Oncology Organizations Issue Guidance for Coronavirus

Marcus Neubauer, MD

Physicians treating patients with cancer may want to consider postponing surgeries or altering therapy plans because of the threat that the coronavirus (COVID-19) poses to this population, according to leading oncology experts. The evidence base to support best practices amidst the COVID-19 pandemic is both limited and evolving and several organizations have been working to provide access to the most up-to date resources.

Although the risk of COVID-19 to cancer patients is unknown, the potential threat of COVID-19 to immunocompromised patients as a result of their disease or the treatment is thought to be significant.¹ Early published reports from China on the outcomes of patients with cancer infected with COVID-19 indicated 3.5 times higher risk of mechanical ventilation, ICU admission, or death compared with patients without cancer.

In the United States, there have been over 7000 confirmed cases of COVID-19, with over 100 deaths.² According to the Centers for Disease Control and Prevention (CDC), most COVID-19 illness is mild, but a recent study out of China suggests serious illness occurs in 16% of cases. Older people and those with severe chronic medical conditions—such as heart disease, lung disease and diabetes—seem to be at higher risk of developing serious COVID-19 illness.³

“Oncology professionals will play a vital role in caring for individuals who are particularly vulnerable to COVID-19,” Marcus Neubauer, MD, chief medical officer for The US Oncology Network told OncLive^® in an email. “These patients will continue to need treatment for cancer or blood disorders, yet they may also present symptoms of the novel viral infection.”

In a soon-to-be-released paper, experts from the Seattle Cancer Care Alliance (SCCA)—of the National Comprehensive Cancer Network (NCCN)—share advice to oncology care physicians on how to provide optimal cancer care during the COVID-19 pandemic. The authors highlight the importance of organizational structure, preparation, agility, and a shared vision for continuing to provide cancer treatment to patients in the face of uncertainty and rapid change.¹

“Responding quickly and confidently to the COVID-19 crisis is the healthcare challenge of our generation,” F. Marc Stewart, MD, medical director, SCCA, said in a press release. “Our overarching goal is to keep our cancer patients and staff safe while continuing to provide compassionate, high-quality care under circumstances we’ve never had to face before.”

In a section concerning treatment decisions the SCCA recommends that for patients with solid tumors the adjuvant therapy with curative intent should proceed. In terms of scheduled surgical procedures, the panel states that while cancer-related surgery is not considered “elective” and does not fall under the guidance for a ban on elective procedures, interventions should be prioritized. For example, surgeon-to-patient phone calls may better optimize which patients with early-stage hormone receptor—positive breast cancer are best suited to continue on prolonged endocrine therapy and delay surgery from those who are at a higher risk, such as patients with an aggressive hematologic malignancy who require stem cell transplantation. Further, enrollment in clinical trials will likely be limited to those who are most likely to benefit from treatment.¹

The CDC is also implementing its pandemic preparedness and response plans and working on multiple fronts to issue specific guidance to better prepare communities to respond to local spread of COVID-19. Although not specific to oncology care providers, the CDC’s site includes current interim guidances on evaluating and testing people for COVID-19 and on the clinical care of people with COVID-19, as well as resources for healthcare professionals caring for patients with COVID-19. There is also information about how healthcare professionals can reduce their own risk of exposure to COVID-19, and includes guidance and resources on infection control, isolation protocols, and personal protective equipment.⁴

“One best practice is to screen all patients who enter the clinic and triage those who are sick,” Neubauer added in his response. “Keeping staff safe and healthy must be a top priority so these professionals can continue to come to work and care for patients. The best way to minimize COVID-19 exposure is with proper personal protective equipment, which is needed by many healthcare professionals at this time. The challenges will be many, but oncology professionals are dedicated, willing and determined to keep their doors open to provide life-saving treatment during this global health crisis.”

