1. Das, Dibash Kumar PhD

Article Content

While efforts to "flatten the curve" are showing some signs of hope, the distressing global experience with COVID-19 has restricted and in some cases devastated the health care systems. Nevertheless, managing cancer care as well as ensuring the well-being of both patients and health care staff remains the focus for the oncology community. To assist with these issues, two articles were recently published in the Journal of the National Comprehensive Cancer Network (JNCNN) presenting the latest insights and recommendations.

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Management Best Practices

Experts from the Seattle Cancer Care Alliance (SCCA) (part of the National Comprehensive Cancer Network [NCCN]), the Fred Hutchinson Cancer Research Center, and the University of Washington shared best practices learned from early experiences managing and treating people with cancer during COVID-19 outbreak in the article titled, "Managing cancer care during the COVID-19 Pandemic: Agility and collaboration toward a common goal" (J Natl Compr Canc Netw 2020:1-4).


Considering the projected shortage of health care resources, along with the predicted increased risk of cancer treatment during this time, challenging decisions about how and when to provide cancer treatment have become an inevitability. The difficulties faced as an institution, nevertheless, must still align with the overarching goal, which remains to offer cancer treatment to patients in need as safely and as reasonably as possible.


"Responding quickly and confidently to the COVID-19 crisis is the health care challenge of our generation," stated co-lead author F. Marc Stewart, MD, Medical Director of the SCCA. "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. We are working around the clock to develop new guidelines and policies to address situations that we couldn't have imagined several weeks ago. When the pandemic ends, we will all be proud of what we did for our patients and each other in this critical moment for humanity."


Some of the predicted challenges include:


* staff shortages due to potential exposure and/or school closings;


* limitations of resources such as hospital beds, mechanical ventilation, and other equipment; and


* impact on treatment from travel bans, including reduced access to international donors for allogeneic stem cell transplantation.



The article emphasizes the critical need of keeping open communication between all stakeholders, including administrators and staff, patients, caregivers, and the general public. In particular, the authors recommend forming an Incident Command Structure (ICS) "to provide early coordination of institution-wide efforts and to rapidly respond to changing information." Moreover, they highlight the need to remain flexible to be able to respond effectively to the rapidly evolving situation.


To help mitigate challenges associated with some of these concerns, the authors recommend several proactive measures which include:


* providing patient information via handouts, signs, web-based communication, and a dedicated phone line for questions and triage;


* rescheduling "well" visits and elective surgeries, and deferring second opinion consultations (where care is already appropriately established);


* increasing hours of general hospital operations to reduce the unnecessary use of emergency department resources;


* reinforcing a strict "stay at home when ill" policy and insuring staff have access to testing;


* restricting travel and enabling work from home wherever possible;


* prioritizing the use of soap and water over hand gel;


* limiting the number of team members who enter patients' rooms;


* considering lower thresholds for blood transfusions;


* moving some procedures from inpatient to outpatient;


* adopting a no visitor policy with rare exceptions such as end-of-life circumstances; and


* having upfront, proactive palliative and end-of-life conversations with cancer patients who may become infected with COVID-19.



Also noted was the importance of physical and emotional well-being of staff and faculty members in order to prevent provider burnout. Those measures include compensation policies, reassignments to administrative roles for immunocompromised staff, and the creation of a back-up labor pool.


Patient & Staff Safety

Reports from Wuhan, China, have revealed that patients with cancer may be at an increased risk of COVID-19 compared with the general population due to frequent hospital visits (Lancet Oncol 2020; NCCN's Best Practices Committee published a peer-reviewed feature in JNCCN (2020:1-6), presenting strategies on how to alleviate transmission of COVID-19 in an effort to decrease morbidity and mortality associated with the disease for patients with cancer without infection, for patients with cancer with COVID-19 infection, and for the health care workers caring for them, while continuing to provide the best possible cancer care.


"The unprecedented challenges we are all facing from the COVID-19 pandemic heighten NCCN's commitment to sharing evidence-based consensus from leading medical experts as rapidly as possible, free-of-charge, to everyone around the world," noted Robert W. Carlson, MD, Chief Executive Officer of NCCN. "We are doing everything we can to review and share reliable information that will help keep oncology patients, providers, and staff safe under the new reality of increased risk."


Health care providers have had to rapidly alter care delivery models while concurrently conceding the crucial unknowns of how these changes may affect clinical outcomes. The use of telemedicine plays a significant role in the treatment of patients with cancer during this difficult time. Through telemedicine, clinicians can help patients while reducing the risk of in-person visits. Nevertheless, not every visit can be performed virtually, and some patients require therapy that cannot be interrupted or changed.


In response, the NCCN Best Practices Committee provides recommendations which can be summarized as follows:


Patient Safety


* Prescreen and screen for COVID-19 symptoms and exposure history via telephone calls or digital platforms.


* Develop screening clinics to allow for patients with symptoms to be evaluated and tested in a dedicated unit with dedicated staff.


* Convert in-person visits to telemedicine visits when possible.


* Limited-visitor or no-visitor policy.


* Limit surgeries and procedures to only essential, urgent, or emergent cases.


* Consideration of alternative dosing schedule to allow for fewer in-person visits to the cancer center and/or the infusion center.


* Switch from infusional therapy to oral oncolytics (if equivalent formulation is available).


* Transition outpatient care to at-home care whenever possible (e.g., pump disconnection, administration of growth factors, hormone therapy).


* Increase interval between scans or use biochemical markers in lieu of scans.


* Provide resources for wellness and stress management for patients.



Health Care Provider Safety


* Assure availability and use of appropriate personal protective equipment (PPE) per guidelines.


* Create a centralized resource or website to communicate recommendations to health care workers about PPE and workflows.


* Implement daily screening tools and/or temperature checks.


* Telecommute when possible, with limited on-site staff participating in rotations on a daily basis.


* Establish clear stay-at-home and return-to-work guidelines.


* Provide resources for wellness and stress management for health care workers.



"We can continue to provide our patients with effective and compassionate care-without sacrificing the health and safety of our teams, colleagues, and families-by carefully evaluating any emerging research and modifying our treatment approaches accordingly," said lead author of the article Pelin Cinar, MD, MS, of the University of California, San Francsico Helen Diller Family Comprehensive Cancer Center.


"People with cancer and their loved ones already go through so much, and now they face new fears around catching COVID-19 or delaying necessary treatment. By sharing these recommendations, we want to reassure the oncology community that there are some aspects of care that we can and will control in order to improve outcomes for people with cancer."


In summary, while these are extraordinary times, institutions should be sure to keep all lines of communication open between staff, as well as with patients. Furthermore, oncology practices should take necessary precautions, while continuing to show dedication, resiliency and adaptability to ensure the safety of both their staff and patients with cancer.


The JNCCN articles contain the most current information at the time of publication, but the authors noted that recommendations regarding public safety, PPE, workflows, and clinical algorithms may change rapidly.


Dibash Kumar Das is a contributing writer.