A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: An International Collaborative Group

The outbreak of coronavirus disease 2019 (COVID-19) has rapidly spread globally since being identified as a public health emergency of major international concern and has now been declared a pandemic by the World Health Organization (WHO). In December 2019, an outbreak of atypical pneumonia, known as COVID-19, was identified in Wuhan, China. The newly identified zoonotic coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is characterized by rapid human-to-human transmission. Many cancer patients frequently visit the hospital for treatment and disease surveillance. They may be immunocompromised due to the underlying malignancy or anticancer therapy and are at higher risk of developing infections. Several factors increase the risk of infection, and cancer patients commonly have multiple risk factors. Cancer patients appear to have an estimated twofold increased risk of contracting SARS-CoV-2 than the general population. With the WHO declaring the novel coronavirus outbreak a pandemic, there is an urgent need to address the impact of such a pandemic on cancer patients. This include changes to resource allocation, clinical care, and the consent process during a pandemic. Currently and due to limited data, there are no international guidelines to address the management of cancer patients in any infectious pandemic. In this review, the potential challenges associated with managing cancer patients during the COVID-19 infection pandemic will be addressed, with suggestions of some practical approaches. IMPLICATIONS FOR PRACTICE: The main management strategies for treating cancer patients during the COVID-19 epidemic include clear communication and education about hand hygiene, infection control measures, high-risk exposure, and the signs and symptoms of COVID-19. Consideration of risk and benefit for active intervention in the cancer population must be individualized. Postponing elective surgery or adjuvant chemotherapy for cancer patients with low risk of progression should be considered on a case-by-case basis. Minimizing outpatient visits can help to mitigate exposure and possible further transmission. Telemedicine may be used to support patients to minimize number of visits and risk of exposure. More research is needed to better understand SARS-CoV-2 virology and epidemiology.

Reorganisation of medical oncology departments during the novel coronavirus disease-19 pandemic: a nationwide Italian survey

The novel severe acute respiratory syndrome coronavirus-2 pandemic is a global health problem, which started to affect China by the end of 2019. In Europe, Italy has faced this novel disease entity (named novel coronavirus disease [COVID-19]) first and severely. COVID-19 represents a significant hurdle for public health services and a potential harm for patients with cancer. The Collegio Italiano dei Primari Oncologi Medici (CIPOMO) is an Italian association of head physicians in oncology departments, which promotes working and research activities in oncology on a national basis. In the midst of the epidemic in Italy, the CIPOMO promoted a national survey aiming to evaluate the impact of COVID-19 on clinical activity of oncologists and the implementation of containment measures of COVID-19 diffusion. Overall, 122 head physicians participated in this survey, with a homogeneous distribution on the national territory. Results show that the following measures for oncologic patients have been promptly implemented through the whole country: use of protective devices, triage of patients accessing the hospital, delay of non-urgent visits and use of telemedicine. Results of this survey suggest that Italian oncology departments have promptly set a proactive approach to the actual emergency. Oncologists need to preserve the continuum of care of patients, as the benefit of ensuring a well-delivered anti-cancer treatment plan outweighs the risk of COVID-19 infection. International cooperation is an important starting point, as heavily affected nations can serve as an example to find out ways to safely preserve health activity during the pandemic.

Personalized Risk-Benefit Ratio Adaptation of Breast Cancer Care at the Epicenter of COVID-19 Outbreak