American Society of Clinical Oncology (ASCO)

ASCO’s coronavirus resources website aims to provide oncology professionals with information and links about COVID-19. In general, ASCO is encouraging anyone caring for patients with cancer to follow the existing CDC guidance where possible. After collating questions from oncology professionals, ASCO also developed a frequently asked questions (FAQs) section and issued responses based on PubMed search of the relevant literature as well as available information from the CDC, WHO, and others.

There is no specific guidance with respect to COVID-19 testing in patients with cancer and ASCO recommends that clinicians follow local and state public health directives and guidance on who should be tested and how the tests should be conducted should be followed. Scheduling routine follow-up visits for patients not on active anticancer treatment should be considered for postponement or conducted via telemedicine. To avoid unnecessary visits to the clinic, at-home routine lab sample collection should be considered.

ASCO says clinicians and patients will need to make individual determinations based on the potential harms of delaying needed cancer-related surgery. Additionally, ASCO recommends that patients scheduled for immunosuppressive therapy should be screened for COVID-19 prior to therapy. In addition, delaying an allogeneic stem cell transplant may be reasonable, particularly if the patient’s malignancy is controlled with conventional treatment. Until further data are available, clinicians are encouraged to follow the recommendations provided by the American Society of Transplantation and Cellular Therapy (ASTCT); https://www.astct.org/connect/astct-response-to-covid-19) and the European Society for Blood and Marrow Transplantation (EBMT) with respect to stem cell transplantation (https://www.ebmt.org/ebmt/news/coronavirus-disease-covid-19-updated-ebmtrecommendations-8th-march-2020).⁵

Additionally, there is no specific evidence or published guidance to support delaying or interrupting adjuvant chemotherapy. Clinical decisions should be individualized considering factors such as the risk of cancer recurrence if adjuvant chemotherapy is delayed, modified or interrupted, the number of cycles of adjuvant chemotherapy already completed and the patient’s tolerance of treatment.

If a patient is diagnosed with COVID-19 on active anticancer treatment, ASCO states to follow the standard clinical management plans for delay or modification of cancer treatments in patients with active infection.

For the latest information and guidance documents, visit https://www.asco.org/asco-coronavirus-information

Community Oncology Alliance (COA)

COA is providing practice resources and protocols on its COVID-19 resource page. Oncology providers can sign up for a free listserv that allows practice professionals to ask questions, network with each other, and share resources.

Available resources include access to data as they become available. One such study from China evaluated the efficacy of tocilizumab as a treatment in severe patients diagnosed with COVID-19.⁶ In this study, patients diagnosed as severe or critical COVID-19 were given tocilizumab in addition to routine therapy. Body temperature of all patients returned to normal on day 1 after receiving tocilizumab and remained stable then after. Fifteen of the 20 patients (75.0%) had lowered their oxygen intake and 1 patient required no oxygen therapy. CT scans manifested that the lung lesion opacity absorbed in 19 patients (90.5%). The percentage of lymphocytes in peripheral blood, which decreased in 85.0% patients (17/20) before treatment returned to normal in 52.6% patients (10/19) on day 5 after treatment. Abnormally elevated C-reactive protein decreased significantly in 84.2% patients (16/19). No obvious adverse reactions were observed, and the authors stated that clinical symptoms of all patients improved with good prognosis.

Another available resource developed by the National Foundation for Infectious Diseases and the Alliance for Aging Research, aims to answer questions about why older people and people with health conditions are more at risk for COVID-19 infection as well provide guidance on best practices for this patient population.⁷ Compromised immune systems are more common in older populations, as well as in those with chronic medical conditions, making this population more susceptible to serious complications from the virus. Recommendations for this population include asking your physician or local pharmacy if ordering online is an available option, looking into online grocery orders, and guidance on what steps to take if symptoms arise.

