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CME

COVID-19 and Patients With Cancer

Overview

  • Coronavirus Disease 2019 (COVID-19) is an acute respiratory disease caused by novel coronavirus SARS-CoV-2 (Centers for Disease Control and Prevention 2020 Mar 22)
  • cancer patients may be at higher risk for developing severe COVID-19, including those
    • receiving chemotherapy, or who received chemotherapy ≤ 3 months
    • receiving extensive radiation therapy
    • who received bone marrow or stem cell transplantation ≤ 6 months, or still treated with immunosuppressive drugs
    • with some types of hematologic cancer that damages immune system (such as chronic leukemia, lymphoma, or myeloma), even if they did not receive treatment
    • with impaired immune system due to leukocytopenia, low immunoglobulin levels, or long-lasting immunosuppression
  • both cancer or history of cancer and anticancer treatment ≤ 14 days before COVID-19 diagnosis appear to be associated with increased risk of severe illness
  • patient and caregiver safety recommendations for oncology practices during COVID-19 include limiting exposure to patients and staff, utilization of telemedicine, and rescheduling/postponing nonurgent appointments
  • evaluation of cancer patients for COVID-19
    • may have atypical presentation or present with mild symptoms and deteriorate rapidly
    • consider that symptoms of neutropenic sepsis and pneumonitis related to therapy can mimic symptoms of COVID-19
    • PubMed32170865Journal of medical virologyJ Med Virol20200314lymphopenia may already be present in oncology patients due to disease or treatment; early studies suggest lymphopenia may be common in COVID-19 patients
    • may be considered priority for testing if symptomatic
  • cancer screening and diagnosis/staging considerations
    • consider postponing screening procedures requiring clinic visits and diagnosis and staging interventions for patients who are suspected of disease at low risk of rapid progression
    • carefully weigh risk and benefits of delaying screening procedures
    • limit staging procedures to those most needed to inform development of initial care plan
  • management considerations for medical oncology patients
    • consider delay or alteration of treatment for patients currently receiving or about to receive chemotherapy due to theoretical increased risk of contracting COVID-19 given immunosuppressive effects of treatment
    • for patients with solid tumors
      • for therapy with definitive intent, consider proceeding with adjuvant therapy
      • for progressive or metastatic disease, delay in treatment may result in worsening symptoms, leading to decreased performance status and inability to receive further treatment
      • surgeries may need to be postponed due to lack of hospital resources
    • PubMed32173855British journal of haematologyBr J Haematol20200315for patients with hematologic malignancies
      • aggressive disease may require to proceed with high-dose therapy and hematopoietic stem cell transplantation (HSCT) with definitive intent
      • consider decreasing immunosuppressive medications or dosing of chemotherapy if feasible
      • decisions on the benefits and risks of continuation of maintenance chemotherapy will have to be taken if the infection rates increase
    • for patients with late-stage disease or with comorbid conditions who may become infected with COVID-19
      • consider which treatment would have the most success and benefit
      • consider prognosis if patient would require mechanical ventilation
      • conduct proactive palliative and end-of-life conversations as soon as possible
    • supportive care
      • attempt to decrease transfusions when possible anticipating blood product shortages
      • consider limiting or postponing supportive therapies, such as bisphosphonate therapy
    • neutropenic fever
      • for prophylaxis, monitor neutrophil count and consider growth factor for treatment regimens at lower level of expected risk (> 10% risk) to minimize risk of neutropenic fever
      • for acute care, prescribe prophylactic empiric antibiotics in patients who are febrile and neutropenic but clinically stable as determined by tele-evaluation or by phone; further evaluation should be done outside emergency department
  • management considerations for bone marrow and stem cell transplant patients
    • defer non-urgent transplants whenever possible
    • hematopoietic stem cell transplant (HSCT) often requires extended hospital stay and prolonged immunosuppression therapy
    • depending on status and risk of disease recurrence, delaying HSCT may not be possible
      • if low-risk disease, consider deferring HSCT process for several weeks to months
      • if high-risk disease, consider deferring until asymptomatic with negative polymerase chain reaction (PCR) testing
    • PubMed32180224British journal of haematologyBr J Haematol20200316consider performing HSCT in outpatient center for appropriate cases
  • management considerations for cancer surgery patients
    • considerations may vary depending on primary cancer site including
    • American College of Surgeons (ACS) guidance regarding surgery and COVID-19
      • consider availability of local institution resources, including protective gear for providers and patients
      • for elective cases with high likelihood of need for postoperative intensive care unit (ICU) or respirator utilization, balance risk of surgery delay to imminent availability of resources for patients with COVID-19
      • consult multidisciplinary experts to consider individual cases, or for institutions with high case volumes to establish triage criteria based on local circumstances
    • American Society of Clinical Oncology (ASCO) guidance for COVID-19 and cancer surgery
      • consider postponing elective surgeries if feasible; however, make individual determinations of potential risks of delaying cancer-related surgery
      • in certain situations where neoadjuvant therapy is an option but not routinely considered (such as early stage breast cancer), consider neoadjuvant therapy instead of surgery or simply delaying surgery
        • weigh risk of delay in definitive surgery against potential burden of case complexity and patient risk of exposure to COVID-19
        • also consider risks of exposure to COVID-19 if neoadjuvant therapy is immunosuppressive or requires clinic visits and clinician-patient contact
  • management considerations for radiation therapy patients
    • consider risks of delaying treatment in patients with potentially curable cancer
    • non-urgent cases that may be delayed up to 2 months include patients with prostate cancer, breast cancer when on adjuvant chemotherapy, and benign central nervous system (CNS) such as meningiomas and schwannomas
    • patients undergoing palliative care may also experience delays except patients with life-threatening or function-threatening situations (for example, spinal cord compression, cranial nerve compression, airway obstruction, hemoptysis, or superior vena cava syndrome)
  • considerations for palliative radiation therapy patients
    • offer short course of palliative radiation therapy to high-priority patients with life expectancy longer than days to weeks
    • priority of palliative radiation therapy is based on treatment indications

Initial Considerations for COVID-19 and Cancer Patients

General Information

  • cancer patients are at risk for serious illness if infected with COVID-19, particularly those
  • malignancies reported as comorbidities in patients hospitalized with confirmed COVID-19
    • PubMed32250385JAMAJAMA20200406malignancies in 8% at admission in cohort study with 1,591 patients (median age 63 years) with laboratory-confirmed COVID-19 admitted to intensive care units in Lombardy, Italy, between February 20 and March 18, 2020 (JAMA 2020 Apr 6 early online)
    • PubMed32031570JAMAJAMA20200207malignancies in 7.2% in cohort study with 138 adults (median age 56 years) with confirmed COVID-19 pneumonia consecutively admitted to Zhongnan Hospital in Wuhan, China, in January 2020 (JAMA 2020 Feb 7 early online)
    • PubMed32279081The journals of gerontology. Series A, Biological sciences and medical sciencesJ Gerontol A Biol Sci Med Sci20200411malignancies in 3.4% at admission (including 1.4% in adults aged < 65 years and 9.1% in adults aged ≥ 65 years) in cohort study with 203 adults aged 20-91 years (median age 54 years) with confirmed COVID-19 admitted to Zhongnan Hospital in Wuhan, China, between January 1 and February 10, 2020 (J Gerontol A Biol Sci Med Sci 2020 Apr 11 early online)
    • PubMed32320003JAMAJAMA20200422malignancies reported in 5.6% at admission in case series with 5,700 patients (median age 63 years, 60.3% males) with confirmed COVID-19 infection hospitalized in 12 New York City hospitals between March 1 and April 4, 2020 (JAMA 2020 Apr 22 early online)
  • PubMed32247319The Lancet. OncologyLancet Oncol20200402cancer patients mortality 5.6% in cohort study with 44,672 patients with confirmed COVID-19 (overall mortality 2.3%) in China's Infectious Disease Information System (Zhonghua Liu Xing Bing Xue Za Zhi 2020 Feb 17;41(2):145 [Chinese], also published in China CDC Weekly 2020;2(8):113 [English])
  • management decisions for cancer patients with COVID-19 depends on many patient variables, including
  • outpatient considerations include a focus on infection and environmental control, such as
  • Study Summary
    cancer or history of cancer may to be associated with increased risk of severe COVID-19
    Details
    Oncologic_Diseasecancer or history of cancer may to be associated with increased risk of severe COVID-19 (Lancet Oncol 2020 Mar)04/08/2020 05:36:48 PMstudySummary
    • Cohort Study based on cohort study
    • 1,590 patients with laboratory-confirmed COVID-19 acute respiratory disease admitted to hospitals in China through January 31, 2020 were analyzed
    • 18 patients (1%) were treated for cancer or had history of cancer at time of hospitalization for COVID-19
    • severe COVID-19 defined as death or composite of admission to intensive care unit and requiring mechanical ventilation
    • patients with cancer or history of cancer were older compared to noncancer patients (age 63 years vs. 48 years, p < 0.001) and more likely to have a smoking history (22.2% vs. 6.8%, p = 0.03)
    • cancer or history of cancer associated with increased risk of severe COVID-19 (adjusted odds ratio 5.4, 95% CI 1.8-16.17)
    • Reference - Lancet Oncol 2020 Mar;21(3):335
  • Study Summary
    anticancer therapy ≤ 14 days before COVID-19 diagnosis associated with increased risk of severe illness
    Details
    Oncologic_Diseaseanticancer therapy ≤ 14 days before COVID-19 diagnosis associated with increased risk of severe illness (Ann Oncol 2020 Mar 26)04/08/2020 05:37:28 PMstudySummary
    • Cohort Study based on retrospective cohort study
    • 28 adults (median age 65 years, 60.7% males) with solid cancer and laboratory-confirmed COVID-19 acute respiratory disease admitted to hospitals in Wuhan, China between January 13 and February 26, 2020 were evaluated
    • 7 patients (25%) had lung cancer, 4 patients (14%) had esophageal cancer, 3 patients (11%) had breast cancer, and 14 patients (50%) had other cancers
    • 10 patients (35.7%) had stage IV cancer
    • 6 patients (21.4%) received anticancer therapy ≤ 14 days before COVID-19 diagnosis (chemotherapy, radiation therapy, targeted therapy, or immunotherapy)
    • 11 patients (39.2%) had ≥ 1 comorbidity (diabetes, chronic cardiovascular disease, chronic pulmonary disease, or chronic liver disease)
    • factors significantly associated with increased risk of developing severe COVID-19 (admission to intensive care unit, mechanical ventilation or death)
      • anticancer therapy ≤ 14 days before COVID-19 diagnosis (hazard ratio [HR] 4.08, 95% CI 1.08-15.3)
      • patchy consolidation on computed tomography (CT) scan at admission (HR 5.44, 95% CI 1.5-19.7)
    • PubMed32224151Annals of oncology : official journal of the European Society for Medical OncologyAnn Oncol20200326Reference - Ann Oncol 2020 Mar 26 early online