Northern Italy has been one of the European regions reporting the highest number of COVID-19 cases and deaths. The pandemic spread has challenged the National Health System, requiring reallocation of most of the available health care resources to treat COVID-19-positive patients, generating a competition with other health care needs, including cancer. Patients with cancer are at higher risk of developing critical illness after COVID-19 infection. Thus, mitigation strategies should be adopted to reduce the likelihood of infection in all patients with cancer. At the same time, suboptimal care and treatments may result in worse cancer-related outcome. In this article, we attempt to estimate the individual risk-benefit balance to define personalized strategies for optimal breast cancer management, avoiding as much as possible a general untailored approach. We discuss and report the strategies our Breast Unit adopted from the beginning of the COVID-19 outbreak to ensure the continuum of the best possible cancer care for our patients while mitigating the risk of infection, despite limited health care resources. IMPLICATIONS FOR PRACTICE: Managing patients with breast cancer during the COVID-19 outbreak is challenging. The present work highlights the need to estimate the individual patient risk of infection, which depends on both epidemiological considerations and individual clinical characteristics. The management of patients with breast cancer should be adapted and personalized according to the balance between COVID-19-related risk and the expected benefit of treatments. This work also provides useful suggestions on the modality of patient triage, the conduct of clinical trials, the management of an oncologic team, and the approach to patients' and health workers' psychological distress.

A Neuroendocrine Tumor Specialty Center in New Orleans' (NOLANETS) Response to Patient Care During the COVID-19 Pandemic

This commentary outlines the steps taken by the New Orleans Louisiana Neuroendocrine Tumor Specialists to minimize the risk of patient exposure to SARS‐CoV‐2 but to continue to provide safe, high‐quality care during the COVID‐19 pandemic.

Targeted sequencing in DLBCL, molecular subtypes, and outcomes: a Haematological Malignancy Research Network report

Based on the profile of genetic alterations occurring in tumor samples from selected diffuse large B-cell lymphoma (DLBCL) patients, 2 recent whole-exome sequencing studies proposed partially overlapping classification systems. Using clustering techniques applied to targeted sequencing data derived from a large unselected population-based patient cohort with full clinical follow-up (n = 928), we investigated whether molecular subtypes can be robustly identified using methods potentially applicable in routine clinical practice. DNA extracted from DLBCL tumors diagnosed in patients residing in a catchment population of ∼4 million (14 centers) were sequenced with a targeted 293-gene hematological-malignancy panel. Bernoulli mixture-model clustering was applied and the resulting subtypes analyzed in relation to their clinical characteristics and outcomes. Five molecular subtypes were resolved, termed MYD88, BCL2, SOCS1/SGK1, TET2/SGK1, and NOTCH2, along with an unclassified group. The subtypes characterized by genetic alterations of BCL2, NOTCH2, and MYD88 recapitulated recent studies showing good, intermediate, and poor prognosis, respectively. The SOCS1/SGK1 subtype showed biological overlap with primary mediastinal B-cell lymphoma and conferred excellent prognosis. Although not identified as a distinct cluster, NOTCH1 mutation was associated with poor prognosis. The impact of TP53 mutation varied with genomic subtypes, conferring no effect in the NOTCH2 subtype and poor prognosis in the MYD88 subtype. Our findings confirm the existence of molecular subtypes of DLBCL, providing evidence that genomic tests have prognostic significance in non-selected DLBCL patients. The identification of both good and poor risk subtypes in patients treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) clearly show the clinical value of the approach, confirming the need for a consensus classification.

ESMO Management and treatment adapted recommendations in the COVID-19 era: Pancreatic Cancer

The COVID-19 pandemic is challenging the capacities of health systems in many countries. National healthcare services have to manage unexpected shortages of healthcare resources that have to be re-allocated according to the principles of fair and ethical prioritisation, in order to maintain the highest levels of care to all patients, ensure the safety of patients and healthcare workers, and save as many lives as possible. Also, cancer care services have to pursue restructuring, following the same evidence-based dispositions. In this article, we propose a guidance to the management of pancreatic cancer during the pandemic, prioritised according to a three-tiered framework, and based on expert clinical judgement and magnitude of benefit expected from specific interventions. Since the availability of resources for diagnostic procedures, surgery and postoperative care, systemic therapy and radiotherapy may differ, the authors have separated the prioritisation analyses. The impact of postponing or abrogating cancer interventions on outcomes according to a high, medium or low priority scale is outlined and discussed. The implementation of healthcare services using telemedicine is explored; it reveals itself as functional and effective for limiting patients' need to travel to centres and thereby has the potential to reduce diffusion of SARS-CoV-2. Pancreatic cancer demands a considerable amount of medical resources. Therefore, the redefinition of its diagnostic and therapeutic algorithms with a rigorous method is crucial in order to ensure the highest quality of continuum of care in the broader context of the pandemic and the challenged healthcare systems.

