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Clinical Infection & Immunity

Review

Volume 5, Number 3, September 2020, pages 55-58

Preliminary Approach to Cancer Patient Care During Unprecedented COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) caused by the pestilent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, succumbing millions of death in short span, has stumbled the entire global healthcare lobby. Cohort studies from China and Italy showed that mostly geriatrics and those having comorbidities such as diabetes, heart disease and malignancies, are the most vulnerable population to be ambushed by this infection [1-3].

Amid ongoing nationwide lockdowns, providing continuous cancer care to the patients was an arduous task for the oncologists across the world. Regional Cancer Centre (RCC) Rohtak is the only cancer center in government set-up catering around 25 million people of Haryana State and neighboring regions too [4]. Each year, approximately 4,000 new cancer patients are enrolled for the cancer treatment in this center and most of them belong to poor socioeconomic strata. To maintain a balance between incessant cancer care and preventing the spread of COVID-19 among such immunocompromised patients was the real challenge. For this a dual approach strategy was formulated keeping in view about the sagacious use of available assets, accessibility and compliance of the patients to the facilities, financial constraints and types of patients reporting in RCC.

Standard operating procedures (SOPs) were formulated by the institute, reckoning the COVID-19 situation and need of cancer patients.

All the attributes of the SOPs formulated were enforced in our RCC. One out of the two entrances was earmarked for patient entry and the other was exclusively for the hospital staff. Outdoor registration of the patients was shifted to a separate bigger aerated room, easily accessible to patients and close to the main entrance of the cancer center. Extra security personnel were engaged for regulating the patient entry and ensuring social distancing among the patients. White circles at a distance of 1 m, on the floor of RCC building, were painted, for ensuring social distancing, among the patients waiting outside the registration unit, outdoor clinics, indoor ward and pharmacy area. Regular sanitization of outpatient clinics and inpatient wards with 1% sodium hypochlorite solution was done to decrease the risk of spread of COVID-19 among patients and medical staff. Strict implementation of these SOPs was ensured in our RCC.

Maximum patients treated on a teletherapy machine were reduced and at a time not more than three patients were allowed in the waiting area.

Entire radiation oncology staff like oncologists, nurses, pharmacists, radiation therapists, bearers, record-keepers, sanitation workers, etc. coming in direct contact with patients or surfaces, were given all the necessary personal protective equipment like N95 masks, surgical caps, gloves, aprons, face shields, hand rub sanitizer (with at least 70% ethanol or isopropyl alcohol), etc. and the regular supply of these was ensured. Instructions regarding proper hand, face and respiratory hygiene were explained to the radiation staff in entirety. Division of duty hours and rotational duties were initiated among doctors and paramedics to reduce exposure time to everyone. Susceptible staff members like pregnant females, elderly or those having any comorbidities were allotted administrative work, thus avoiding direct contact with patients.

Few safety measures for patients were adopted like outpatient department (OPD), so registration timings were reduced to 9 am to 11:30 am to limit the daily patient load and ensure proper social distancing norms. At the main entrance of the center, thermal screening of all the patients was done and their travel history was also recorded. Five patients at a time were allowed to enter the OPD clinic and another five were distributed with numbered tokens and kept in the waiting area of RCC premises. Wearing mask was made mandatory both for patients and their attendants. Importance of wearing masks, social distancing and proper hand hygiene techniques were displayed with the help of charts in the waiting area for the patients.

Some treatment-related modifications were done like triaging of patients based on urgency of immediate intervention in the form of radiation or chemotherapy, required/beneficial or not. Individualistic approach was adopted for each patient based on various factors like site of malignancy, stage of disease, age, general condition and presence of other co-morbid conditions, etc. A point-based scoring system based on checklist prepared in the RCC was used for risk categorization of all cancer patients, for COVID-19 testing (Table 1).

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Table 1. Point-Based Scoring Checklist for COVID-19 Risk Categorization

Patients with score of > 6 were of high risk category and were subjected to COVID-19 testing and in this subset of patients, chemotherapy and radiotherapy were started only when their COVID-19 test report came negative. Patients with score ≤ 6 were taken up for active oncological intervention without COVID-19 testing. Wherever applicable, hypofractionated regimens of radiation were utilized to decrease workload of patients on radiation machines. Oral metronomic chemotherapy was preferred wherever feasible, to prolong the follow-up duration. After chemotherapy, patients were discharged after day care observation to reduce number of indoor admissions. Intractable pain, either due to advanced disease, painful bone metastasis or any other reason was treated by palliative radiotherapy and/or oral opioids in divided doses or buprenorphine transdermal patches. If the general condition of the patient was too poor to tolerate any active oncological intervention, then best supportive care at home/preferably telemedicine was advised. Repeated referral to radiodiagnosis department for imaging was avoided and preference was given to clinical examination. Teleconsultation as a tool was adopted to prevent repeated OPD visits for minor ailments, queries or psychological support.