Recommendations for Oncology Practices During COVID-19

Patient Safety

  • prescreen and screen for COVID-19 symptoms and exposure history using telephone calls or digital platforms
  • develop screening clinics for evaluation and testing of patients with symptoms in dedicated unit with dedicated staff
  • use telemedicine visits whenever possible
  • limit or exclude visitors
  • limit surgeries and procedures to essential, urgent, or emergent cases
  • consider alternative dosing schedule to reduce in-person visits
  • change therapy to oral oncolytic if possible
  • transition outpatient care to care at home if possible (for example, pump disconnection, administration of growth factors, or hormone therapy)
  • increase interval between scans, or use biochemical markers instead of scans
  • offer resources for patient wellness and stress management
  • Reference - J Natl Compr Canc Netw 2020 Apr 3:doi:10.6004/jnccn.2020.7572

Caregiver Safety

  • appropriate personal protective equipment (PPE) should be available to all caregivers
  • offer centralized resource to communicate recommendations to caregivers for rapidly changing guidelines about PPE and workflows change
  • implement daily screening tools and/or temperature checks
  • limit if possible onsite staff participating in rotations on a daily basis
  • establish stay-at-home and return-to-work guidelines
  • offer resources for caregiver wellness and stress management
  • Reference - J Natl Compr Canc Netw 2020 Apr 3:doi:10.6004/jnccn.2020.7572

American Society of Clinical Oncology (ASCO) Guidance for COVID-19

Cancer Screening and Diagnosis/Staging

  • consider postponing screening procedures requiring clinic visits and diagnosis and staging interventions for patients who are suspected of disease at low risk of rapid progression
  • carefully weigh risk and benefits of delaying screening procedures
  • limit staging procedures to those most needed to inform development of initial care plan
  • Reference - ASCO Guidance for COVID-19 Patient Care

Surveillance

  • consider postponing clinic visits whenever possible, especially for patients considered at relatively low risk of recurrence or for those that are asymptomatic during follow-up period
  • if existing recommendations offer follow-up range (such as 3-6 months), consider delaying scheduled intervention to longest recommended frequency duration (for example, 6 months if range is 3-6 months)
  • Reference - ASCO Guidance for COVID-19 Patient Care

European Society for Medical Oncology (ESMO) General Guidance on COVID-19 and Cancer Patients

  • ESMO guidance on COVID-19
    • cancer patients at risk include those
      • receiving chemotherapy, or who received chemotherapy ≤ 3 months
      • receiving extensive radiation therapy
      • who received bone marrow or stem cell transplantation ≤ 6 months, or still treated with immunosuppressive drugs
      • with some types of hematologic cancer that damage immune system (such as chronic leukemia, lymphoma, or myeloma), even if they did not receive treatment
      • with impaired immune system due to leukocytopenia, low immunoglobulin levels, or long-lasting immunosuppression
    • recommendations for healthcare professionals
      • set up proactive action and contingency plans for provision of cancer care in setting of COVID-19 pandemic
      • explore strategies for splitting cancer healthcare personnel to operating and back-up crews for rotating in shifts epidemiologically compatible with COVID-19 incubation time of 14 days
      • explore phone or web conferencing for consultation of stable patients, particularly patients on oral formulation
      • implement strategies for "previous day" phone triages to identify patients with flu-like symptoms to reduce mass gathering of patients in waiting rooms
      • discuss risk and benefits of palliative therapy in setting of COVID-19 pandemic while taking into account disease prognosis, patient comorbidity and preferences, and risk of COVID-19 infection
      • discuss risk and benefits of maintenance therapy and option for "therapy holidays"
      • prioritize adjuvant therapy in patients with resected, high-risk disease who may have significant absolute survival benefits
      • discuss options to reduce number of hospital visits
      • discuss shorter/accelerated or hypo-fractionated radiation therapy schedules with radiation oncologist if appropriate
      • use blood product when strictly necessary; donors may continue donating blood with appropriate precautions
      • develop information material for cancer patients as well as psychological support projects for healthcare professionals and patients
    • Reference - ESMO guidance for COVID-19

National Institute for Health and Care Excellence (NICE) Rapid Guideline on COVID-19 and Cancer Patients

  • Oncologic_DiseaseNational Institute for Health and Care Excellence COVID-19 rapid guidelines on delivery of systemic anticancer treatments (NICE 2020 Apr:NG161)05/06/2020 02:23:55 PMNICE COVID-19 rapid guideline on delivery of systemic anticancer treatments
    • minimize in-person contact by use of
      • telephone or video consultations
      • limiting or postponing nonessential in-person follow-up appointments
      • home delivery services for medicines if possible
      • drive-through pick-up for medications
      • local services for blood tests if possible
    • for patients not known to have COVID-19
      • ask patients to attend appointments without family members or caregivers to reduce risk of transmission
      • minimize time in waiting room by careful scheduling, encouraging patients not to arrive early, and texting patients when ready to be seen so they can wait in car
    • for patients with COVID-19 symptoms at presentation
      • patients receiving chemotherapy or radiation therapy may display atypical presentation; symptoms of COVID-19 may be difficult to differentiate from pneumonitis or neutropenic sepsis at initial presentation
      • advise patients to contact their local cancer chemotherapy helpline to make sure symptoms are adequately addressed
      • screen and triage patients known or suspected to have COVID-19, or in close contact with someone with confirmed infection
      • for patients with fever with or without respiratory symptoms, suspect neutropenic sepsis and
        • refer patients immediately for assessment in secondary or tertiary care
        • treat as acute medical emergency and offer immediate empiric antibiotics
      • if patient tests positive for COVID-19
        • continue treatment only if urgent control of cancer needed
        • defer further systemic treatment (if feasible) until patient has ≥ 1 negative test
    • References - NICE COVID-19 Rapid Guideline on Delivery of Systemic Anticancer Treatments, NICE COVID-19 Rapid Guideline on Delivery of Radiation Therapy

COVID-19 and Medical Oncology Patients

Evaluation of Cancer Patients for COVID-19

Inpatient Considerations

  • consider delay or alteration of treatment for patients currently receiving or about to receive chemotherapy due to theoretical increased risk of contracting COVID-19 given immunosuppressive effects of treatment (Br J Haematol 2020 Mar 15 early online, NICE COVID-19 Rapid Guideline on Delivery of Systemic Anticancer Treatments)
  • for patients with solid tumors
    • for therapy with definitive intent, consider proceeding with adjuvant therapy
    • for progressive or metastatic disease, delay in treatment may result in worsening symptoms, leading to decreased performance status and inability to receive further treatment
    • surgical cases may need to be postponed due to lack of hospital resources
    • PubMed32197238Journal of the National Comprehensive Cancer Network : JNCCNJ Natl Compr Canc Netw202003201-41Reference - J Natl Compr Canc Netw 2020 Mar 20 early online
  • PubMed32173855British journal of haematologyBr J Haematol20200315for patients with hematologic malignancies
    • aggressive disease may require to proceed with high-dose therapy and hematopoietic stem cell transplantation (HSCT) with definitive intent
    • consider decreasing immunosuppressive medications or dosing of chemotherapy if feasible
    • decisions on the benefits and risks of continuation of maintenance chemotherapy will have to be taken if infection rates increase
    • Reference - Br J Haematol 2020 Mar 15 early online, J Natl Compr Canc Netw 2020 Mar 20 early online
  • for patients with late-stage disease or with comorbid conditions who may become infected with COVID-19
    • consider which treatment would have the most success and benefit
    • consider prognosis if patient would require mechanical ventilation
    • conduct proactive palliative and end-of-life conversations as soon as possible
    • PubMed32197238Journal of the National Comprehensive Cancer Network : JNCCNJ Natl Compr Canc Netw202003201-41Reference - J Natl Compr Canc Netw 2020 Mar 20 early online
  • transfusional support
    • PubMed32197238Journal of the National Comprehensive Cancer Network : JNCCNJ Natl Compr Canc Netw202003201-41attempt to decrease blood product transfusions when possible anticipating blood product shortages due to
      • deferral of donors resulting in reduction in blood donor pool
      • blood transfusion staff shortages
      • limited supply of reagents
    • PubMed32401360The Medical journal of AustraliaMed J Aust20200513consider avoiding prophylactic platelet transfusions to asymptomatic patients with chronic bone marrow failure syndromes or patients following autologous hematopoietic stem cell transplant without active bleeding
    • limit transfusional support to patients at high risk of bleeding
    • consider deferral of non-urgent therapy that would result in pancytopenia and require transfusion
    • PubMed32401360The Medical journal of AustraliaMed J Aust20200513Reference - Med J Aust 2020 May 13 early onlinefull-text
  • supportive care - consider limiting or postponing supportive therapies, such as bisphosphonate therapy (Br J Haematol 2020 Mar 15 early online)
  • PubMed32243501Blood advancesBlood Adv20200414471307-13101307recovery from COVID-19 infection reported in 60-year-old man with multiple myeloma treated with tocilizumab 8 mg/kg IV in case report (Blood Adv 2020 Apr 14;4(7):1307)
  • PubMed32243697American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200403fatal pneumonia due to COVID-19 reported in 2 transplant recipients (59-year-old kidney transplant recipient, and 51-year-old allogeneic bone marrow transplant recipient) treated with methylprednisolone plus prophylactic antibiotics therapy, maximum mechanical ventilation, and withdrawal of immunosuppressive therapy in case series (Am J Transplant 2020 Apr 3 early online)

American Society of Clinical Oncology (ASCO) COVID-19 Guidance

Immunosuppressive Therapy and Chemotherapy

  • withholding critical immunosuppressive therapy or other anticancer treatments generally not recommended since it may pose risk of compromised disease control and long-term survival
  • decision on modifying or withholding chemotherapy should be based on indication for chemotherapy, goals of care for patient, where patient is in treatment course, and patient tolerance to treatment
  • for patients in deep remission receiving maintenance therapy, stopping chemotherapy may be an option
  • some patients may be eligible to switch from IV to oral chemotherapy formulations, decreasing clinic visits, but also requiring greater vigilance from healthcare team to ensure proper medication usage
  • if local transmission of COVID-19 affects particular cancer center, consider any of the following
    • chemotherapy break for 2 weeks
    • infusion at unaffected satellite centers or at another facility
  • consider home infusion if medically and logistically feasible for patient, medical team, and caregivers
  • there may be potential value in prophylactic growth factors and prophylactic antibiotics in maintaining overall health of patient to make them less vulnerable to potential COVID-19 complications
  • Reference - ASCO Guidance for COVID-19 Patient Care

Immunotherapy

  • consider benefits and harms of continuing therapy with checkpoint inhibitors since they may have serious immune-related adverse events
  • consider reducing frequency of checkpoint inhibitors dosing if feasible
  • Reference - ASCO Guidance for COVID-19 Patient Care

Neutropenic Fever

  • for prophylaxis, monitor neutrophil count and consider growth factor for treatment regimens at lower level of expected risk (> 10% risk) to minimize risk of neutropenic fever
  • for acute care, prescribe prophylactic empiric antibiotics in patients who are febrile and neutropenic but clinically stable as determined by tele-evaluation or by phone; further evaluation should be done outside emergency department
  • Reference - ASCO Guidance for COVID-19 Patient Care

