SARS-CoV-2 / COVID 19 infection and cancers: what are the recommendations for healthcare professionals ?

T he pandemic of the COVID-19 virus started in China in December 2019. In response to the spread of COVID-19 on French territory, Professor F. Chauvin, President of the High Council for Public Health, organized around Pr Benoit You a working group to make recommendations on COVID-19 and solid cancers. 

This working group brings together oncologists and radiotherapists from multiple regions working in the regional public sector or CHU, in the private sector as well as in the PBC. The recommendations were adopted and published on March 14, 2020.

COVID-19 and solid cancers: general and available data

Before the appearance of this new coronavirus, COVID-19, it was reported concerning the seasonal influenza virus a much greater risk of respiratory distress and death in cancer patients compared to the rest of the population. Regarding COVID-19, the mortality rate would be less than 2% according to the initial Chinese data, but with great heterogeneity. 

Indeed, higher mortality has been recorded in older patients and / or with comorbidities. Data specific to cancer patients is available based on recent Chinese experience. In this study, the COVID-19 infection rate appeared to be higher in cancer patients than in the general population (1% vs. 0.29%). 

Specifically, among infected patients, the risk of having severe respiratory complications requiring resuscitation care was higher in patients with cancer than in patients without cancer (39% vs 8%, p = 0, 0003). 

In terms of prognosis, a history of chemotherapy or surgery in the months preceding infection was an important prognostic factor for developing severe respiratory complications (OR = 5.34, p = 0.0026). Similarly, cancer patients had a faster rate of respiratory deterioration of 13 versus 43 days (HR = 3.56, 95% CI [1.65–7.69]).

Summary of recommendations

Given these initial data, the working group proposed recommendations around three points:

  1. prevention of contamination;
  2. H iérarchisation care; 
  3. organization of patient care by establishments.

These proposals apply to solid cancer patients and are complementary to the recommendations for the general population issued by the health authorities.

Prevention of contamination

It is proposed by the working group to insist on the need for infection prevention in cancer patients:

  1. avoid contact of patients infected with COVID-19 with cancer patients;
  2. promote home support and telemedicine;
  3. anticipate stocks of prophylactic antivirals that could be shown to be effective in the coming weeks based on ongoing clinical trials;
  4. favor alternatives to conventional hospitalization: favor oral forms of treatment over the intravenous, favor intravenous administration in hospitalization at home. . . ;
  5. limit hospitalizations in the oncology and radiotherapy departments of patients in support or comfort care who could be treated in other care structures;
  6. favor therapeutic breaks in situations of metastatic cancer of slow progression (example: metastatic breast cancer, colon-rectum cancer, prostate cancer..);
  7. prophylaxis of febrile neutropenia by GCSF must be absolutely prescribed in the case of chemotherapy associated with a risk of febrile neutropenia 20%, studied in the case of chemotherapy associated with a risk of febrile neutropenia between 10 and 20%, or even <10% depending on the particular situation of the patient, as well as in the case of a patient who has already had a neutropenic event in the past;
  8. it may be useful to contact the patients scheduled for hospitalization or consultation the next day to ensure that they do not present any symptom suggestive of the virus, before authorizing them to come to the oncology or radiotherapy department.

Elderly patients (> 70 years) and / or carrying multiple comorbidities suffering from cancer must be the subject of very special attention and avoid as much as possible any risk of contamination in view of the risk of respiratory complication and increased death.

Hierarchy of care

In an exceptional situation which would imply a significant tightening of the oncology and radiotherapy services linked to the epidemic, it is proposed to prioritize the management of cancer patients. 

The rules described below do not apply to pediatric patients and patients followed in hematology (see with the relevant working groups). “These rules are advisory, and the final decision will rest with the referring doctor of the patients concerned, depending on the patient’s particular situation and their pathology”.

Prioritization of care

The prioritization in the choice of patients to be treated should integrate the nature of the therapeutic strategy (curative versus palliative), the age of the patients, the probable life expectancy, and the recent nature or not of the diagnosis. Prioritization could follow the following descending order:

  1. curative therapeutic strategy, favoring patients < 60 years old and / or whose life expectancy is> 5 years;
  2. palliative therapeutic strategy, patients < 60 years old and / or whose life expectancy is > 5 years) and at the start of therapeutic management;
  3. another therapeutic situation, giving priority to cases where the spread of the disease, the rapidity of the course or the symptomatology would cause fear of a rapid clinical worsening. This opinion is advisory, and the final decision rests with the referring doctor and the team in charge of the patient.

Recommendations by type of treatment

For surgery: limit hospitalization times, prioritize the populations and pathologies defined above and deprogram non-urgent interventions. For radiotherapy:

  1. curative radiotherapy: any adjustments will be decided by the referring doctor;
  2. analgesic radiotherapy: maximum reinforcement of the analgesic treatment and possible adjustments at the discretion of the referring doctor (hypofractionation in particular).

For chemotherapy: favor chemotherapy for curative purposes (pre or post operative) and avoid weekly protocols.

Organization of patient care by establishments

The rules below do not take into account local specificities in the organization of care systems, and will have to be adapted according to the choices made by health establishments and Regional Health Agencies.

Patients with cancer not affected by the virus, or cured

It is proposed to continue the care taking into account the adjustments proposed above.

Cancer patients infected with the virus

Barring exceptions, oncological treatments should be stopped while taking care of the viral infection. If hospitalization is necessary, patients will be taken care of in other medical services involved in the fight against the virus. 

They should be given priority since they are more at risk of developing severe forms of the virus.

Management of oncology and radiotherapy services

Ideally, no patient with the virus will be treated in these services. The diagnosis of a viral infection in a patient will lead to their rapid management in another versatile service with collaborative monitoring, taking into account its priority nature. 

If patients with COVID-19 were absolutely to be treated in oncology departments, they should be isolated from other patients (isolation of a service sector, fragmentation of oncology departments…). Certain services could be brought to function in degraded mode with a reduced staff compared to the usual functioning. 

This “degraded” mode must however be adapted to the organization of each service, and implemented optimally with the establishment’s risk management unit to ensure patient safety.