NCCN Issues Guidance for Cancer Care During the COVID-19 Pandemic

The challenges of managing cancer during the COVID-19 pandemic raise new concerns for oncologists, nurses, and the entire cancer care team. The management of patients with cancer, who are at increased risk from this new respiratory infection, has rapidly become even more urgent.

The National Comprehensive Cancer Network (NCCN) has just published a special feature in its Journal of the National Comprehensive Cancer Network.1

The full article can be accessed at https://jnccn.org/view/journals/jnccn/aop/article-10.6004-jnccn.2020.7560/article-10.6004-jnccn.2020.7560.xml.

In this article, a group of oncology and infectious disease experts from the Seattle area provide advice from their early experience with the coronavirus, highlighting 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.

Increased Risk

“People with cancer appear to be at increased risk of COVID-19, and their outcomes are worse than individuals without cancer,” Robert W. Carlson, MD, NCCN Chief Executive, said in a press release from the NCCN. “The NCCN Member Institutions are rapidly gaining experience in preventing and managing COVID-19,” he added.

“The potential threat of COVID-19 to our immunocompromised patients as a result of their disease or the treatment we provide is thought to be significant, tipping the usual risk/benefit balance in extreme ways,” noted the article’s authors, who are from the Seattle Cancer Care Alliance (SCCA), which includes Fred Hutchinson Cancer Research Center and the University of Washington.

“There are limited data in immunosuppressed hosts, but early published reports from China on the outcomes of patients with cancer infected with COVID-19 indicated a 3.5 times higher risk of needing mechanical ventilation or ICU admission or dying compared with patients without cancer,” they added. Early coordination of institution-wide efforts to address diminishing supplies and hospital resources is essential during the rapidly changing information about COVID-19, those experts say.

“Responding quickly and confidently to the COVID-19 crisis is the health care challenge of our generation,” co-lead author F. Marc Stewart, MD, Medical Director of the SCCA, said in the 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.”

Don’t Delay Cancer Treatment

The authors emphasize the importance of triaging patients with cancer and respiratory symptoms to reduce exposure to other patients and staff. In the clinic, symptomatic patients should be diverted to a separate secondary screening area for potential COVID-19 testing.

A “stay at home when ill” policy and access to testing for symptomatic staff have been key to limiting exposure to the novel virus. Early coordination that includes an “incident command” structure to centralize information for staff, patients, and the community is essential. Telemedicine has been expanded to include all well visits.

Making clinical decisions regarding the delay of treatment for patients with cancer who are currently receiving or are about to begin chemotherapy is essential.

“For solid tumor patients, adjuvant therapy with curative intent likely should proceed, despite the threat of COVID-19 infection during treatment,” the authors recommend. “For patients with metastatic disease, treatment delays may lead to worsening performance status and loss of the window to treat. Considerations should include how such delays may lead to admission for symptom palliation, which further stresses inpatient resources.”1

“The recommendations highlight our initial preparations and what we did up front at our center. The situation is evolving rapidly, and day by day we’re reassessing these recommendations. The current recommendations as published are a starting point, but I imagine that some will need to be revised as things change,” Masumi Ueda, MD, MA, lead author and a researcher at Fred Hutchinson, said in an interview with Oncology Practice Management. “For example, resources continue to shrink, and I think that we will be making even more difficult decisions about what kind of treatments we continue.”

Stem-cell transplantation and cellular immunotherapies cannot be delayed in patients with aggressive hematologic malignancy, the report points out.

“Our oncology disease groups are tasked with determining what treatments can be selected to lessen immunosuppression, moved from the inpatient to outpatient clinic, and delayed,” the authors emphasize.1

Inpatient Oncology

The priority for inpatient oncology units includes preparation for a shortage of beds and resources, and may require reallocation of units, hospital wards, and entire systems.

“A big part of oncology treatment now is trying to move from inpatient to outpatient, so one thing the SCCA is doing is trying to extend infusion clinic hours and give some of the chemotherapy for which we usually have to admit patients for on an outpatient basis instead,” Dr Ueda said.

To ease a potentially overwhelmed health system in the case of rapid transmission, “we may have to recommend that patients get treated elsewhere. A lot of our patients come from outside the greater Seattle area,” Dr Ueda said.

“With the use of telemedicine and connecting with community doctors, some of the treatment that is usually performed in Seattle may be moved toward community sites. We are trying to partner as much as we can with our community doctors and be available for questions and telemedicine. Our goal is to offer as much help to community physicians and rural sites as we can, even without physically seeing the patient,” she added.

End-of-life and palliative care discussions with patients with cancer who are infected with COVID-19 are important, especially for those with late-stage cancer or for patients with comorbid conditions (eg, heart or lung dysfunction), because survival among this group is rare.

“It is our duty to not only educate but also provide resources to help patients make decisions regarding treatment during this period of uncertainty,” the authors advise. “With dwindling resources, oncologists must also consider carefully what treatments are most likely to be successful, symptom-relieving, or lifesaving, and consider those patients likely to get the greatest benefit from treatments.”1

ASH Launches COVID-19 Webpage

The American Society of Hematology (ASH) is also ramping up its efforts to help hematologists care for their patients amid the coronavirus outbreak and has launched a webpage with resources related to COVID-19 (www.hematology.org/covid-19).

“The curated ASH COVID-19 resource page will serve as a hub for daily updates to help guide the hematology community through the uncertainty of this global public health threat,” according to ASH.

The resources on the page range from federal policies affecting medical practice to specific guidance for treating patients with hematologic conditions, including blood cancers, who may have COVID-19.


Reference

  1. Ueda M, Martins R, Hendrie PC, et al. Managing cancer care during the COVID-19 pandemic: agility and collaboration toward a common goal. J Natl Compr Canc Netw. 2020;18:1-4.

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