Behind the numbers and the panic of a viral pandemic: fixed restrictive oncology guidance may jeopardize patients' survival

To protect cancer patients from COVID-19 exposure, prioritization strategies are being implemented at global level. Measures include use of tele-health services, deferring elective surgeries, delaying non life-saving therapies, interrupting maintenance and supportive care regimens and suspending screening and regular follow-up visits. Nonetheless, the risk of infection may not always outweigh oncology treatment benefit. Lives of most oncology patients depend on their ability to receive medical, surgical and radiotherapy care. Postponing screening, follow-up and radical surgeries increase patients' risk of developing metastatic disease. A viral pandemic lasts long time and exhibits seasonal and geographical variations. Though vaccines will be available only in the 2021, a global, aggressive, all-embracing and protracted slowdown of oncologic activities will severely jeopardize patients' outcomes. A present international oncologists' panel, ECPC and FAVO, strongly suggest that Hospital measures in a specific geographical area/Nation should be in line with the local epidemic, and restrictions adopted should be adapted and stratified over time.

The increasing value of eHealth in the delivery of patient-centred cancer care

The increasing use of eHealth has ushered in a new era of patient-centred cancer care that moves beyond the traditional in-person care model to real-time, dynamic, and technology-assisted assessments and interventions. eHealth has the potential to better the delivery of cancer care through improved patient-provider communication, enhanced symptom and toxicity assessment and management, and optimised patient engagement across the cancer care continuum. In this Review, we provide a brief, narrative appraisal of the peer reviewed literature over the past 10 years related to the uses of patient-centred eHealth to improve cancer care delivery. These uses include the addressal of symptom management, health-related quality of life, and other patient-reported outcomes across cancer care. In addition, we discuss the challenges of, and opportunities for, accessibility, scalability, and implementation of these technologies, important areas for further development, and future research directions.

How to Guarantee the Best of Care to Patients with Cancer During the COVID-19 Epidemic: The Italian Experience

Italy and the rest of the world are experiencing an outbreak of a novel beta‐coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). In this context, in Italy, we reorganized the National Health System and prioritized the clinical cancer care scenario, balancing risk of SARS‐CoV‐2 transmission versus the magnitude of clinical benefit deriving from a specific therapeutic approach. As initial actions, we recommended that routine screening be suspended and that patients with early and advanced cancer be treated as outpatients as much as possible and at the nearest medical center. Patients who need to be hospitalized for cancer treatment were protected from potential SARS‐CoV‐2 infection by creating a dedicated diagnostic and therapeutic internal pathway for cancer treatment. We implemented reorganization of the hospital networks, based on a hub‐and‐spoke design. Stronger personal protection was made available for patients with cancer. Because of the extreme burden created by COVID‐19, antitumor treatment was initiated only after considering patient performance status, comorbidities, biology of disease, and the likely impact of treatment on outcome. Treatment strategies were discussed in the context of a multidisciplinary tumor board. Treatment decision making balanced risk and benefits of treatment in the context of the specific pandemic level, on a case‐by‐case basis.

This commentary describes the reorganization of the Italian National Health System in response to the COVID‐19 epidemic, specifically as applied to best care for cancer patients at this critical time.

COVID-19 Guidance for Triage of Operations for Thoracic Malignancies: A Consensus Statement From Thoracic Surgery Outcomes Research Network

The extraordinary demands of managing the COVID-19 pandemic has disrupted the world’s ability to care for patients with thoracic malignancies. As a hospital’s COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.