National Institute for Health and Care Excellence (NICE) COVID-19 Guideline on Delivery of Systemic Anticancer Treatments

  • NICE COVID-19 rapid guideline on delivery of systemic anticancer treatments
    • treatment priority
      • clearly communicate, with written documentation if possible, prioritization of systemic chemotherapy treatment and reason for decision to patient, families, and carers
      • make prioritization decisions based on multidisciplinary team and ensure each patient is considered on an individual basis
      • priority table
        Table 1. Prioritizing Treatment for Systemic Chemotherapy
        Priority LevelCategorization Based on Treatment Intent and Risk:Benefit Ratio
        1
        • Definitive treatment with high chance of success (> 50%)
        • Adjuvant or neoadjuvant therapy which adds ≥ 50% chance of cure to surgery or radiation therapy alone, or to treatment at relapse
        2
        • Definitive treatment with intermediate chance of success (20%-50%)
        • Adjuvant or neoadjuvant therapy which adds 20%-50% chance of cure to surgery or radiation therapy alone, or to treatment at relapse
        3
        • Definitive treatment with low chance of success (10%-20%)
        • Adjuvant or neoadjuvant therapy which adds 10%-20% chance of cure to surgery or radiation therapy alone, or to treatment at relapse
        • Nondefinitive treatment with high chance (> 50%) of > 1 year of life expectancy
        4
        • Definitive treatment with very low chance of success (0%-10%)
        • Adjuvant or neoadjuvant therapy which adds < 10% chance of cure to surgery or radiation therapy alone, or to treatment at relapse
        • Nondefinitive treatment with intermediate chance (15%-50%) of > 1 year of life expectancy
        5
        • Nondefinitive treatment with high chance (> 50%) of palliation or temporary tumor control, and < 1 year expected extension of life
        6
        • Nondefinitive treatment with intermediate chance (15%-50%) of palliation or temporary tumor control, and < 1 year of life expectancy
      • also take into account for prioritization
        • level of immunosuppression associated with individual treatment, cancer type, and other patient-specific risk factors
        • capacity issues, such as limited resource (workforce, intensive care equipment, facilities)
        • balancing risk of cancer not treated optimally with risk of patient being immunosuppressed and seriously ill from COVID-19
    • for patients receiving chemotherapy with COVID-19 symptoms at presentation
      • patients on chemotherapy may display atypical presentation; symptoms of COVID-19 may be difficult to differentiate from pneumonitis or neutropenic sepsis at initial presentation
      • for patients with fever with or without respiratory symptoms, suspect neutropenic sepsis and
        • refer patients immediately for assessment in secondary or tertiary care
        • treat as acute medical emergency and offer immediate empiric antibiotics
    • modifications to management strategies
      • consider modifications to usual care to reduce patient exposure to COVID-19
      • consider delivery of systemic anticancer treatment in different and less immunosuppressive regimens, different locations, or via alternate routes of administration; options include
        • switching IV administration to subcutaneous or oral formulations where beneficial
        • using shorter treatment regimens
        • decreasing frequency of immunotherapy regimens
        • providing repeat oral or at-home medications without patient attending hospital
        • deferring treatment that prevent long-term complications such as bone disease
        • using home delivery or oral medications where possible
        • using treatment breaks for long-term treatment
      • ensure each patient is considered on individual basis by multidisciplinary team
      • discuss risk and benefits of changing treatment regimens or having treatment breaks with patients, families, and caregivers
    • Reference - NICE COVID-19 Rapid Guideline on Delivery of Systemic Anticancer Treatments

British Society for Hematology (BSH) Considerations for COVID-19 and Malignant Hematology Patients

Chronic Myeloid Leukemia (CML)

  • for CML patients receiving tyrosine kinase inhibitors (TKI)
    • patients with CML do not appear to be at higher risk of COVID-19, although data is limited; they can be at higher risk if older (aged > 70 years), have comorbidities, or receive treatment that may suppress immune system
    • case reports of patients with CML receiving TKI had similar outcomes from COVID-19 as general population
    • treatment with TKI does not cause clinically significant immunosuppression
    • avoid interrupting or reducing TKI medication without advice of CML specialist team
    • patients with CML do not fall in category of at-risk individuals who require 12 weeks of self-isolation
    • life expectancy of patients with CML is approaching that of general population; thus decision to consider these patients at high risk for COVID-19 should not impact triage or other in-patient treatment-related outcomes
    • Reference - BSH Advice for Patients with CML receiving TKI 2020 Mar 23

Myeloproliferative Neoplasms (MPNs)

  • for patients with MPNs
    • patients with MPN who are on aspirin alone, blood thinning tablets (warfarin, apixaban, rivaroxaban), venesection alone, or no treatment are not considered at high risk for COVID-19
    • patients > 70 years old with MPN, or any patient with MPN and additional comorbidities such as heart disease, high blood pressure, or diabetes, are considered more high risk
    • unclear risk for patients < 70 years old on medication to control blood count or MPN (such as hydroxycarbamide, interferon, anagrelide, busulfan, or combination)
    • patients taking ruxolitinib may be at higher risk for COVID-19
    • patients should continue on their medication to keep control of MPN
    • no current evidence for aspirin worsening COVID-19
    • Reference - BSH Advice for Patients with MPNs 2020 Mar 30

United Kingdom Myeloma Forum Guidance for COVID-19 and Multiple Myeloma Patients

  • Oncologic_DiseaseUK Myeloma Forum (UKMF) guidance on management of patients with multiple myeloma during COVID-19 outbreak (UKMF 2020 Mar 25)05/06/2020 02:04:15 PMfor newly diagnosed patients with multiple myeloma
    • with CRAB criteria (hypercalcemia, Renal insufficiency, Anemia, bone lesions)
      • offer primary treatment, since untreated newly diagnosed myeloma may adversely affect disease-related morbidity
      • first-line treatment includes
        • for transplant-eligible patients: bortezomib once weekly for 6 cycles plus dexamethasone 20 mg or lower once weekly, plus either thalidomide or cyclophosphamide
        • for transplant-ineligible patients
          • lenalidomide plus dexamethasone for 9 cycles, followed by single-agent lenalidomide
          • if already treated with lenalidomide plus dexamethasone, consider lowering steroid dose after cycle 9
    • with SLiM criteria (≥ 60% clonal bone marrow plasma cells, serum free light chain ratio involved-to-uninvolved > 100, and >1 focal lesion detected on magnetic resonance imaging) or with anemia only
      • observe
      • 80% likely need treatment ≤ 2 years after diagnosis
  • for patients with relapsed multiple myeloma
    • if symptomatic (for example with bone disease), consider benefit vs. risk of offering therapy
    • if biochemical relapse only, consider deferring treatment if feasible and clinically appropriate
    • consider using oral rather than IV regimen to reduce hospital admissions
  • hematopoietic stem cell transplantation (HSCT)
    • autologous HSCT (AHSCT)
      • not curative for myeloma and results in months of immune suppression
      • consider deferring AHSCT except for patients with high-risk disease (such as genetically defined high-risk, clinically aggressive disease, or extramedullary disease)
      • ensure full cycles of treatment given to increase disease response in anticipation of AHSCT when appropriate
    • allogeneic HSCT should be deferred given high risk of infectious complications post procedure
    • see also COVID-19 and Bone Marrow and Stem Cell Transplant Patients section for additional information
  • supportive care
    • consider oral bisphosphonates instead of IV formulation to decrease need for hospitalization
    • offer antibiotic prophylaxis to reduce risk of infections
    • consider erythropoiesis stimulating agents (ESAs) to decrease or prevent need for blood transfusions where indicated
    • consider granulocyte colony stimulating factor (GCSF) to reduce the need for additional appointments for monitoring and blood tests
  • Reference - UK Myeloma Forum Guidance on Myeloma Management during COVID-19 Outbreak 2020 Mar 25

COVID-19 and Stem Cell Transplantation and Cellular Therapy Patients

ManagementManagement

Hematopoietic Stem Cell Transplantation and Cellular Therapies

Hematopoietic Stem Cell Transplantation (HSCT)

  • HSCT complex procedure which nearly always involves
    • extended hospital admission
    • prolonged immunosuppression therapy
    • close follow up and need for phlebotomy, transfusional support, and multiple appointments
    • Reference - Br J Haematol 2020 Mar 15 early online
  • PubMed32180224British journal of haematologyBr J Haematol20200316increased risk of complications and superimposed infections in HSCT patients with concomitant COVID-19 infection due to
  • depending on status and risk of disease recurrence, delaying HSCT may not be possible
    • if low-risk disease, consider deferring HSCT process for several weeks to months
    • if high-risk disease, consider deferring until asymptomatic with negative polymerase chain reaction (PCR) testing
    • Reference - Br J Haematol 2020 Mar 15 early online
  • PubMed32180224British journal of haematologyBr J Haematol20200316consider performing HSCT in outpatient center for appropriate cases (Br J Haematol 2020 Mar 15 early online)

Cellular Cancer Therapies

  • PubMed32298807Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow TransplantationBiol Blood Marrow Transplant20200414chimeric antigen receptor (CAR) T-cell therapy is one of the cellular therapies offered to some patients with relapsed hematologic malignancies
  • many CAR T-cell recipients require inpatient admissions due to toxicities associated with the therapy and are at increased risk of infection
  • considerations for cellular cancer therapies
    • delay and/or cancel non-urgent cases if feasible
    • prioritize products to be given outpatient
    • minimize nonessential blood work
  • Reference - Biol Blood Marrow Transplant 2020 Apr 14 early onlinefull-text, Med J Aust 2020 May 13 early onlinefull-text

American Society for Clinical Oncology (ASCO) Guidance on Stem Cell Transplantation

American Society for Transplantation and Cellular Therapy (ASTCT) Guidelines on COVID-19 Management of Hematopoietic Stem Cell Transplant and Cellular Therapy Patients

  • Oncologic_DiseaseASTCT guidelines on COVID-19 management of hematopoietic stem cell transplant (HSCT) and cellular therapy patients (ASTCT Interim Guidelines for COVID-19 Management in HSCT and Cellular Therapy Patients 2020 Apr 16)05/18/2020 03:45:31 PMASTCT guidelines on COVID-19 management of hematopoietic stem cell transplant (HSCT) and cellular therapy patients
    • for high prevalence of COVID-19 in community
      • test all patients by polymerase chain reaction (PCR) of respiratory specimens at time of initial evaluation and again 2 days prior to conditioning/lymphodepletion therapy
      • consider longer deferral of therapy for certain conditions (such as multiple myeloma, germ cell tumor, or consolidative hematopoietic stem cell transplant)
    • for patients with suspected COVID-19 or symptoms of acute respiratory tract infection
      • perform multiplex PCR testing for COVID-19 and other respiratory viruses
      • defer procedures (including peripheral blood stem cell mobilization, bone marrow harvest, T cell collections, and conditioning/lymphodepletion therapy) for ≥ 14 days, until repeat PCR testing is negative, and patient is asymptomatic
    • for patients with confirmed COVID-19
      • defer HSCT or cellular therapy procedure if feasible
      • for high-risk patients, defer treatment until patient asymptomatic and ≥ 2 consecutive negative PCR tests each about 1 week apart
      • for patients requiring therapy, offer less intense conditioning if feasible
    • for patients in close contact with a COVID-19-positive person
      • defer procedures (including peripheral blood stem cell mobilization, bone marrow harvest, T cell collections, and conditioning/lymphodepletion therapy) for ≥ 14 (preferably 21) days
      • closely monitor patient for development of symptoms
      • perform PCR testing and consider deferring until ≥ 2 consecutive negative PCR tests each about 1 week apart
    • for donors with confirmed COVID-19, avoid donation; consider eligibility > 28 days if without symptoms and negative PCR testing for COVID-19
    • Reference - ASTCT Interim Guidelines for COVID-19 Management in HSCT and Cellular Therapy Patients 2020 Apr 20