Some cancer site-specific modifications were also incorporated to adjust the new norms, e.g., in head and neck cancers (HNCs), the most common cancer group reporting to RCC [5], and radical chemoradiation was reserved for probable good responders like patients with early stage and young age. Most of the locally advanced head and neck cancer (LAHNC) patients were given palliative radiation with 20 Gy in 5 fractions over 5 days and then reviewed after 1 month for further supplementary radiation or split course accelerated hypofractionated radiotherapy (SCAHRT). Oral metronomic chemotherapy was the expedient mode of treatment in recurrent, residual and metastatic HNC.

In breast cancer, hypofractionated radiation therapy with either 40 Gy in 15 fractions over 3 weeks or 26 Gy in 5 fractions over 1 week was adopted as adjuvant treatment wherever indicated [6, 7]. Oral metronomic chemotherapy was prescribed in recurrent and/or metastatic triple-negative breast cancer (mBC and TNBC). Patients on hormone therapy were given 3 months upfront medicines to minimize their follow-up.

Lung cancer is the most common type of cancer susceptible to COVID-19 infection as demonstrated by three Chinese cohorts, thus hypofractionated radiation therapy was adopted as preferred regimens [8, 9].

In gastrointestinal cancers like esophagus, induction chemotherapy was considered prior to concomitant chemoradiation in potentially curable cases, and hypofractionated radiation with Walsh regimen of 40 Gy in 15 fractions over 3 weeks was adopted as preferred radiation regimen [10, 11]. Locally advanced disease especially with severe pain, dysphagia or bleeding was treated with palliative radiation as 20 Gy/5 fractions/5 days or 8 Gy single session. In hepatocellular carcinoma, molecular targeted therapy (e.g. sorafenib) was used. Substitution of oral capecitabine was done with 5-fluorouracil whenever possible, and short course neoadjuvant radiotherapy was given in carcinoma rectum while delaying surgery [12].

Three monthly androgen deprivation therapy was given to patients of carcinoma prostate. While in case of soft tissue sarcomas, neoadjuvant radiation preferably hypofractionated regimens were given to accommodate the delay in definitive surgery.

In bone tumors, extensive metastatic disease and/or chemotherapy non-responders were preferably advised supportive care. Treatment of benign lesions was withheld for a short while (Fig. 1).

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Figure 1. Radial Venn diagram showing relationship between multiple factors with approach to cancer patient care during unprecedented COVID-19 pandemic. COVID-19: coronavirus disease 2019.

Reckoning the overwhelming COVID-19 situation and need of the cancer patients, SOPs were formulated by the institute. We developed our own scoring checklist for COVID-19 and accordingly risk categorization of the patients was done. Consequently, we modified the existing treatment protocols in equation with COVID-19 pandemic, to manage the clinical workload and henceforth reduce the treatment exposure time of the cancer patients, at the very core of health system, with the limited resources.

Liang et al were the one who initially focused physicians’ attention to modify cancer treatment protocols during this ongoing COVID-19 pandemic, mainly because of immunocompromised state of the cancer patients receiving chemotherapy or undergoing radiation, who are susceptible to infection and their culmination into more serious events like ICU admissions and related mortality [1]. We suggest that treatment modification or interruption should be individualized and should not be assumed as standard treatment, based on factors associated with each patient. Thus, making these quirky guidelines depending on the peculiar characteristics of cancer patients arriving our cancer institute has helped oncologists to somewhat encompass the spread of this rapidly unfurling deadly virus to both staff and the patients, till date.

Acknowledgments

None to declare.

Financial Disclosure

None to declare.

Conflict of Interest

None to declare.

Author Contributions

Study conception and design: all authors contributed equally. Acquisition of data: all authors contributed equally. Drafting of manuscript: three authors, namely, Malik, Sehgal and Dhull contributed equally. Critical revision: all authors were involved in the review section and contributed equally.

Data Availability

The authors declare that data supporting the findings of this study are available within the article.

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Clinical Infection and Immunity is published by Elmer Press Inc.