Pivotal Considerations for Optimal Deployment of Healthy Volunteers in Oncology Drug Development

Oncology drug development is among the most challenging of any therapeutic area, with first-in-human trials expected to deliver information on both safety and activity. Until recently, therapeutic approaches in oncology focused on cytotoxic chemotherapy agents, ruling out even the possibility of enrolling normal healthy volunteers (NHVs) in clinical trials due to safety considerations. The emergence of noncytotoxic modalities, including molecularly targeted agents with more favorable safety profiles, however, has led to increasing numbers of clinical pharmacology studies of these agents being conducted in NHVs. Beyond rapid enrollment and cost savings, there are other advantages of conducting specific types of studies in NHVs with the goal of more appropriate dosing decisions in certain subsets of the intended patient populations, allowing for enrollment of such patients in therapeutic trials from which they might otherwise have been excluded. Nevertheless, the decision must be carefully weighed against potential disadvantages, and although the considerations surrounding conduct of clinical trials using NHVs are generally well-defined in most other therapeutic areas, they are less well-defined in oncology.

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer

The number of deaths from colorectal cancer in Japan continues to increase. Colorectal cancer deaths exceeded 50,000 in 2016. In the 2019 edition, revision of all aspects of treatments was performed, with corrections and additions made based on knowledge acquired since the 2016 version (drug therapy) and the 2014 version (other treatments). The Japanese Society for Cancer of the Colon and Rectum guidelines 2019 for the treatment of colorectal cancer (JSCCR guidelines 2019) have been prepared to show standard treatment strategies for colorectal cancer, to eliminate disparities among institutions in terms of treatment, to eliminate unnecessary treatment and insufficient treatment and to deepen mutual understanding between healthcare professionals and patients by making these guidelines available to the general public. These guidelines have been prepared by consensuses reached by the JSCCR Guideline Committee, based on a careful review of the evidence retrieved by literature searches and in view of the medical health insurance system and actual clinical practice settings in Japan. Therefore, these guidelines can be used as a tool for treating colorectal cancer in actual clinical practice settings. More specifically, they can be used as a guide to obtaining informed consent from patients and choosing the method of treatment for each patient. Controversial issues were selected as clinical questions, and recommendations were made. Each recommendation is accompanied by a classification of the evidence and a classification of recommendation categories based on the consensus reached by the Guideline Committee members. Here, we present the English version of the JSCCR guidelines 2019.

[Advanced practice nurse in oncology]

In many countries, health systems are facing major difficulties in maintaining the quality, continuity and safety of the care provision. That is why healthcare systems are being reformed across the world. These reforms are redefining the boundaries between medical and paramedical professions, and have resulted in the emergence of advanced practices, notably in nursing. The field of oncology is not immune from these issues. It must deal with the evolution of techniques and technologies, the increase in knowledge as well as an evolution in the needs of patients with cancer. In France, advanced practice nurses appear to have found their place in oncology as they can take an active part in the priorities fixed by the different national cancer plans, notably through the prevention role which is one of the objectives.

Les réseaux territoriaux de cancérologieTerritorial oncology networks

In the often long and difficult care pathway of patients with cancer, the oncology care network has an important role to play. Of all the coordination programmes, it is the one which enables the patient's medical and psychosocial situation to be constantly evaluated throughout their illness.

Immunization of Children with Cancer in India Treated with Chemotherapy - Consensus Guideline from the Pediatric Hematology-Oncology Chapter and the Advisory Committee on Vaccination and Immunization Practices of the Indian Academy of Pediatrics

JUSTIFICATION

Children with cancer need to be immunized against the common vaccine-preventable diseases after completion and sometimes during ongoing treatment of cancer. However, the immunization schedule for these children needs to be altered due to disease and treatment related immune-suppression. Consequently, there are many guidelines/practice statements from around the world to address this issue, however, there is no such comprehensive guideline from India catering to the need of Indian children with cancer.

PROCESS

A guideline was drafted after reviewing the available literature. The draft guideline was discussed and modified in a meeting attended by pediatric oncologists from the PHO chapter and vaccine experts from the ACVIP of the IAP. Subsequently, the modified draft was reviewed and recommendations were finalized.