European Society for Blood and Bone Marrow Transplantation (EBMT) Guidelines

  • Oncologic_DiseaseEuropean Society for Blood and Bone Marrow Transplantation (EBMT) recommendations for COVID-19 (EBMT 2020 Apr 7)05/06/2020 01:59:28 PMEBMT guidelines
    • transplant centers
      • restrict visitors as much as possible on transplant floors
      • caregivers with respiratory symptoms should remain at home
      • clinic visits deemed not critical should be deferred or substituted with telemedicine visits if appropriate
    • transplant procedures
      • defer nonurgent transplants whenever possible
      • secure stem cell product access by freezing product before start of conditioning or have alternative back-up donor
      • patients who are COVID-19 positive should not be treated in rooms with positive pressure or laminar air flow
    • transplant candidates
      • minimize risk of COVID-19 by home isolation for 14 days before start of transplant conditioning
      • avoid unnecessary clinic visits
      • test all patients for COVID-19; results should be negative prior to start of conditioning regardless of whether upper respiratory symptoms are present
      • defer transplant or CAR T-cell therapy on patients with COVID-19 for ≥ 3 months; if not feasible, defer treatment until patient is asymptomatic and has 2 repeated negative virus polymerase chain reaction (PCR) tests, at least 24 hours apart
      • if transplant candidate was in close contact with someone diagnosed with COVID-19, transplant procedures should not be performed for at least 14 days (preferably 21 days) from last contact; monitor closely for presence of COVID-19 and confirm PCR negativity before transplant procedure
    • transplant donors
      • transplant donors with confirmed COVID-19 must be excluded from donations; defer collection for ≥ 28 days after recovery unless need for donation is urgent
      • transplant donors in close contact with someone diagnosed with COVID-19 should be excluded from donation for ≥ 28 days and closely monitored for presence of COVID-19
      • if patient's need for transplant necessary and donor is completely well and test for COVID-19 is negative, consider earlier collection if local quarantine requirements permit
      • if transplant donor travels to high risk areas for COVID-19, exclude donor for 28 days
      • donors within 28 days should practice good hygiene and avoid large crowds and large group gatherings
      • test donors again for COVID-19 just prior to mobilization procedure if non-frozen cells are being used
      • product can be frozen at harvest site if prolonged transport of product anticipated
    • stem cell transplant and CAR T-cell recipients
      • limit risk of exposure to individuals with COVID-19 as much as possible and ensure hygienic routines including hand washing and use of alcohol-based hand sanitizers
      • refrain from travel; if travel is necessary, travel by private car is recommended if feasible
      • test patients prior to entering transplant ward, even if asymptomatic; repeat tests if there is strong suspicion of COVID-19 in cases of pneumonia or severe illnesses
      • test for other respiratory viral pathogens including influenza and respiratory syncytial virus test, preferably with PCR
      • patients diagnosed with COVID-19 should have chest imaging, preferably with computed tomography (CT) and evaluation of oxygenation impairment
      • routine bronchoalveolar lavage not recommended unless co-infection suspected
      • if abnormal CT and clinically indicated (such as in patients receiving invasive mechanical ventilation), lower respiratory tract aspirate or bronchoalveolar lavage should be collected and tested for COVID-19
      • no clear recommendations for treatment due to limited data and unknown risk vs benefit
    • Reference - EBMT recommendations for COVID-19 2020 May 18

National Institute for Health and Care Excellence (NICE) COVID-19 Guideline on Hematopoietic Stem Cell Transplantation

  • Oncologic_DiseaseNational Institute for Health and Care Excellence COVID-19 rapid guidelines on hematopoietic stem cell transplantation (NICE 2020 Apr:NG164)05/06/2020 02:10:06 PMtransplant candidates not known to have COVID-19
    • for 2 weeks prior to scheduled hematopoietic stem cell transplantation (HSCT), follow strict adherence to protective measures, such as staying home, limiting contact with others, and limiting time outside
    • > 72 hours prior to initiating conditioning therapy, obtain testing at least once for respiratory viruses and COVID-19
    • autologous HSCT
      • defer all cases of autologous HSCT for myeloma, low-grade lymphoproliferative disease, and nonmalignant indications if feasible
      • defer until risks associated with COVID-19 pandemic have passed
      • individual cases should be decided by multidisciplinary team
    • allogeneic HSCT
      • defer most cases for nonurgent indications or chronic hematologic malignancy
      • defer HSCT ≥ 3 weeks (if clinical status allows) if patient has been in contact with someone who is COVID-19 positive
      • individual cases should be decided by multidisciplinary team
  • transplant candidates with known or suspected COVID-19
    • test any symptomatic patient for respiratory viruses, including COVID-19
    • for patients who test positive for COVID-19
      • defer HSCT for ≥ 3 months if possible
      • if high risk of disease progression, morbidity, or mortality, defer HSCT until asymptomatic and have 3 repeated negative polymerase chain reaction (PCR) tests (at least 1 week apart)
  • donors not known to have COVID-19
    • for ≥ 4 weeks prior to scheduled donation, follow strict adherence to protective measures, such as staying home, limiting contact with others, and limiting time outside
    • if donor has had close contact with someone with COVID-19 and has been self-isolating, defer donation by ≥ 4 weeks from first day of isolation
    • test for COVID-19 at time of assessment and at time of harvest for donations being cryopreserved
    • test for COVID-19 at time of assessment and again 1 to 2 days before starting conditioning for donations freshly collected
    • communicate with donor to alert registry if develop illness within 2 weeks after donation
  • donors known or suspected to have COVID-19
    • defer donations ≥ 3 months after symptom resolution in those that test positive for COVID-19
    • consider alternative donor sources (haploidentical family members or umbilical cord blood) if HSCT urgent and cannot be deferred; individual cases should be decided by multidisciplinary team
    • positive donors should not provide any blood donations for ≥ 3 months after symptom resolution
  • transplant recipients post-HSCT
    • practice strict protective isolation; consider need for procedures outside of isolation only if necessary
    • isolate patients who test COVID-19 positive in negative pressure space (if not feasible, offer neutral pressure space)
    • practice strict isolation post-HSCT until risks associated with COVID-19 have passed for those who had
      • autologous HSCT ≤ 1 year
      • allogeneic HSCT if any of the following
        • received transplant ≤ 2 years
        • continue on immunosuppressive therapy regardless of date of HSCT
        • have chronic graft-versus-host disease
        • have evidence of ongoing immunodeficiency
  • treatment priority
    • discuss risks, benefits, and possible outcomes of different treatment options with patient, families, and carers
    • make prioritization decisions based on multidisciplinary team and ensure each patient is considered on an individual basis
    • priority table
      Table 2. Prioritizing Treatment for HSCT
      Priority LevelCategorization Based on Treatment Intent and Risk:Benefit Ratio
      1Urgent allogeneic HSCT due to high risk of disease progression, morbidity, or mortality
      2High-grade lymphomas or urgent cases needing autologous HSCT for definitive intent
      3Chronic conditions including most nonmalignant indications and low-risk malignant indications for allogeneic HSCT; defer most cases until risks associated with COVID-19 pandemic have passed
      4Allogeneic HSCT recipients with a relatively low predicted survival (such as 20%-30% five-year survival based on pre-HSCT features)
      5Autologous HSCT for myeloma, low-grade lymphoproliferative diseases, and nonmalignant diseases
      Abbreviation: HSCT, hematopoietic stem cell transplantation.
    • consider risk of patients developing COVID-19 and needing critical care support post-HSCT and risk of disease progression or relapse
    • consider deferring HSCT in patient with
      • predicted poor outcomes
      • risk from further treatment and immunosuppression that would increase risk of developing COVID-19
  • further procedural considerations
    • use granulocyte-colony stimulating factor (G-CSF) mobilized peripheral blood stem cells instead of bone marrow as stem cell source (to avoid harvesting and hospital admissions)
    • cryopreserve and transport all donor donations prior to starting conditioning therapy
    • for allogeneic HSCT, attempt to identify alternative donor or umbilical cord blood unit in case of donor issues
    • for autologous HSCT, consider utilizing G-CSF alone to minimize the use of mobilization chemotherapy (and subsequent immunosuppression)
  • Reference - NICE COVID-19 Rapid Guideline on Hematopoietic Stem Cell Transplantation

COVID-19 and Cancer Surgery Patients

General Principles

  • Oncologic_DiseaseAmerican College of Surgeons (ACS) guidance regarding surgery and COVID-19 (ACS 2020 Mar 24)05/06/2020 01:48:15 PMAmerican College of Surgeons (ACS) guidance regarding surgery and COVID-19
    • consider availability of local institution resources, including protective gear for providers and patients
    • for elective cases with high likelihood of need for postoperative intensive care unit (ICU) or respirator utilization, balance risk of surgery delay to imminent availability of resources for patients with COVID-19
    • consult multidisciplinary expert panels to consider individual cases, or for institutions with high case volumes to establish triage criteria based on local circumstances
    • Reference - ACS Guidance on COVID-19 2020 Mar 24
  • Oncologic_DiseaseAmerican Society of Clinical Oncology (ASCO) guidance for COVID-19 and cancer surgery (ASCO2020)05/06/2020 01:24:51 PMAmerican Society of Clinical Oncology (ASCO) guidance for COVID-19 and cancer surgery
    • consider postponing elective surgeries if feasible; however, make individual determinations of potential risks of delaying cancer-related surgery
    • in certain situations where neoadjuvant therapy is an option but not routinely considered (such as early stage breast cancer), consider neoadjuvant therapy instead of surgery or simply delaying surgery
      • weigh risk of delay in definitive surgery against potential burden of case complexity and patient risk of exposure to COVID-19
      • also consider risks of exposure to COVID-19 if neoadjuvant therapy is immunosuppressive or requires clinic visits and clinician-patient contact
    • Reference - ASCO Guidance for COVID-19 Patient Care 2020 Apr 2

