publication date: Mar. 13, 2020
COVID-19 and the cancer patient: A call to action for balancing cancer care and viral risk
By Karen E. Knudsen, MBA, PhD
Executive vice president of oncology services, Jefferson Health;
Enterprise director, Sidney Kimmel Cancer Center;
Hillary Koprowski Professor and Chair,
Department of Cancer Biology, Thomas Jefferson University;
Chair, Cancer Biology
By Roy Jensen, MD
Director, The University of Kansas Cancer Center and
Kansas Masonic Cancer Research Institute;
William R. Jewell Distinguished Kansas Masonic Professor;
Professor of pathology and laboratory medicine, anatomy and cell biology, cancer biology
and molecular biosciences
As COVID-19 has now officially been declared a source of the pandemic, with increasing incidence across the nation, it is without question that the needs of patients with particular vulnerabilities should garner particular attention.
Given the specialized needs of cancer patients, it is imperative to consider how we, as the major cancer centers, may address and communicate how the impact of COVID-19 could impact the timing and delivery of cancer care, and to communicate this information to cancer patients.
At the time of writing, the catchment areas served by the cancer centers under our direction have reported 55 COVID-19 patients, some of whom have been diagnosed within our health systems. There are 50 patients in the Sidney Kimmel catchment areas in Pennsylvania and New Jersey, and five patients within KU’s catchment area—Kansas and Western Missouri.
As such, discussions began centering on how our individual systems have begun to address the problem of COVID-19 in the backdrop of cancer care.
As cancer center leaders, we are responsible for delivering accurate information to our faculty and staff, and to our patients.
As the president and president-elect of the Association of American Cancer Institutes, we are pleased to announce that AACI is launching a platform for its members to share coronavirus experiences and best practices.
Details on accessing the platform will be made available to members of AACI, which comprises 100 of the leading academic and freestanding cancer research centers in North America, with the goal of sharing rapidly changing experiences and best practices for delivering cancer care in the backdrop of COVID-19.
In the spirit of sharing information, here is what the institutions we lead are doing to handle the COVID-19 cases:
The SKCC strategy
As part of a large, 14-hospital, two-state academic health system, the Sidney Kimmel Cancer Center at Jefferson Health follows enterprise guidance on limiting exposure to COVID-19.
Similar to other health care organizations, these guidelines include expanded strategies for exposure control, patient and caregiver education, domestic and international travel restrictions, remote work options, and additional measures to limit exposure across all sites of care.
Most critically, further protective procedures have been implemented with the unique needs of cancer patients in mind.
At SKCC, the cancer-focused effort is led by Dr. Neal Flomenberg, chair of the Department of Medical Oncology and a bone marrow transplant expert, in partnership with a number of key stakeholders, including Jefferson’s infectious disease team, as well as collaboration with cancer leaders from the Fox Chase Cancer Center.
In alignment with overall guidance from Jefferson Health, the additional cancer-focused principles were developed for clear communication with patients and care teams.
Cancer-specific “contain and control” procedures were specifically geared toward: 1) patients undergoing active treatment, and 2) patients requiring bone marrow transplant.
For patients undergoing active treatment, the goal is to stay as close as possible to the intended treatment schedule.
Guiding principles and specialized programs for these patients are designed to:
Balance risk: Understanding that long delays or interruptions in treatment could have significant consequences in terms of outcome, mitigating the risk of cancer progression remains the primary goal.
Limit cancer center visits for patients symptomatic for respiratory infection: At SKCC, care teams are proactively calling patients 48 hours prior to visits, so that those with any concerning symptoms may be directed to an appropriate viral screening plan rather than presenting to the cancer center and potentially exposing patients or caregivers.
Enhance crowd-control in the Center through expanded hours: Handwashing and crowd control is critical for reducing risk of viral infection. At SKCC, patients are encouraged to take advantage of the center’s evening and weekend hours for infusion, including both Saturdays and Sundays. Receiving treatment at off-peak times has the potential to further reduce risk and exposure for vulnerable patients.
Follow-up by telehealth: While use of telehealth visits has already been embedded in follow-up care for SKCC cancer patients, made possible through our JeffConnect Program, enhanced usage of the telemedicine program has been implemented to reduce the number of visits and resulting exposures for patients no longer on active treatment.
For patients requiring bone marrow transplant, additional consideration is merited.
Complementing the guidelines above, additional consideration was given for patients requiring bone marrow transplant. For this class of patient, the following enhanced procedures were implemented:
Priority scheduling and proactive screening: Given the difficulty in predicting the impact of the delay even in seemingly stable transplant patients, every effort should be made to ensure that transplants proceed as scheduled. Screening for influenza, RSV or other illnesses should be performed within seven days of admission.
Use of telehealth for pre- and post-transplant guidance. At SKCC, telehealth communication has been enhanced for pre-transplant classes, and for post-transplant patients after discharge, again with the goal of limiting exposure.
Expanded visitor exposure limitation and guidelines: Guidelines for BMT patients always include handwashing, masks and gloves for anyone entering the room. During the pandemic it may be prudent to limit visitors to the rooms of BMT patients. At SKCC, visitors are limited now to 1 per day. There is also an education aspect, wherein visitors are reminded to wash both in and out of the room and to refrain from entering the center if respiratory tract or any other infectious disease symptoms are present.
Addressing special consideration for donors: It goes without saying that for allogenic transplants, the health of both the donor and the recipient needs to be considered. Donors reporting symptoms of illness that could be consistent with COVID-19 should be tested and deferred until recovery if positive. Donors who are asymptomatic but reporting sick contact should be deferred for donation to reassess for symptoms. Travel restrictions to and from countries outside the U.S. may limit the availability of some unrelated donors and needs to be considered in determining the best donor and transplant option for the patient. Haploidentical transplantation from a related donor should be strongly considered for these patients.
