Call for ensuring cancer care continuity during COVID-19 pandemic

Abstract

On 11 March 2020, WHO declared the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to be a pandemic, and the related syndrome was then named coronavirus disease 2019 (COVID-19). As of 6 April 2020, 1 211 203 confirmed cases and 67 596 deaths have been recorded worldwide, Italy being one of the worst affected countries so far. Frail patients, such as elderly people or those with underlying conditions, are at higher risk of complications related to COVID-19.1.Zhou F. Yu T. Du R. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.The Lancet. 2020; 395: 1054-1062doi:10.1016/S0140-6736(20)30566-3Abstract Full Text Full Text PDF PubMed Scopus (18905) Google Scholar The burden of SARS-CoV-2 infection among patients with cancer has not been established yet, but their potential immunocompromised state is of concern.2.Liang W. Guan W. Chen R. et al.Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.http://www.ncbi.nlm.nih.gov/pubmed/32066541Lancet Oncol. 2020; 21: 335-337doi:10.1016/S1470-2045(20)30096-6Google Scholar Preliminary data suggest an increased risk of developing infection-related severe events (ie, admission to the intensive care unit, mechanical ventilation or death) in the case of antitumour treatment administration within two weeks before COVID-19 diagnosis. Therefore, the authors suggested that treatment strategies likely to cause immunosuppression should be avoided or retained at decreased dosages.3.Zhang L. Zhu F. Xie L. et al.Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China.Annals of Oncology. 2020; doi:10.1016/j.annonc.2020.03.296Google Scholar The Italian directives for the management of onco-haematological patients on therapy during the COVID-19 pandemic recommend considering treatment delays on a case-by-case basis, taking into account the characteristics of the patient and the disease.4.Lambertini M. Toss A. Passaro A. et al.Cancer care during the spread of coronavirus disease 2019 (COVID-19) in Italy: young oncologists’ perspective.ESMO Open. 2020; 5 (e000759)doi:10.1136/esmoopen-2020-000759Abstract Full Text Full Text PDF Scopus (142) Google Scholar By reporting consecutive cases of SARS-CoV-2 infection among patients with cancer treated at our centre, we aim to call for the need for adequate and dedicated facilities to manage cancer care after infection with SARS-CoV-2. Between 10 March and 6 April, 17 patients with a median age of 68 years (range 46–89) tested positive for SARS-CoV-2 by RT-PCR on nasopharyngeal swab. Among these patients, 16 (94%) had symptoms related to COVID-19; eight had severe respiratory symptoms, and 13 (76%) were admitted to hospital (table 1). At a median follow-up of 15 days since the confirmed diagnosis of SARS-CoV-2 infection, the case fatality rate was 24%: four patients out of 17 died due to severe COVID-19, two of whom were on oncological follow-up (ie, off therapy). All 12 patients (100%) who were on therapy in different settings have experienced treatments delays or permanent discontinuation, and one patient did not undergo the scheduled diagnostic procedures. Notably, we had patients with mild symptoms or no symptoms who had antineoplastic treatments delayed; these treatments had a curative purpose as well as a high probability of long-term disease control (eg, neoadjuvant chemotherapy for locally advanced triple-negative breast cancer, chemo-radiotherapy for limited-stage small-cell lung cancer, first-line ALK inhibitor for advanced lung adenocarcinoma). Similarly, other patients currently in hospital with mild COVID-19 syndrome might need to resume their therapeutic plan after complete resolution of their symptoms despite SARS-CoV-2 still being detectable potentially for weeks. According to hospital guidelines, recovery is defined by two consecutive negative RT-PCR tests obtained at least 24 hours apart, performed at least 15 days after the resolution of signs and symptoms. Moreover, if we assume that there is a non-negligible proportion of asymptomatic cases that are a potential source of transmission to other patients with cancer,5.Bai Y. Yao L. Wei T. et al.Presumed asymptomatic carrier transmission of COVID-19.JAMA. 2020; 323: 1406doi:10.1001/jama.2020.2565Crossref PubMed Scopus (3095) Google Scholar we estimate that the number of unrecognised patients with SARS-CoV-2 infection might be higher than expected. Widespread testing for SARS-CoV-2 among patients with cancer and their healthcare providers could also help to control the potential negative consequences of this outbreak on cancer care. Based on our preliminary experience, we are opening a new unit that will work as a regional cancer hub for the care of patients with cancer affected by COVID-19 within a multidisciplinary team. With the current uncertainty, the important aim behind this decision is to ensure continuity of care to those selected patients who can reasonably receive oncological treatments in spite of SARS-CoV-2 positivity, balancing the risks associated with the infection and the disruption of proper antineoplastic strategies.Table 1Patient’s, disease and treatment characteristicsGenderAgeTumour typeSettingCOVID-19 syndromeHospitalisation due toCOVID-19Treatment not started/delayed/discontinuedTreatmentM71NSCLCUnresectable stage IIISevereYesNot startedCT+RTM54NSCLCMetastatic1st lineAsymptomaticNoDelayedCT+ITM68GlioblastomaFollow-up (after Stupp)SevereYesNANAM73NSCLCMetastatic1st lineMildNoDelayedALKiF68Pleural mesotheliomaMetastatic>1st lineSevereYesNot startedCTM64ProstateMetastatic>1st lineSevereYesDelayedETF46BreastNeoadjuvantMildNoDelayedCTF66BreastMetastatic>1st lineSevereYesDelayedET+mTORiF51BreastMetastatic>1st lineMildYesDelayedCTF68BreastMetastatic1st lineSevereYesDelayedCT+anti-HER2F79BreastFollow-up (after adjuvant ET)MildYesNANAM70NSCLCFollow-up (after surgery)MildYesNANAM66NSCLC; duodenal cancerMetastatic1st line for both cancersSevereYesDiscontinuedCT+ITF66SCLCLocalisedMildYesNot startedCT+RTM89ProstateFollow-up (after RT)SevereYesNANAM75SCLCMetastatic1st lineMildNoDelayedCTM76Single lung lesion not biopsied yetDiagnosisMildYesNANAALKi, ALK inhibitor; CT, chemotherapy; ET, endocrine therapy; F, female; HER2, human epidermal growth factor receptor 2; IT, immunotherapy; M, male; mTORi, mTOR inhibitor; NA, not applicable; NSCLC, non-small-cell lung cancer; RT, radiotherapy; SCLC, small-cell lung cancer; Stupp, Stupp protocol. Open table in a new tab ALKi, ALK inhibitor; CT, chemotherapy; ET, endocrine therapy; F, female; HER2, human epidermal growth factor receptor 2; IT, immunotherapy; M, male; mTORi, mTOR inhibitor; NA, not applicable; NSCLC, non-small-cell lung cancer; RT, radiotherapy; SCLC, small-cell lung cancer; Stupp, Stupp protocol.

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