For more information, visit https://communityoncology.org/coronavirus-covid-19-practice-resources-and-protocols/

National Comprehensive Cancer Network

NCCN Member Institutions are sharing insights and information to help providers respond to COVID-19. These include a factsheet for patients and visitor policy from Huntsman Cancer Institute. Included on the Huntsman site is a document to help oncology care professionals discuss COVID-19 with their patients.⁸ It advises physicians and patients to limit visitors, practice good hygiene, and watch for signs of infection. Patients are advised to contact their physician if they experience a fever higher than 100.3 degrees F, they feel short of breath, or they develop a cough, runny nose, or congestion.

Self-screen signs from the University of California San Francisco are also available for download. Provided in English, Spanish, Russian, Simplified and Traditional Chinese, the signs advise anyone with a cough, fever, or difficulty breathing to place a mask on immediately and instruct viewers to inform the front desk of any travel outside of the United States in the past few weeks. The NCCN plans to update the site as more resources become available.

For more information https://www.nccn.org/covid-19/default.aspx

• The American Medical Association: The AMA has several resources for physicians: a physician’s guide to COVID-19 and FAQs, past publications on vaccine development, infection control, and public health preparedness. Also featured are research papers on the epidemiology of COVID-19, clinical management, health preparedness, and information for patients. For more information, visit https://www.ama-assn.org/delivering-care/public-health/covid-19-2019-novel-coronavirus-resource-center-physicians
• The Food and Drug Administration: The FDA’s resource page includes updates on the latest research, including potential COVID-19 diagnostics, FAQs, and the agency’s role in developing medical countermeasures. The FDA issued on March 20 a new guidance for conducting clinical trials during the COVID-19 pandemic.⁹ The agency recognizes that challenges may arise, for example, from quarantines, site closures, travel limitations, interruptions to the supply chain for the investigational product. The FDA is aware that protocol modifications may be required, and that there may be unavoidable protocol deviations due to COVID-19. For more information, visit https://www.fda.gov/emergency-preparedness-and-response/mcm-issues/coronavirus-disease-2019-covid-19
• The World Health Organization: WHO is gathering the latest scientific findings and knowledge on COVID-19 and compiling it in a database, including an update on research, an international clinical trials registry, and a database of publications on COVID-19. For more information, visit https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov

References

1. Ueda M, Martins R, Hendrie Paul, et al. Managing cancer care during the COVID-19 pandemic: agility and collaboration toward a common goal [published online March 17, 2020]. J Natl Compr Canc Netw. doi: 10.6004/jnccn.2020.7560.
2. Johns Hopkins University & Medicine coronavirus resource center. coronavirus.jhu.edu/map.html. Accessed March 18, 2020.
3. Coronavirus disease 2019 (COVID-19). Centers for Disease Control and Prevention. www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html. Accessed March 18, 2020.
4. Information for healthcare professionals. Centers for Disease Control and Prevention. www.cdc.gov/coronavirus/2019-ncov/hcp/index.html. Accessed March 18, 2020.
5. COVID-19 clinical oncology frequently asked questions (FAQs). American Society of Clinical Oncology. asco.org/sites/new-www.asco.org/files/content-files/blog-release/pdf/COVID-19-Clinical Oncology-FAQs-3-12-2020.pdf. Accessed March 18, 2020.
6. Xu X, Han M, Li, T, et al. Effective treatment of severe COVID-19 patients with tocilizumab. chinaXiv:202003.00026. doi: 10.12074/202003.00026.
7. Common questions and answers about COVID-19 for older adults and people with chronic health conditions. Alliance for Aging Research. agingresearch.org/common-questions-and-answers-about-covid-19-for-older-adults-and-people-with-chronic-health-conditions/. Accessed March 18, 2020.
8. COVID-19 and cancer patients. Huntsman Cancer Institute. nccn.org/members/committees/bestpractices/files/HCI-covid19-cancer-patients-factsheet.pdf. Accessed March 18, 2020.
9. FDA guidance on conduct of clinical trials of medical products during COVID-19 pandemic. Food and Drug Administration. bit.ly/38WVr13. Accessed March 20, 2020.