, schedule
appointments to reduce waiting times.
– Encourage patients not to arrive early – consider measures such as texting them when ready to see them so they can wait in their car.
Clinical guide for the management of cancer patients during the coronavirus pandemic
• Follow broader trust actions and protocols including testing and isolation of patients with coronavirus symptoms.
If staff are required to self-isolate due to contact with a confirmed case of coronavirus, consider ways they can continue to provide care and/or support Tumour board meeting 
For example:
• virtual attendance at MDT meetings
• telephone or video consultations, especially follow-ups
• identifying vulnerable patients and making contact to discuss changes to care and treatment
• identifying patients suitable for remote monitoring/follow-up
• data entry (where remote access enabled).
Overall considerations
• We should avoid unproductive attendances at hospital.
• Senior decision-making at the first point of contact should reduce or even prevent
the need for further attendances.
• A decrease in elective work will allow for a greater senior presence at the front door.
• Clinicians may need to work in unfamiliar environments or outside of their sub- specialist areas. They will need to be supported.
• No patient should be scheduled for surgery without discussion with a consultant.
• The longer hours will allow ED access and help reduce crowding in waiting rooms.
• The possibility of a seven-day service may need to be considered.
• Consider postponing long-term follow-up patients until the crisis has passed.
• Can a follow-up virtual clinic be developed with your facility
• CT scanning may be limited as it is the investigation of choice for coronavirus pneumonitis.

Author: nammamadrasnews

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