Refining care team visits: During the pandemic, additional steps are being taken at SKCC to limit the number of individuals entering the patient’s room. For example, options include electing for a single physician to enter the room rather than the whole care team, and for transplant unit staff to carry food trays in and out of the rooms. Reducing the frequency of checking vital signs for patients who are feeling well and show no signs of neutropenia may be prudent, balanced with more frequent interviewing over the phone or intercom.
The KU strategy
The University of Kansas Cancer Center physician and administrative leadership, led by Dr. Steve Stites, executive vice president of clinical affairs and chief medical officer of The University of Kansas Health System and vice chancellor of clinical affairs at the University of Kansas Medical Center, developed precautions for COVID-19, given the unique vulnerability of cancer center patients. The cancer center leadership implemented the following measures to maximize the health and well-being of patients and care teams:
Cancer center leadership is recommending the deferral of all professionally-related domestic and/or international travel involving public transportation. Similar travel for personal reasons is strongly discouraged and is a personal judgment decision. Please consider the CDC-recommended travel precautions.
Cancer center leadership is also recommending refraining from participation in any local, regional and/or national professionally related meetings and conferences at this time. Virtual technological participation is strongly encouraged. Cancer center organized meetings and events are currently being rescheduled.
Within all cancer center locations, we are limiting patient-affiliated visitors and caregivers to one person that may accompany patients to cancer center appointments, assuming they undergo standard visitor screening. We are strongly encouraging other desired participants to use phone or other technology to participate in the appointment. New patients will be notified through cancer center nurse navigation, and patient in-clinic signage is being developed.
Non-employed personnel that are not absolutely essential for current active and specific patient care (i.e., vendors, MSL) shall not be allowed access to cancer center facilities. Access for employee and faculty candidates should be granted on a case-by-case basis, depending upon the judgment of the hiring supervisor or department/division chair, respectively. In-clinic signage is being developed.
Employees have been instructed that if they are feeling ill, they are to contact their health care provider and to stay home.
Cancer center protocol for patients calling with symptoms:
Ambulatory screening protocol at registration/arrival
Ask every patient to review the travel screening sign at the front desk and ask the patient, ”Do you have any of the following symptoms including fever, cough, and difficulty breathing?”
“Have you traveled internationally in the last month or had close contact with a person under investigation for COVID-19?”
Isolate–if the patient answers yes to these questions:
Ask the patient to don a surgical mask (available at the front desk).
Call/page your clinic or nurse manager (the manager will then isolate the patient in the designated room and call the health system infection prevention and control team.
Talking points to be used if patients ask whether it’s safe to come for their appointment, or with other questions:
Q. Am I safe if I keep my appointment?
Yes, it is safe to be here. Our care team is following all recommended protocols from the Centers for Disease Control and Prevention. Our primary goals are to ensure the safety of everyone and to continue serving you with the best care.
Q. What are we doing to make sure the disease does not spread?
We have processes, supplies and areas of our facility that are designed to prevent the spread of the virus to other patients, visitors, staff and physicians. Our expert clinicians regularly care for patients with severe respiratory illnesses and other infectious diseases. They are well trained and follow specific procedures using equipment, tools and techniques in place to protect themselves and patients.
Q. Can I reschedule?
We want to assure you it is safe to be here. Although it is better for your health to proceed with your scheduled visit, if you are uncomfortable with keeping the appointment we can help you reschedule. We will likely consult with your physician or clinical professional to ensure your health is not compromised if you reschedule.
Q: Where is a trusted resource for information about this virus in the United States and Kansas or Missouri?
We highly recommend the websites for the Centers for Disease Control as well as the Kansas Department of Health and Environment. You can find links on our website kansashealthsystem.com.
Q: What should I do if I think I have been exposed to the virus and have symptoms of an upper respiratory infection?
Please call your physician’s office and let them know ahead of your scheduled appointment time or ahead of an urgent care visit.
Talking points if employees are worried about their safety:
Q: Can I decline to see a patient with suspected or known COVID-19?
It is safe to see patients while wearing proper protective gear. We see highly infectious patients every day (influenza, TB, measles, etc.). The expectation is that our medical professionals will not refuse to see any health system patient. If individual departments, divisions or service lines would like to prioritize who of their specialty sees patients, that’s perfectly acceptable. In an effort to preserve resources, residents and students should not routinely be seeing these patients unless there is an urgent medical or procedural need. It is important to note that at the hospitals located in the epicenter of the outbreak in Washington state, there has been no known patient-to-patient or patient-to-provider transmission.
Q: Testing is becoming more widely available. Who should get tested?
With this anticipated increase in availability of testing, we are aware there will be questions about clinical guidelines for appropriate testing. We will be sharing an internal testing guideline early tomorrow. A few important points: an order will be required for testing, and we will limit collection at our sites to those with an order from one of our health system providers. We will not collect specimens for orders from other systems or offices.
Q: Do I need to wear a PAPR for every patient with a cough?
We know that SARS-CoV-2 is likely transmitted like other coronaviruses—by droplets. We are continuing to place known or suspected patients on airborne and droplet precautions including PAPR, gowns and gloves where available (which is an abundance-of-caution recommendation). The CDC changed their guidelines and now recommend if airborne precautions are not available it is safe to assess/treat patients wearing surgical masks, eye or face shields, gloves and gown.
This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.