Breast Cancer

  • American College of Surgeons (ACS) guidelines for triaging breast cancer surgery patients
    • for semi-urgent situations with limited number of patients with COVID-19, hospital resources including intensive care unit (ICU) ventilation capacity not limited, and COVID-19 cases not rapidly increasing
      • limit surgery to patients likely to have survival compromised if surgery not performed ≤ 3 months
      • proceed as soon as feasible with following cases
        • patients finishing neoadjuvant treatment
        • discordant biopsies likely malignant
        • resection of malignant recurrence
        • patients with triple negative (estrogen receptor [ER] negative, progesterone receptor [PR] negative, and human epidermal growth factor receptor 2 [HER2] negative) tumors, HER2 positive tumors, or clinical stage T2 or N1 ER positive/PR positive/HER2 negative tumors
          • depending on institutional resources, may proceed with surgery rather than offering immunocompromising neoadjuvant chemotherapy
          • consider breast conserving surgery when feasible and defer definitive mastectomy and/or reconstruction until after COVID-19 pandemic resolves
          • defer autologous reconstruction
      • defer following cases
        • resection of benign lesions such as fibroadenomas or nodules
        • duct excisions
        • discordant biopsies likely benign
        • high-risk lesions such as atypia or papillomas
        • prophylactic surgery for cancer and noncancer cases
        • delayed sentinel lymph node biopsy for cancer identified on excisional biopsy
        • cTisN0 lesions, whether ER positive or negative
        • re-excision surgery
        • tumors responding to neoadjuvant hormonal treatment
        • cT1N0 ER positive/PR positive/HER2 negative tumors (offer endocrine therapy)
        • inflammatory and locally advanced breast cancer (offer neoadjuvant therapy)
      • consider alternative treatment options to surgery including
        • for patients with clinical stage T1N0 (and some with T2 or N1) ER positive/PR positive/HER2 negative tumors, consider endocrine therapy
          • patients with low-intermediate grade tumors, lobular breast cancer, cancer with low OncoType DX scores (< 25) or luminal A gene expression signatures may not benefit from chemotherapy
          • high-level evidence supports efficacy and safety of 6-12 months of neoadjuvant endocrine therapy
        • for patients with triple negative or HER2 positive tumors, consider neoadjuvant therapy
        • for patients with inflammatory and locally advanced breast cancer, offer neoadjuvant systemic therapy
    • for urgent situations with many patients with COVID-19, limited ventilator capacity, limited operating room (OR) supplies, or COVID-19 cases within hospital rapidly increasing
      • limit surgery to patients likely to have survival compromised if not performed within next few days
      • proceed as soon as feasible with following cases
        • incision and drainage of breast abscess
        • evacuation of hematoma
        • revision of ischemic mastectomy flap
        • revascularization/revision of autologous tissue flap (defer autologous reconstruction)
      • defer all other breast procedures
      • consider neoadjuvant therapy for eligible cases
      • consider observation for remaining cases
    • for situations where all hospital resources are routed to COVID-19, no ventilator or ICU capacity, OR supplies exhausted
      • limit surgery to patients likely to have survival compromised if not performed within next few hours
      • cases that should be done and deferred are same as in urgent setting
      • consider neoadjuvant therapy for eligible cases
      • consider observation for remaining cases
    • Reference - ACS Guidance on COVID-19 2020 Mar 24
  • Oncologic_DiseaseSociety of Surgical Oncology considerations for surgery in patients with breast cancer (SSO 2020 Mar 30)05/06/2020 01:31:16 PMSociety of Surgical Oncology considerations for surgery in patients with breast cancer
    • for atypia, prophylactic or risk-reducing surgery and benign breast disease
      • may defer consults and resultant surgeries ≥ 3 months unless patient experiencing abscess or infection that failed conservative or medical management, or ultrasound-guided percutaneous drainage
      • may defer delayed or second stage reconstruction ≥ 3 months
    • for ductal carcinoma in situ (DCIS) - test all core biopsies demonstrating DCIS for hormone receptor status
      • for ER positive DCIS, consider treatment with endocrine therapy for 3-5 months (tamoxifen or aromatase inhibitor at discretion of medical oncologist); reassess by telemedicine every 8-12 weeks to screen for progression (such as new mass or bloody nipple discharge)
      • for ER negative DCIS, consider delaying treatment if low volume disease and low clinical or radiographic suspicion of invasive disease; reassess by telemedicine every 4 weeks to screen for progression (such as new mass or bloody nipple discharge) and keep patients on high priority for operation when deemed safe
      • for large volume ER negative DCIS, high-grade DCIS, or palpable DCIS, consider delaying treatment with close follow-up at discretion of multidisciplinary board; reassess by telemedicine every 4 weeks to screen for progression (such as new mass or bloody nipple discharge) and keep patients on high priority for operation when deemed safe
      • for DCIS with microinvasion, perform hormone receptor testing on microinvasion component if feasible and treat as per invasive cancer guidelines if ER positive; if invasive component is ER negative, treat as per ER negative DCIS guidelines and do not offer neoadjuvant chemotherapy; patients should be on high priority for operation when deemed safe
    • for ER positive invasive breast cancer
      • stage I-II
        • perform genomic testing on core biopsy if likely to determine treatment (endocrine vs. chemotherapy)
        • consider neoadjuvant therapy for at least 3-5 months if amendable to endocrine therapy, and reassess by telemedicine every 4 weeks to screen for progression
          • if patient is postmenopausal, consider aromatase inhibitor or tamoxifen at discretion of medical oncologist
          • if patient is premenopausal, consider ovarian suppression and either tamoxifen or aromatase inhibitor
        • start chemotherapy if indicated
      • for advanced-stage cancers (III-IV), consider primary endocrine or chemotherapy per multidisciplinary discussion
    • for triple negative or HER2 positive invasive breast cancer
      • for patients with T2 N0-N3 M0 or T0-T4 N1-N3 M0 disease, start neoadjuvant therapy
      • consider patients with T1 N0 M0 disease as high priority for surgery; may consider neoadjuvant therapy in large T1 tumors or as per multidisciplinary board recommendations
    • after neoadjuvant chemotherapy
      • for ER positive invasive breast cancer
        • if patient had partial or complete clinical response, consider converting to endocrine therapy to delay surgery vs. offering surgery in 4-8 weeks; reassess patient by telemedicine every 2-4 weeks to screen for progression
        • if patient also has HER2 positive disease, consider converting to endocrine therapy in addition to HER2 targeted therapy to delay surgery vs. offering surgery in 4-8 weeks; reassess patient by telemedicine every 4 weeks to screen for progression
      • for triple negative or HER2 positive invasive breast cancer
        • if possible, depending on response, delay surgery up to 4-8 weeks, but keep patients on high priority for surgery when deemed safe
    • special considerations, surgical emergencies, or unusual cases
      • for patients with progressive disease while receiving systemic therapy, angiosarcoma, or malignant phyllodes tumors, offer urgent surgery without delay
      • all surgeries amendable to same day discharge or 23-hour observation stay should be performed as such while following enhanced recovery after surgery protocols to ensure timely discharge
      • telemedicine
        • consider for postoperative visits, unless patient has acute issue or requires suture or drain removal
        • use for second opinion consultations where patient is actively being treated
        • use for surveillance visits or delay visits for 1-3 months if they are coupled with routine mammogram
    • Reference - Society of Surgical Oncology Resources on COVID-19 2020 Mar 30

Thoracic Cancers

  • American College of Surgeons guidelines for triaging thoracic cancer surgery patients
    • for semi-urgent situations with limited number of patients with COVID-19, hospital resources including intensive care unit (ICU) ventilation capacity not limited, and COVID-19 cases not rapidly increasing
      • limit surgery to patients likely to have survival compromised if surgery not performed within next 3 months
      • proceed as soon as feasible with following cases
        • solid or predominately solid (> 50%) lung cancer or presumed lung cancer > 2 cm, clinical lymph node negative
        • lymph node positive lung cancer
        • post induction therapy cancer
        • esophageal cancer T1b or greater
        • chest wall tumors of high malignant potential not manageable by alternative approaches
        • stenting for obstructing esophageal tumor
        • staging to start treatment (mediastinoscopy, diagnostic video-assisted thoracoscopic surgery for pleural dissemination)
        • symptomatic mediastinal tumors where diagnosis not amendable to needle biopsy
        • patients enrolled in clinical trials
      • consider deferring following cases
        • predominantly ground glass (< 50% solid) nodules or cancers
        • solid nodule or lung cancer < 2 cm
        • indolent histology (carcinoid, slowly enlarging nodule)
        • thymoma (nonbulky, asymptomatic)
        • pulmonary oligometastases unless clinically necessary for pressing therapeutic or diagnostic indication where surgery will impact treatment
        • patients unlikely to separate from mechanical ventilation or likely to have prolonged ICU needs
        • tracheal resection unless aggressive histology
        • bronchoscopy
        • upper endoscopy
        • tracheostomy
      • consider alternative treatment option to surgery including
        • endoscopic management for early stage esophageal cancer (T1a/b superficial)
        • neoadjuvant therapy (for example, chemotherapy for 5 cm lung cancer), if eligible for adjuvant therapy
        • stereotactic ablative radiation therapy
        • ablation (such as cryotherapy or radiofrequency ablation)
        • stent for obstructing cancers, followed by chemoradiation therapy
        • debulking (endobronchial tumor) only if alternative therapy not an option due to increased risk of aerosolization (for example, stridor postobstructive pneumonia not responsive to antibiotics)
        • nonsurgical staging (endobronchial ultrasound, imaging, interventional radiology biopsy)
        • follow patients after neoadjuvant therapy for local only failure (such as salvage surgery)
        • chemotherapy extension for patients completing planned neoadjuvant course
    • for urgent situations with many patients with COVID-19, limited ventilator capacity, limited operating room (OR) supplies, or COVID-19 cases within hospital rapidly increasing
      • limit surgery to patients likely to have survival compromised if not performed within next few days
      • proceed as soon as feasible with following cases
        • perforated cancer of esophagus not septic
        • tumor-associated infection that is compromising but not septic (such as debulking for post obstructive pneumonia)
        • management of surgical complications in a hemodynamically stable patient (hemothorax, empyema, infected mesh)
      • defer all thoracic procedures typically scheduled as routine/elective
      • offer alternative treatment options including
        • transferring patients to hospital that is in semi-urgent setting
        • neoadjuvant therapy if eligible for adjuvant therapy
        • stereotactic ablative radiation therapy
        • ablation (such as cryotherapy or radiofrequency ablation)
        • reconsider neoadjuvant therapy as definitive chemoradiation and follow patients for local only failure (such as salvage surgery)
    • for situations where all hospital resources are routed to COVID-19, no ventilator or ICU capacity, OR supplies exhausted
      • limit surgery to patients likely to have survival compromised if not performed within next few hours
      • proceed as soon as feasible with following cases
        • perforated cancer of esophagus in septic patient
        • threatened airway
        • tumor-associated sepsis
        • management of surgical complications in unstable patient (active bleeding not amendable to nonsurgical management, dehiscence of airway, anastomotic leak with sepsis)
      • defer all other cases
      • alternative treatment approaches same as in urgent setting
    • Reference - ACS Guidance on COVID-19 2020 Mar 24

