covid 19

1. Cancer Care during
COVID-19
pandemic
DR. R. RAJKUMAR D.M.
CONSULTANT MEDICAL ONCOLOGIST
VELAMMAL SPECIALITY HOSPITAL

3. Prevalence of
Coronavirus in
India
Worldometer. COVID-19 Coronavirus Pandemic. 2020. Available at: www.worldometers.info/coronavirus/ (accessed 128h April 2020)

5. What we know about COVID-19?
According to the WHO, the virus comes from a family of Coronaviridae (CoV). It is officially
named as SARS-CoV-2
Coronaviruses have caused everything from the common cold to the well-known Middle East
Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV).
It’s a novel strain (nCoV) discovered in 2019, transmitted between both animals and people with
incubation period of 2-14 days after exposure.
Human-human transmission is more common
No known treatment or immunization

6. How do people get infected

11. Pandemic

13. Evidences suggest ….
 Individuals with cancer are more susceptible to infection than individuals without cancer .Such
patients might be at increased risk of COVID-19 and have a poorer prognosis.
While timely screening is important, the need to prevent the spread of coronavirus and to
reduce the strain on the medical system is more important right now.
Routine visits to health facilities are safe and regular screening tests should be rescheduled after
the restrictions to slow the spread of COVID-19 are lifted.
Cancer guidelines during the COVID-19 pandemic. www.thelancet.com/oncology Published online April 2, 2020.

15. Cancer patients in SARS-CoV-2 infection: a nationwide analysis
in China
A prospective cohort study was conducted among 2007 cases from 575 hospitals to monitor
COVID-19 cases throughout China.
 1% of the total COVID-19 cases had a history of cancer, which was higher than the incidence of
cancer in the overall Chinese population i.e. patients with cancer might have a higher risk and
poorer outcomes from COVID-19 than individuals without cancer.
 Three major strategies were proposed for patients with cancer in this COVID-19 crisis -
1. An intentional postponing of adjuvant chemotherapy or elective surgery for stable cancer
should be considered in endemic areas.
2. Stronger personal protection provisions should be made for patients with cancer or cancer
survivors.
3. More intensive surveillance or treatment should be considered when patients with cancer
are infected with SARS-CoV-2, especially in older patients or those with other comorbidities.
Liang W.Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.The Lancet Oncology 2020;21(3);335-337

16. AIM
 Reduce exposure to CoV(high CFR)
 Not to loose control over cancer – intact anti cancer efficacy.
 Reduce work load – manpower and infrastructure become available for COVID treatment.

17. Cancer-specific case fatality rate
 Most comprehensive data available to date is a Report of the WHO-China Joint Mission on
Coronavirus Disease.
 This report indicates that in China, as of the data cut-off (February 20) the case fatality rate for
patients with cancer as a comorbid condition and laboratory confirmed infection was 7.6%.
 This is as compared to: overall 3.8%, no comorbid condition 1.4%, cardiovascular disease 13.2%,
diabetes 9.2%, hypertension 8.4%, chronic respiratory disease 8.0%.
https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf

18. Guidance from ASCO on Cancer patients care during the COVID-
19 outbreak
 Elective surgeries at inpatient facilities to be rescheduled if possible.
 Systemic treatments like chemotherapy and immunotherapy, leave cancer patients vulnerable
to infection. But stopping anticancer or immunosuppressive therapy is not recommended, as
there is no direct evidence to support changes in regimens during the pandemic.
 For patients already in deep remission and receiving maintenance therapy, stopping treatment
may be an option.
 Patients advised to switch from IV to oral therapies, which would decrease the frequency of
clinic visits.
https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19

19. ASCO GUIDELINES
 If local coronavirus transmission is an issue at a particular cancer center, options may include taking a 2-week
treatment break or arranging treatment at a different facility.
 Evaluate if home infusion is medically and logistically feasible.
 In some settings, delaying or modifying adjuvant treatment presents with some risk and these risks will need to be
considered in light of the magnitude of potential benefits.
 There is an ongoing active research for the use of prophylactic antiviral therapy in cancer patients undergoing active
therapy.
https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19

20. Can/should potentially immunosuppressive therapy be stopped,
delayed, or interrupted?
 There is no direct evidence to support changing or withholding chemotherapy or
immunotherapy in patients with cancer. Therefore, routinely withholding critical anti-cancer or
immunosuppressive therapy is not recommended.
Clinical decisions should be individualized that consider factors such as the risk of cancer
recurrence if therapy is delayed, modified or interrupted; the number of cycles of therapy
already completed; and the patient’s tolerance of treatment.
https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19

21. Impact of concomitant medications on covid-19 outcomes
Anecdotal and controversial information suggests that use of RAAS antagonists (e.g., ACE
inhibitors) may increase the risk of acquiring COVID-19 or reduce the severity of the disease in
those infected.
https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19

22. Can/should surgery be cancelled or delayed?
 CDC’s guidance for health care facilities suggests that “elective surgeries” at in-patient facilities
be rescheduled if possible.
 ACS has issued guidance provides additional advice related to triage of patients for surgery.
 Clinicians and patients will need to make individual determinations based on the potential
harms of delaying needed cancer-related surgery; in many cases these surgeries cannot be
considered “elective”.
https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19

