Caring for our cancer patients in the wake of COVID-19

Summary In response to our current global pandemic, unprecedented healthcare changes may have significant consequences for cancer patients in the United Kingdom. We explore why cancer patients may be more susceptible to severe infection and complications, highlighting various interventions that may help to ensure continuity of care in this unique cohort.

that this is based on a small patient number (n = 18) and a heterogeneous population. 2 Furthermore, some chemotherapy agents and immune-checkpoint inhibitors (ICI) can themselves contribute to or cause pneumonitis. 4,5 Thus, managing COVID-19 in these patients could be challenging and requires a multidisciplinary approach due to the difficulties in distinguishing the contributions of SACT versus COVID-19.
In addition, the effect that novel anticancer treatments (such as ICI and targeted therapies) will have on the virulence and/or severity of COVID-19 has yet to be established. There is sparse literature commenting on the role of any other existing coronavirus strains and their interaction with these agents. However, as treatments such as ICI manipulate the immune system in various ways, it should be considered that their use could predispose to atypical manifestations of the coronavirus. 6 Lessons learned from previous outbreaks, such as the 2012 Middle-East respiratory syndrome coronavirus (MERS-CoV) and the 2003 severe acute respiratory syndrome (SARS-CoV), have helped shape current guidance for COVID-19, but there are little data on how these infections affected cancer patients. Although both SARS and MERS largely pre-dated targeted therapies and ICI, there are a few studies specifically investigating the effect of chemotherapy during these times. For example, Chen et al. reported that of a cohort of 79 patients with non-small-cell lung cancer, none of them were documented to have contracted SARS, five were possible cases (proven negative) and during that time only ten of 373 chemotherapy sessions were delayed. 7 The current global COVID-19 pandemic is unprecedented and continues to evolve. As such, how best to treat and support our cancer patients remains uncertain. New, comprehensive national guidance has assisted us to amend our practice accordingly during these challenging times, and there are several changes we can implement to ease the impact of this disease on our unique patient cohort 8 :

Rationalise treatments
-Prioritise SACT to patient groups who will have most benefit, e.g., in the neoadjuvant and adjuvant 'curative' setting -Consideration of treatment delays, especially in 'high risk' patients such as those with established cardiovascular comorbidities 8,9 -Prioritisation and rationalisation of surgeries based on urgency, symptoms and possibility of cure of cancer, also mindful of the need for subsequent post-operative critical care beds • Limit morbidity -Consideration of increased use of prophylactic granulocytecolony-stimulating factor alongside chemotherapy regimens to minimise neutropenic durations -Early identification of infection with on-the-door triage/ assessments in those with fevers and symptoms -Delaying all treatments in COVID-positive or query patients, as this would enter an unknown field in which we do not fully understand the consequences -Ensure that patients are fully vaccinated (especially against influenza) to help rule out differential diagnoses in patients with possible respiratory infections -Provision of oncological support in decision-making for admitted COVID-19 cancer patients With interventions such as those listed above, it is hoped that we can limit the impact of COVID-19 on our cancer patient population and not succumb to its 'distraction effect' in delivering their care. 10 Despite our best efforts, there will be further challenges awaiting us as fallout to changes in standard practice once we have recovered from the pandemic. But for now, we must focus on the immediacy of protecting our cancer patients as best as we can.

ADDITIONAL INFORMATION
Ethics approval and consent to participate No ethical approval was required for this paper.
Consent to publish Not applicable.
Data availability No data were collected for use in this paper. Any data highlighted in this paper from previous studies have been referenced.