Colorectal Cancer

  • American College of Surgeons (ACS) guidelines for triaging colorectal cancer surgery patients
    • for semi-urgent situations with limited number of patients with COVID-19, hospital resources including intensive care unit (ICU) ventilation capacity not limited, and COVID-19 cases not rapidly increasing
      • proceed as soon as feasible with following cases
        • nearly obstructing colon or rectal cancer
        • cancers requiring frequent transfusions
        • asymptomatic colon cancers
        • rectal cancers following neoadjuvant chemoradiation therapy with no response
        • cancers with concern about local perforation and sepsis
        • early stage rectal cancers where adjuvant therapy not appropriate
      • consider deferring 3 months following cases
        • malignant polyps, either with or without prior endoscopic resection
        • prophylactic indications for hereditary conditions
        • large, benign appearing asymptomatic polyps
        • small, asymptomatic colon or rectal carcinoids
      • consider alternative treatment options to delay surgery including
        • for locally advanced resectable colon cancer, neoadjuvant chemotherapy for 2-3 months followed by surgery
        • for rectal cancer with clear and early evidence of downstaging from neoadjuvant chemoradiation therapy, additional chemotherapy if can be given and wait-time safe
        • for locally advanced rectal cancer or recurrent rectal cancer requiring exenterative surgery, additional chemotherapy if can be given
        • for oligometastatic disease, systemic therapy if effective systemic therapy available
    • for urgent situations with many patients with COVID-19, limited ventilator capacity, limited operating room (OR) supplies, or COVID-19 cases within hospital rapidly increasing
      • proceed as soon as feasible with following cases
        • nearly obstructing colon cancer where stenting is not option
        • nearly obstructing rectal cancer (offer diversion)
        • cancers with high (inpatient) transfusion requirements
        • cancers with pending evidence of local perforation and sepsis
      • defer all other colorectal procedures typically scheduled as routine
      • consider alternative treatment options including
        • transferring patients to hospitals with capacity
        • neoadjuvant therapy for colon and rectal cancer
        • more local endoluminal therapies for early colon and rectal cancers where safe
    • for situations where all hospital resources are routed to COVID-19, no ventilator or ICU capacity, and OR supplies exhausted
      • limit surgery to patients with high mortality risk within hours if surgery deferred
      • proceed as soon as feasible with following cases
        • perforated, obstructed, or actively bleeding (inpatient transfusion dependent) cancers
        • cases with sepsis
      • defer all other cases
      • consider alternative treatment options including
        • transferring patients to hospitals with capacity
        • diverting stomas
        • chemotherapy or radiation
    • Reference - ACS Guidance on COVID-19 2020 Mar 24
  • Oncologic_DiseaseSociety of Surgical Oncology considerations for surgery in patients with colorectal cancer (SSO 2020 Apr 6)05/06/2020 01:38:27 PMSociety of Surgical Oncology considerations for surgery in patients with colorectal cancer
    • for all cancers in polyps or other early stage disease, defer surgery
    • for obstructed (divert only if rectal), perforated, or acutely transfusion dependent patients, proceed with surgery
    • for nonmetastatic colon cancer, proceed with definitive surgery
    • consider all options for neoadjuvant therapy including utilization of total neoadjuvant therapy for rectal cancer and consider neoadjuvant chemotherapy for locally advanced and metastatic colon cancer
    • for rectal cancer neoadjuvant radiation therapy, highly consider short course regimen (5 days of 5 Gy) compared to long course chemoradiation therapy
    • for locally advanced rectal cancer, delay surgery for 12-16 weeks following neoadjuvant therapy
    • Reference - Society of Surgical Oncology Resources on COVID-19 2020 Mar 30

Gastrointestinal and Hepatobiliary Cancers

  • Oncologic_DiseaseSociety of Surgical Oncology considerations for surgery in patients with gastrointestinal and hepatobiliary cancer (SSO 2020 Apr 6)05/06/2020 01:40:07 PMSociety of Surgical Oncology considerations for surgery in patients with gastrointestinal and hepatobiliary cancer
    • for upper gastrointestinal cancer
      • delay or refer surgeries out to other centers if inadequate resources to manage potential complications
      • cases should be individualized and discussed with multidisciplinary board regarding priorities, resources, personalized treatment plans based on hospital, patient, and tumor specifics
    • for gastric and esophageal cancer
      • if cT1a lesions amenable to endoscopic resection, offer endoscopic management if feasible
      • if cT1b cancers, offer resection
      • if cT2 or higher and node positive tumors, offer neoadjuvant therapy
      • consider proceeding directly to neoadjuvant therapy without staging laparoscopy due to concerns about laparoscopic surgery in patients with COVID-19 and increased use of resources; if staging laparoscopy performed, consider minimizing use of personal protective equipment and staff involved and/or exposed in procedure using appropriate pneumoperitoneum risk-reduction strategies
      • patients completing neoadjuvant chemotherapy may remain on chemotherapy if responding to and tolerating therapy and resources do not support proceeding to resection; if patient not responding to systemic therapy, consider resection and/or referral
      • consider treating patients with gastric outlet obstruction or hemorrhage with endoscopic measures to allow for enteral nutrition or control of bleeding; proceed to surgery if measures fail
      • consider short-term deferral of surgery in less biologically aggressive cancers, such as gastrointestinal stromal tumors, unless symptomatic or bleeding
    • for hepato-pancreato-biliary (HPB) cancer
      • offer resection to all patients with aggressive HPB malignancies (gastric cancer, duodenal cancer, ampullary cancer, pancreatic adenocarcinoma, colorectal cancer metastatic to liver) as indicated
      • consider neoadjuvant chemotherapy if systemic chemotherapy is indicated in addition to surgery
      • if responding to and tolerating neoadjuvant chemotherapy, continue and delay surgery
    • for asymptomatic pancreatic neuroendocrine tumors, duodenal and ampullary adenomas, gastrointestinal stromal tumors, and high-risk intraductal papillary mucosal neoplasms, defer surgery unless delays will affect resectability
    • for liver metastases, offer ablation or stereotactic radiation surgery instead of resection where possible
    • for hepatocellular carcinoma, consider ablation or embolization over surgical resection
    • Reference - Society of Surgical Oncology Resources on COVID-19 2020 Mar 30

Endocrine and Head and Neck Cancers

  • Oncologic_DiseaseSociety of Surgical Oncology considerations for surgery in patients with endocrine and head and neck cancer (SSO 2020 Mar 30)05/06/2020 01:39:18 PMSociety of Surgical Oncology considerations for surgery in patients with endocrine and head and neck cancer
    • endocrine surgery
      • delay most uncomplicated endocrine surgeries including
        • functional adrenal tumors that are medically controlled, and asymptomatic nonfunctional adrenal adenomas
        • many neuroendocrine tumors (NETs) not listed below may be suitable for somatostatin analogues or medical therapy
      • diseases and presentations identified as urgent surgery (about ≤ 4-8 weeks during current COVID-19 pandemic) include
        • thyroid
          • thyroid cancer that is current or impending threat to life, those threatening morbidity with local invasion (for example, trachea or recurrent laryngeal nerve), or aggressive biology (rapidly growing tumor or recurrence, rapidly progressive locoregional disease including lymph nodes)
          • severely symptomatic Graves disease that failed medical therapy
          • highly symptomatic goiter or goiter at risk for impending airway obstruction
          • open biopsy with diagnostic intent for suspected anaplastic thyroid cancer or lymphoma
        • parathyroid - hyperparathyroidism with life-threatening hypercalcemia that cannot be controlled with medical therapy
        • adrenal
          • adrenocortical cancer or highly suspected adrenocortical cancer
          • pheochromocytoma or paraganglioma not controlled with medical management
          • significantly symptomatic Cushing syndrome not controlled with medical management
        • NETs
          • symptomatic small bowel NETs (for example, obstruction, bleeding/hemorrhage, significant pain, or concern for ischemia)
          • symptomatic and/or functional pancreatic NETs not controlled with medical management
          • nonfunctional pancreatic NETs causing symptoms (jaundice, bleeding, obstruction) after failure of somatostatin analogues and medical therapy
          • lesions with significant growth or short doubling times
          • generally delay cytoreductive operations and metastasectomy but consider on individual basis, especially if progressing after multiple therapies (somatostatin analogues, chemotherapy, biologic therapy, peptide receptor radionuclide therapy [PRRT])
        • endocrine disorder that threatens pregnant mother or her fetus
    • nonendocrine head and neck cancer
      • consider all procedures involving upper aerodigestive tract as high risk; other procedures not involving entering airway but involving head and neck are medium risk due to proximity to airway
      • proceed with emergency procedures such as for stridor, bleeding, and obstruction
      • for high-risk procedures, increased personal protective equipment (PPE) including standard PPE equipment and N95 masks for all personnel in operating room
      • consider delay of urgent procedures on case-by-case (such as tracheostomy, endoscopic nasogastric tube insertion, esophageal stenting)
      • delay cosmetic procedures including reconstruction
      • consider radiation therapy if diagnoses has equivalent results with surgery and radiation therapy
      • consider keeping patients on systemic therapy (for example, neoadjuvant therapy) to allow delaying surgery
      • consider N95 masks for medium-risk procedures
      • reduce operative time, if possible, with modifications to or deferral of reconstruction plans
      • minimize number of people in operating room as much as possible
      • patients should self-quarantine for 2 weeks prior to surgery and be tested for COVID-19 as close to the time of surgery as will allow results, if possible
    • surveillance for delayed surgical procedures
      • adrenal
        • computed tomography (CT) or magnetic resonance imaging (MRI) every 3-6 months
        • functional tumors
          • appropriate laboratory studies every 3-6 months
          • continue medical management of functional tumors
      • parathyroid - medical management when necessary
      • thyroid - ultrasound surveillance (including nodal basins) and physical exam every 3-6 months
      • neuroendocrine tumors
        • CT or MRI every 3-6 months
        • functional tumors
          • appropriate laboratory studies every 3-6 months
          • continue medical management of functional tumors
        • consider deferring endoscopic surveillance for gastric, duodenal, or rectal neuroendocrine tumors due to emerging evidence on the risk of transmission of COVID-19 with procedures involving the gastrointestinal tract
    • safety considerations for surgeons performing head and neck procedures
      • surgeons performing head and neck are at higher risk of COVID-19
      • utilize appropriate PPE and conform to Centers for Disease Control and Prevention (CDC) and local institution recommendations
      • avoid or minimize any aerosol-generating procedures such as intubation/extubation as these are high risk situations for COVID-19 transmission
      • fit test for N95 masks prior to use
    • Reference - Society of Surgical Oncology Resources on COVID-19 2020 Mar 30