23.  If surgery requires post-operative intensive care, the current capacity of the intensive care units
available for that care should be considered as part of decision making.
In some situations where neoadjuvant therapy is available but not routinely considered, it may
be reasonable to consider neoadjuvant therapy instead of surgery or simply delaying surgery.
 Neoadjuvant therapy that requires clinic visits and clinician-patient contact or that itself is
immunosuppressive is associated with risks to the patient that must also be considered.
https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19

24. Guidance from ESMO on Cancer patients care during the COVID-19 outbreak

25. Guidance from ESMO on Cancer patients care during the COVID-
19 outbreak
 Improving tele-consultation services for stable patient, reducing clinic visits, and
switching to subcutaneous or oral therapies, rather than intravenous ones, when
possible.
 Adequate training on prevention and control of infection is key to make sure that all
medical staff stay safe, thus ensuring safe cancer care environments for patients.
 At work, the use of PPE’s is recommended and at home, Basic protective measures.

27. A framework for critical care triage

28. Initial approach to critically ill
patients with suspected COVID-19
Phua J. Intensive care management of COVID-19: challenges and
recommendations. The Lancet Respiratory Medicine. Published: April 06, 2020

30. Guidance from ESSO on Cancer patients care during the COVID-
19 outbreak
 All new cancer patients will need to be managed, appropriate consultations should be
undertaken by telephone or video call as much as possible.
 Triage all referrals. Advised against seeing patients older than 70 years in the clinic, unless
urgent.
.Cases should be prioritised by the clinical teams and coordinated centrally.
 No surgery for benign disease or risk-reduction should be performed.

31. MDT/tumour board Meetings should be done remotely via video conferencing or telephone. If a
face to-face MDT is felt to be urgent and necessary, aim to minimise the number of staff present
to one surgeon, one oncologist, one pathologist, one radiologist and one nurse.
ESSO also emphasised the need to protect and preserve surgical workforce.
Rest and recuperation, as well as psychological support should be factored into planning.

32. Telephone/web-mediated consulting should be improved to reinforce support to patients
remotely as the impact of the COVID-19 on cancer patients may be high in terms of anxiety,
fear and psychological distress.

33. ASTRO Guidelines for Radiation Oncologist’s during the COVID-
19 outbreak
 Appropriate evidence-based guidelines should be followed while striving for the shortest possible
course of radiotherapy e.g., single-fraction treatment for bone pain, hypofractionation where
appropriate.
 Encourage routine non-95, surgical masking of radiation therapists for all patients.
 New patient consults may be triaged on a case-by-case basis according to the urgency of the
situation post discussion with the referring physician.
All patients in follow-up should be screened prior to their appointments, with consideration to delay
the appointment or use remote (telemedicine) follow-up, if appropriate.

35.  Patients with breast and prostate cancer who have just completed their course of radiation and
have none/mild post-treatment symptoms should not be scheduled for follow-up visits < 3-
months, and remote follow-up is encouraged.
 All other patients should be scheduled on a case-by-case basis in consultation with their
physician.
 For asymptomatic patients, follow-up appointments every 3 to 6 months may be appropriate.
 Post treatment symptomatic patients, regardless of the interval since completing treatment,
should receive follow-up as scheduled.

36. ASTCT and EBMT guidelines for Hematologists during the
COVID-19 outbreak
 “Different cancers produce immune suppression to different extents”.
 Hematological malignancies often directly compromise the immune system unlike other solid
tumors, wherein immune suppression is not treatment-related.
 Due to the rapidly changing situation, access to a stem cell donor might be restricted either due to
the donor becoming infected, logistical reasons at the harvest centers in the middle of a strained
health-care system, or travel restrictions across international borders.
 It is strongly recommended to have secured stem cell product access by freezing the product before
start of conditioning or to have an alternative donor as a back-up.

37. Issues with Allo transplant
Donor can be infected.
No bed available for donor.
Travel issues
CRYOPRESERVATION – before starting conditioning

38. USFDA guidance on managing clinical trials during the time of
COVID-19
 On the regulatory side, the USFDA has issued guidance on managing clinical trials during the
time of COVID-19, as have the US National Cancer Institute and the European Medicines Agency
 If trial participants need to be isolated, access to public places is limited, or health-care
professionals have to take up different duties. It suggested that trial organisers consider
suspensions, extensions, and postponements, depending on circumstances.
Cancer guidelines during the COVID-19 pandemic. www.thelancet.com/oncology Published online April 2, 2020.

39. Issues with Clinical trials
 Need for isolation
 Lack of staff
Suggestions:
Suspend
Extend
Postpone

41. Conclusions
 COVID-19 pandemic has swamped current health-system capacity.
Avoid unnecessary exhaustion of resources – infrastructure/blood products/ manpower.
 Higher CFR in cancer patients.
 Judicious postponing of anti cancer treatment to manage risk benefit ratio.
Change to oral/subcut injections when feasible.
 Support patient’s emotional wellbeing and ensure adequate psychosocial support throughout the pandemic.
Treatment decisions during the COVID-19 pandemic will rely on the precautionary principle, transparent and
evidence-based prioritization of cases for triage.

42. Thank You