OBJECTIVES

To review the current evidence and generate a nationally relevant guideline for immunization of children receiving chemotherapy for cancer.

RECOMMENDATIONS

Live vaccines are contraindicated during and up to 6 months after end of chemotherapy. Non-live vaccines are also best given after 6 months from the end of treatment for durable immunity. Annual inactivated influenza vaccine is the only vaccine recommended for all children during chemotherapy whereas hepatitis B vaccine is recommended only for previously unimmunised children with risk of transfusion associated transmission of infection. Post-treatment re-immunization/catch-up schedule largely depends on the pre-chemotherapy immunization status. Sibling immunization should continue uninterrupted except for oral polio vaccine which needs to be substituted by the injectable vaccine. Inactivated influenza vaccine is recommended and varicella vaccine is encouraged for all contacts including siblings.

Exploring the impact and experience of fractional work in medicine: a qualitative study of medical oncologists in Australia

OBJECTIVES

Fractional (part-time) appointments are becoming more commonplace in many professions, including medicine. With respect to the contemporary oncological landscape, this highlights a critical moment in the optimisation of employment conditions to enable high-quality service provision given growing patient numbers and treatment volume intensification. Data are drawn from a broader study which aimed to better understand the workforce experiences of medical oncologists in Australia. This paper specifically aims to examine a group of clinicians' views on the consequences of fractional work in oncology.

DESIGN

Qualitative, one-on-one semistructured interviews. Interview transcripts were digitally audio recorded and transcribed verbatim. Data were subject to thematic analysis supported by the framework approach and informed by sociological methods and theory.

SETTING

New South Wales, Australia.

PARTICIPANTS

Medical oncologists (n=22), including 9 female and 13 male participants, at a range of career stages.

RESULTS

Four key themes were derived from the analysis: (1) increasing fractional employment relative to opportunities for full-time positions and uncertainty about future opportunities; (2) tightening in role diversity, including reducing time available for research, mentoring, professional development and administration; (3) emerging flexibility of medical oncology as a specialty and (4) impact of fractional-as-norm on workforce sustainability and quality of care.

CONCLUSION

Fractional appointments are viewed as increasing in oncology and the broader consequences of this major shift in medical labour remain unexamined. Such appointments offer potential for flexible work to better suit the needs of contemporary oncologists; however, fractional work also presents challenges for personal and professional identity and vocational engagement. Fractional appointments are viewed as having a range of consequences related to job satisfaction, burnout and service delivery. Further research is needed to provide a critical examination of the multiple impacts of workforce trends within and beyond oncology.

Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA.

AIMS

We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting.

METHODS

A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics.

RESULTS

One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services.

CONCLUSION

Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.

Global Consultation on Cancer Staging: promoting consistent understanding and use

Disease burden is the most important determinant of survival in patients with cancer. This domain, reflected by the cancer stage and codified using the tumour-node-metastasis (TNM) classification, is a fundamental determinant of prognosis. Accurate and consistent tumour classification is required for the development and use of treatment guidelines and to enable clinical research (including clinical trials), cancer surveillance and control. Furthermore, knowledge of the extent and stage of disease is frequently important in the context of translational studies. Attempts to include additional prognostic factors in staging classifications, in order to facilitate a more accurate determination of prognosis, are often made with a lack of knowledge and understanding and are one of the main causes of the inconsistent use of terms and definitions. This effect has resulted in uncertainty and confusion, thus limiting the utility of the TNM classification. In this Position paper, we provide a consensus on the optimal use and terminology for cancer staging that emerged from a consultation process involving representatives of several major international organizations involved in cancer classification. The consultation involved several steps: a focused literature review; a stakeholder survey; and a consultation meeting. This aim of this Position paper is to provide a consensus that should guide the use of staging terminology and secure the classification of anatomical disease extent as a distinct aspect of cancer classification.