Gynecologic Cancers

  • American College of Surgeons (ACS) considerations for timing of gynecologic cancer surgery as suggested by Temple University
    • perform emergency surgery without delay (acute and severe vaginal bleeding)
    • surgeries that if significantly delayed could cause significant harm
      • cancer or suspected cancer including
        • ovarian, tubal, or peritoneal cancer
        • ovarian masses if cancer is suspected
        • endometrial cancer and endometrial intraepithelial neoplasia
        • cervical cancer
        • vulvar cancer
        • vaginal cancer
        • gestational trophoblastic neoplasia
      • surgeries that can be delayed for few weeks
        • dilation and curettage (D&C) with or without hysteroscopy for abnormal uterine bleeding (pre- or postmenopausal) when cancer is suspected
        • cervical conization or loop electro-excision procedure to exclude cancer
        • excision of precancerous or possible cancerous lesions of vulva
      • surgeries that can be delayed for several months
        • surgery for fibroids if sarcoma not suspected
        • surgery for adnexal masses that are most likely benign (for example, desmoid cyst)
        • cervical conization or loop-electro-excision procedure for high-grade squamous intraepithelial lesions
        • therapeutic D&C with or without hysteroscopy for abnormal uterine bleeding when cancer no suspected
      • Reference - ACS Guidance on COVID-19 2020 Mar 24

Peritoneal Surface Malignancies

  • Oncologic_DiseaseSociety of Surgical Oncology considerations for surgery in patients with peritoneal surface malignancy (SSO 2020 Mar 23)05/06/2020 01:41:11 PMSociety of Surgical Oncology considerations for surgery in patients with peritoneal surface malignancy
    • manage patients on individual basis if significantly symptomatic or with imminent threat to life or well-being
    • maintain communication between local hospital administration to evaluate local burden of COVID-19 and availability of supplies
    • maintain communication between patient and physician in making decisions to proceed with surgery
    • consider cytoreductive surgery (significant utilization of resources) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) only if health system is well resourced to perform rescue for patients without exposing them to unnecessary risk
    • offering of HIPEC following cytoreductive surgery must be individualized decision; considerations to avoid HIPEC during or after cytoreductive surgery must include
      • risk of development of neutropenia in patient
      • risk of peri-operative complications and longer hospital stay
      • increased operative time and personnel involved
    • surgical decisions stratified by histology and COVID-19 risk
      Table 3. Surgery Decisions by Histology and COVID-19 Risk
      HistologyHigh-Risk Region for COVID-19* Low-Risk Region for COVID-19
      Symptomatic patientsConsider surgery if local conditions permitConsider surgery if local conditions permit
      Low-grade appendixDefer surgery for 6 weeks or longerConsider deferring surgery for 6 weeks or longer
      High-grade appendix colorectalDefer surgery for 4-6 weeksConsider deferring surgery for 4-6 weeks
      Mesothelioma ovarian cancerConsider systemic chemotherapyConsider systemic chemotherapy
      Desmoplastic small-round cell tumorsConsider deferring surgery for 2-4 weeks and consider additional systemic chemotherapyConsider deferring surgery for 2-4 weeks and consider additional systemic chemotherapy
      Gastric cancerDefer surgery for 2-4 weeks and consider systemic chemotherapyConsider deferring surgery for 2-4 weeks and consider systemic chemotherapy
      Peritoneal metastases from neuroendocrine tumors/gastrointestinal stromal tumors Defer surgery for 6 weeks or longerConsider deferring surgery for 6 weeks or longer
      Malignant bowel obstructionOperate only if emergent or failure to progressConsider operating only if emergent or failure to progress

      * Numerous or rapidly growing community acquired infections, limited resources.

    • Reference - Society of Surgical Oncology Resources on COVID-19 2020 Mar 30

Sarcomas

  • Oncologic_DiseaseSociety of Surgical Oncology considerations for surgery in patients with sarcoma (SSO 2020 Mar 30)05/06/2020 01:41:48 PMSociety of Surgical Oncology considerations for surgery in patients with sarcoma
    • prioritize surgery for primary soft tissue sarcoma without metastatic disease; however
      • consider deferring ≥ 3 months resection of
        • newly diagnosed truncal/extremity atypical lipomatous tumor
        • classic dermatofibrosarcoma protuberans without fibrosarcomatous degeneration
        • desmoid
      • consider deferring for short intervals (depending on resources and if asymptomatic) resection of other low-grade sarcomas
        • with known indolent behavior such as retroperitoneal well-differentiated liposarcoma
        • with low metastatic risk such as myxoid liposarcoma and low grade-fibromyxoid tumor)
      • consider deferring reexcision for R1 margins in extremity/truncal lesions if operating room resources limited and no evidence of residual disease on imaging
    • if indication for radiation therapy, perform preoperatively
      • may administer in lower-risk outpatient setting to allow delaying surgery by 3-4 months
      • consider preoperative radiation therapy as bridge therapy to delay surgery when appropriate, even when treatment not standard but there is evidence that it may not cause harm (for example, preoperative radiation therapy in retroperitoneal liposarcoma)
    • consider neoadjuvant chemotherapy for high-grade sarcomas at any site or for recurrent disease to delay surgery when it can be safely delivered in outpatient setting
    • consider neoadjuvant imatinib in localized gastrointestinal stromal tumors as bridge therapy, even if formal indication does not exist, provided mutation is sensitive (BCR-ABL1)
    • consider active observation protocols or low-toxicity systemic options in patients with recurrent disease; offer surgery for recurrent disease in patients
      • likely to have relatively high chance of obtaining long-term disease control in context of complete gross resection (such as patients with long disease-free interval or solitary site or recurrence)
      • who require immediate palliation (due to bleeding or obstruction)
      • who do not have indolent histologies (well differentiated liposarcoma in the retroperitoneum or classic solitary fibrous tumor) that can be managed with active observation
    • Reference - Society of Surgical Oncology Resources on COVID-19 2020 Mar 30

COVID-19 and Radiation Therapy Patients

ManagementManagement

American Society of Clinical Oncology (ASCO) COVID-19 Guidance for Radiation Therapy

  • ASCO guidance for patients with cancer receiving radiation therapy (in accordance with American Society for Radiation Oncology [ASTRO] guidance)
    • patient consults should be scheduled on case-by-case basis depending on urgency of situation
    • consider risks of delaying treatment in patients with potentially curable cancer
    • nonurgent cases that may be delayed up to 2 months include patients with prostate cancer, breast cancer when on adjuvant chemotherapy, and benign central nervous system (CNS) such as meningiomas and schwannomas
    • consider deferring or delaying palliative care patients if prognosis poor or other palliative treatment options available except patients with life-threatening or function-threatening situations (for example, spinal cord compression, cranial nerve compression, airway obstruction, hemoptysis or other tumor bleeding, or superior vena cava syndrome)
    • Reference - ASCO Guidance for COVID-19 Patient Care

National Institute for Health and Care Excellence (NICE) COVID-19 Guideline on Delivery of Radiation Therapy

  • Oncologic_DiseaseNational Institute for Health and Care Excellence COVID-19 rapid guidelines on delivery of radiotherapy (NICE 2020 Mar:NG162)05/06/2020 02:23:05 PMNICE COVID-19 rapid guideline on delivery of radiation therapy
    • screening and scheduling
      • for patients known or suspected to have COVID-19, avoid canceling radiation therapy appointments only based on COVID-19
      • for patients with COVID-19 symptoms at presentation, assess and triage to check whether they have disease or have been in close contact with someone with confirmed infection
      • schedule treatments based on patients' COVID-19 status
        • schedule patients with known or suspected COVID-19 at a specific time of day
        • schedule patients at increased risk of severe COVID-19 (for example, patients with lung cancer) at a different time from patients with COVID-19
    • treatment priority
      • clearly communicate, with written documentation if possible, prioritization of radiation therapy treatment and reason for decision to patient, families, and carers, including discussion of risks and benefits of modifications to or interruption of treatment
      • make prioritization decisions based on multidisciplinary team and ensure each patient is considered on an individual basis
      • avoid radiation therapy treatment for benign conditions unless immediate threat to life or function
      • priority table
        Table 4. Prioritizing Treatment for Radiation Therapy
        Priority LevelTreatment
        1
        • Definitive radiation therapy or chemoradiation therapy if all of the following
          • Patients with rapidly proliferating (category 1) tumors
          • Treatment already initiated
          • Little to no possibility to compensate for treatment gaps
        • External beam radiation therapy plus subsequent brachytherapy if both of the following
          • Patients with rapidly proliferating tumors
          • Treatment already initiated
        • Radiation therapy not yet started if both of the following
          • Patients with rapidly proliferating (category 1) tumors
          • Treatment would start in normal circumstances, based on clinical need or current cancer treatment waiting times
        2
        • Urgent palliative radiation therapy for patients with malignant spinal cord compression who have salvageable neurological function
        3
        • Definitive radiation therapy for patients with less aggressive (category 2) tumors
        • Postoperative radiation therapy for patients with either of the following
          • Tumors with aggressive biology
          • Known residual disease after surgery
        4
        • Palliative radiation therapy if symptom improvements reduce need for additional treatments
        5
        • Adjuvant radiation therapy if both of the following
          • Complete tumor resection
          • < 20% risk of 10-year local recurrence
        • Definitive radiation therapy for prostate cancer for patients receiving neoadjuvant hormone therapy
      • also take into account for prioritization
        • patient-specific risk factors including comorbidities and level of immunosuppression
        • capacity issues, such as limited resource (workforce, intensive care equipment, facilities)
        • balancing risk of cancer not treated optimally with risk of patient being seriously ill from COVID-19
    • immunosuppressed patients
      • patients receiving radiation therapy for certain cancers may be immunosuppressed and may have atypical presentations of COVID-19
      • suspect neutropenic sepsis in immunosuppressed patients receiving radiation therapy presenting with fever with or without respiratory symptoms
        • refer patients with suspected neutropenic sepsis for prompt assessment in secondary or tertiary care
        • manage suspect neutropenic sepsis as acute medical emergency and promptly offer empiric antibiotic treatment
    • considerations for modifications of treatment plan include individual patient's clinical circumstances and decision based on multidisciplinary team
    • follow RADS (Remote, Avoid, Defer, Shorten) principle to help plan individual patient's treatment
        • remote visits - use phone or video assessments instead of in-person contact
        • avoid treatment if little or no benefit, or if alternative treatment is available
        • defer treatment if clinically appropriate
        • shorten treatment - if treatment necessary, use shortest safe form
    • Reference - NICE COVID-19 Rapid Guideline on Delivery of Radiation Therapy

International Guidelines on Radiation Therapy for Breast Cancer

  • international guidelines on radiation therapy for breast cancer during COVID-19 pandemic
    • discuss risks and benefits of radiation therapy during COVID-19 pandemic with patients to facilitate shared decision making
    • omit radiation therapy for patients ≥ 65 years old or < 65 years old with relevant comorbidities with invasive breast cancer ≤ 30 mm with clear margins, grade 1-2, estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) negative, and lymph node negative who are planned for endocrine therapy
    • deliver radiation therapy in 5 fractions only for all patients requiring radiation therapy with lymph node negative tumors not requiring boost; options include
      • 28-30 Gy in 5 weekly fractions
      • 26 Gy in 5 daily fractions of 5.4 Gy for 1 week
    • omit boost radiation therapy to reduce fractions or complexity in most patients, unless ≤ 40 years old or > 40 years old with significant risk factors for local relapse
    • consider omitting lymph node radiation therapy in postmenopausal women requiring whole breast radiation therapy after sentinel lymph node biopsy and primary surgery for T1, ER positive, or HER2 negative grade 1-2 tumors with 1-2 macrometastases
    • offer moderate hypofractionation for all breast/chest wall and nodal radiation therapy, for example 40 Gy in 15 fractions for 3 weeks
    • PubMed32241520Clinical oncology (Royal College of Radiologists (Great Britain))Clin Oncol (R Coll Radiol)20200501325279-281279Reference - Clin Oncol (R Coll Radiol) 2020 May;32(5):279

Palliative Radiation Therapy for Oncologic Emergencies

Patient Evaluation and Triage

  • Oncologic_Diseaseconsiderations on palliative radiation therapy for oncologic emergencies in the setting of COVID-19 (Adv Radiat Oncol 2020 Apr 8 early online)05/08/2020 11:14:04 AMinitial clinical evaluation
    • assess through telemedicine history of present illness, performance status, current symptoms, and imaging studies
    • only arrange in-person history and physical examination (such as for neurologic evaluation or pain assessment) if crucial for decision making, limited to single radiation oncologist or advanced practice provider
    • discuss overall prognosis and goals of care with patient, primary medical oncologist, and supportive care specialists prior to planning radiation therapy
    • offer best supportive care with medical treatment alone if estimated life expectancy is days to weeks
    • PubMed32363243Advances in radiation oncologyAdv Radiat Oncol20200408Reference - Adv Radiat Oncol 2020 Apr 8 early onlinefull-text
  • patient triage
    • priority of radiation therapy is based on treatment indications
    • triage algorithm
      • if radiation therapy will likely alleviate symptoms
        • for patients with life expectancy of days to week, offer best supportive care
        • for patients with longer life expectancy
          • for patients with high priority, offer short course of palliative radiation therapy
          • for patients with medium or low priority, either
            • delay palliative radiation therapy
            • offer best supportive care
      • if radiation therapy would not alleviate symptoms, recommend other intervention
  • follow-up visits
    • visits through telemedicine encouraged to reduce risk of exposure
    • if patient requires urgent care, arrange nursing or physican visit
    • if face-to-face evaluation needed, adhere to proper social-distancing, handwashing, assessment of personal risk factors, and proper personal protective equipment use
    • PubMed32363243Advances in radiation oncologyAdv Radiat Oncol20200408Reference - Adv Radiat Oncol 2020 Apr 8 early onlinefull-text

Brain Metastases

  • palliative radiation therapy for brain metastases
    • prior to treatment, evaluate patient prognosis, histology, age, and competing risks and neurologic symptoms
    • offer stereotactic radiosurgery (SRS) for patients with good prognosis who are eligible for treatment of all or dominant lesions to delay or avoid whole brain radiation
    • for patients with urgent indications (such as progressive neurologic symptoms from multiple brain metastases or leptomeningeal disease), offer whole brain radiation
      • consider standard fractionation with 30 Gy in 10 fractions with memantine for patients with long-term survival to limit neurocognitive complications
      • consider shorter fractionation schedule (20 Gy in 5 fractions) rather than standard fractionation to limit exposure to COVID-19
    • consider observation only with best supportive care for patients with limited prognosis
    • PubMed32363243Advances in radiation oncologyAdv Radiat Oncol20200408Reference - Adv Radiat Oncol 2020 Apr 8 early onlinefull-text

Spinal Cord Compression

  • palliative radiation therapy for spinal cord compression
    • discuss with multidisciplinary team including neurosurgeon and evaluate degree of spinal cord compression and presence or absence of spinal instability
    • consider single-fraction radiation therapy (8 Gy in 1 fraction) rather than multifractionation given that single-fraction provides acceptable rates of palliation, allows for retreatment, and limits exposure to COVID-19; however, benefits and risks must be weighed prior to decision
    • PubMed32363243Advances in radiation oncologyAdv Radiat Oncol20200408Reference - Adv Radiat Oncol 2020 Apr 8 early onlinefull-text

Tumor Bleeding

  • palliative radiation therapy for tumor bleeding
    • radiation therapy dosing for tumor bleeding using 3.7 Gy in 4 fractions twice daily effective in pelvic malignancy and head and neck malignancy
    • consider 4 Gy in 5 fractions to limit radiation therapy to single treatment at end of day to decrease risk of exposure in patients with, or suspected to have COVID-19
    • PubMed32363243Advances in radiation oncologyAdv Radiat Oncol20200408Reference - Adv Radiat Oncol 2020 Apr 8 early onlinefull-text

Superior Vena Cava (SVC) Syndrome and Airway Obstruction

  • palliative radiation therapy for SVC syndrome and airway obstruction
    • SVC syndrome can lead to severe airway obstruction and hemodynamic instability
    • radiation therapy effective for hemoptysis but limited for dyspnea or cough
    • radiation therapy reported doses include 8.5 Gy in 2 fractions given one week apart or 4 Gy in 5 fractions given daily
      • 8.5 Gy in 2 fractions given one week apart useful for patients who may be discharged after first fraction
      • 4 Gy in 5 fractions given daily might have less spinal cord toxicity in patients with prior radiation therapy treatment or in those who may need future treatment
    • discuss with multidisciplinary team for patients requiring palliative radiation therapy for malignant airway obstruction (such as lung or mediastinal tumor)
    • PubMed32363243Advances in radiation oncologyAdv Radiat Oncol20200408Reference - Adv Radiat Oncol 2020 Apr 8 early onlinefull-text

Symptomatic Bone Metastases

  • palliative radiation therapy for symptomatic bone metastases
    • for patients with impending fracture
      • discuss with multidisciplinary team need for orthopedic surgery and/or interventional radiology for mechanical stabilization and role of radiation therapy
      • consider surgical intervention for impending fracture to reduce risk of prolonged hospitalization associated with pathologic fracture
    • consider radiation therapy if localized pain from metastases may require admission
    • for uncomplicated bone metastases, offer 8 Gy in 1 fraction
    • for patients with less urgent symptoms allowing time for treatment planning, consider single-fraction stereotactic body radiation therapy (SBRT) to provide faster and more durable palliation
    • PubMed32363243Advances in radiation oncologyAdv Radiat Oncol20200408Reference - Adv Radiat Oncol 2020 Apr 8 early onlinefull-text

Guidelines and Resources

Guidelines and Resources

Guidelines

International Guidelines

  • World Health Organization interim guidance on clinical management of severe acute respiratory infection when novel coronavirus infection is suspected can be found at WHO 2020 Mar 13
  • American Society for Radiation Oncology (ASTRO)-European SocieTy for Radiotherapy and Oncology (ESTRO)
    • practice recommendations for risk-adapted head and neck cancer radiotherapy during the COVID-19 pandemic: an ASTRO-ESTRO consensus statement can be found at ASTRO-ESTRO
    • practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: an ESTRO-ASTRO consensus statement can be found at ESTRO-ASCO
  • PubMed32275740BloodBlood20200410International Lymphoma Radiation Oncology Group (ILROG) emergency guidelines for radiation therapy of hematological malignancies during the COVID-19 pandemic can be found in Blood 2020 Apr 10 early online
  • Oncologic_Diseaseinternational guidelines on radiation therapy for breast cancer during COVID-19 pandemic (Clin Oncol (R Coll Radiol) 2020 May)05/04/2020 03:39:56 PMPubMed32241520Clinical oncology (Royal College of Radiologists (Great Britain))Clin Oncol (R Coll Radiol)20200501325279-281279international guidelines on radiation therapy for breast cancer during COVID-19 pandemic can be found in Clin Oncol (R Coll Radiol) 2020 May;32(5):279
  • PubMed32402764Journal of geriatric oncologyJ Geriatr Oncol20200510International Society of Geriatric Oncology (SIOG) global perspective on caring for older patients with cancer during the COVID-19 pandemic can be found in J Geriatr Oncol 2020 May 10 early online

United States Guidelines

  • Centers for Disease Control and Prevention (CDC) interim infection prevention and control recommendations for patients with suspected or confirmed COVID-19 in healthcare settings can be found at CDC 2020 Apr
  • National Comprehensive Cancer Network (NCCN) resources on COVID-19 can be found at NCCN
  • American Society of Clinical Oncology (ASCO) COVID-19 patient care information can be found at ASCO 2020
  • Society of Surgical Oncology (SSO) resources on COVID-19
  • American College of Surgeons (ACS) guidance on COVID-19 can be found at ACS 2020 Mar 24
  • American Society of Hematology (ASH) resources on COVID-19 can be found at ASH 2020 Apr 8
  • American Society of Breast Surgeons (ASBrS), National Accreditation Program for Breast Centers (NAPBC), National Comprehensive Care Network (NCCN), Commission on Cancer (CoC), and American College of Radiology (ACR) recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic can be found at The COVID-19 Pandemic Breast Cancer Consortium
  • American Society for Transplantation and Cellular Therapy (ASTCT)

United Kingdom Guidelines

  • Oncologic_DiseaseBritish Society for Hematology (BSH) guidance on COVID-19 (BSH 2020 Apr 22)05/06/2020 02:34:21 PMBritish Society for Hematology (BSH) guidance on COVID-19 can be found at BSH 2020 May 26
  • National Institute for Health and Care Excellence (NICE) COVID-19 rapid guidelines on
  • National Health Services (NHS) England-endorsed interim treatment change options during COVID-19 pandemic can be found at NHS 2020 Apr 27
  • UK Myeloma Forum (UKMF) guidance on management of patients with multiple myeloma during COVID-19 outbreak can be found at UKMF 2020 Mar 25

Canadian Guidelines

  • PubMed32267828Canadian Urological Association journal = Journal de l'Association des urologues du CanadaCan Urol Assoc J20200501145E154-E158E154Canadian Urologic Oncology Group (CUOG) and Canadian Urological Association (CUA) recommendations on managing prostate cancer during the COVID-19 pandemic can be found in Can Urol Assoc J 2020 Apr 28 early online
  • canadian recommendations on prioritizing systemic therapies for genitourinary malignancies during the COVID-19 pandemic can be found in Can Urol Assoc J 2020 May;14(5):E154

European Guidelines

Australian and New Zealand Guidelines

  • Oncologic_Diseaseinterim consensus guidance on managing hematology and oncology patients during the COVID-19 pandemic (Med J Aust 2020 May 13 early online)05/14/2020 03:16:55 PMPubMed32401360The Medical journal of AustraliaMed J Aust20200513interim consensus guidance on managing hematology and oncology patients during the COVID-19 pandemic can be found in Med J Aust 2020 May 13 early onlinefull-text; guidance is endorsed by
    • Australasian Leukaemia and Lymphoma Group
    • Australasian Lung Cancer Trials Group
    • Australian and New Zealand Children’s Haematology/Oncology Group
    • Australia and New Zealand Society of Palliative Medicine
    • Bone Marrow Transplantation Society of Australia and New Zealand
    • Cancer Society of New Zealand
    • Clinical Oncology Society of Australia
    • Haematology Society of Australia and New Zealand
    • National Centre for Infections in Cancer
    • New Zealand Cancer Control Agency
    • New Zealand Society for Oncology
    • Palliative Care Australia
  • Queensland Health COVID-19 cancer guidelines can be found at Queensland Health

Review Articles

References

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