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Systemic Anti-Cancer Therapy

NCCP advice for Medical Professionals on the management of patients undergoing Systemic Anti-Cancer Therapy (chemotherapy) in response to the current novel coronavirus (COVID-19) pandemic (CD19-013-003 / 28.04.20)


Overview
  • Current events surrounding the COVID 19 pandemic are challenging and all public health bodies are placing the safety of patients, staff and communities first in all decisions.
  • This is an evolving situation. This advice is based on current information, it is additional to the advice of the NPHET, the HSE and the DoH, and will be updated as necessary.
  • The NCCP acknowledges that each hospital is working under individual constraints, including staff and infrastructure, and as a result will implement this advice based on their own unique circumstances.   
  • The purpose of this advice is to maximise the safety of patients receiving Systemic Anti-Cancer Therapy (SACT) and make the best use of HSE resources, while protecting staff from infection. It will also enable services to match the capacity for cancer treatment to patient needs if services become limited due to the COVID-19 pandemic.
  • This advice is available on the NCCP website here1. The NCCP asks that this advice is not posted on hospital websites or elsewhere due to the risk of out of date versions being in circulation. We would advise that sites wishing to add this advice to their own websites should link directly to the NCCP webpage. This will ensure that the correct version is available.
  • To note there is also patient advice, which is also updated regularly, which is available here2
NPHET, HSE and DoH advice

Hospitals and hospital staff will operate under the overarching advice of the National Public Health Emergency Team (NPHET), the HSE and the DoH. Information is available at:

Communication with patients receiving Systemic Anti-Cancer Therapy (SACT) (Chemotherapy) for the treatment of cancer

Communicate with patients and support their mental wellbeing, signposting to charities and support groups where available, to help alleviate any anxiety and fear they may have about COVID-19.

Patients should have the opportunity to discuss and consider the following when suggested by their Consultant:

  • Proposal for a treatment deferral or treatment break
  • Modifications to their treatment to reduce the risk of immunosuppression or reduce the number of dayward attendances required to deliver the treatment

Patients who continue to attend for treatment should be:

  • Contacted 24-48 hours prior to their planned SACT appointment to ascertain their COVID 19 exposure status.
  • Advised to follow the relevant parts of the guidance of the NPHET, the HSE and the DoH
  • Advised to attend appointments without family members or carers, where possible, to reduce the risk of contracting or spreading the infection.
  • Advised to contact their dayward acute oncology service if they feel unwell to ensure their symptoms are appropriately assessed.
  • Informed as to the steps being taken in the hospital to reduce the risk of infection by:
    • Minimising face to face contact
    • Ensuring that any patients with COVID-19 symptoms are identified for the safety of the patient and others
    • Minimising the time patients spend in daywards and waiting rooms
Patients, COVID-19 exposure and treatment decisions
  • Information on the exposure of patients to COVID-19 will inform treatment decisions. The risk of cancer not being treated in line with the original treatment plan must be balanced with the risk of the patient being immunosuppressed and becoming seriously ill from COVID-19.
  • In terms of COVID-19 exposure patients may:
    • Have active COVID-19 disease – these patients should have their SACT treatment deferred until they are clinically well and no longer infectious (defined by the HPSC Expert Advisory Group as a minimum of 14days since onset of first symptoms and 5days fever free3). “These patients can then resume their treatment once clinically well. Given the possibility of prolonged viral shedding in profoundly immunosuppressed patients, they should be considered potentially infectious for an additional three weeks. As a precaution, these patients should be cared for in a single room to minimise contact with other vulnerable patients during this period. Alternatively, consideration can be given to a repeat COVID test to guide need for additional precautions or to the cohorting of patients who have recently recovered from COVID, i.e. within the first three-week period following recovery.”
    • Have suspected COVID-19 disease as per the HPSC (Health Protection Surveillance Centre) algorithms – these patients should be tested in line with the HPSC algorithm and their treatment deferred. Where there is a strong clinical suspicion of COVID-19, particularly if known to be a contact with a confirmed case, then a negative test result should be interpreted with caution due to the false negative rate.  Separately, where testing turnaround time is considerably delayed, patients should be risk assessed as if they have confirmed COVID-19 disease, noting that if clinically well they can resume treatment once 14days have passed since onset of first symptoms and they are 5 days fever free.
    • Be a close contact4 (e.g. household contact) of either a suspected or confirmed case of COVID-19 but have no symptoms. As per the HPSC recommendations, close contacts are advised to “restrict their movements5” until for 14 days since last close contact.  These patients should have their SACT treatment deferred until the 14 days6 has passed unless it is deemed necessary that the treatment should proceed by the treating Consultant, considering the risk:benefit ratio of treatment.  If proceeding with treatment the patient should receive their treatment in isolation from other patients receiving treatment.
    • Have had no known exposure - these patients should continue with their SACT treatment in line with the recommendations in Section 5 below.
Advice for Oncology/Haematology SACT Day Ward and Inpatient Wards Services
  • Consult the most up-to-day information for health care professionals on the HPSC website7 and link with your local infection prevention and control team for specific advice.
  • Operate under the hospital advice.
  • Patients receiving supportive care treatment only should have their treatment deferred based on the recommendation of their treating Consultant considering the risk:benefit ratio of treatment.
  • Patients receiving treatment for their cancer should continue treatment based on the recommendation of their treating Consultant considering the risk:benefit ratio of treatment. This should consider:
    • The intention of treatment - balancing the risk of cancer not being treated in line with the original treatment plan with the risk of the patient being immunosuppressed8 and becoming seriously ill from COVID-19.
    • The level of immunosuppression associated with the proposed treatment and cancer type, and any other patient-specific risk factors particularly those with respiratory disease in addition to their cancer
    • Patients with significant lymphocytopenia
  • Inpatient Oncology/Haematology wards:  Hospitals should maintain their inpatient Oncology/Haematology wards to allow patients to continue to be cohorted appropriately.  These wards may be relocated during the COVID-19 situation.
  • Out-patients / Day wards
    • Minimise face-to-face contact by:
      • Implementing telephone or video consultations (particularly for follow-up appointments and pretreatment consultations) in line with the State Claims Agency Risk Advisory Notice - Providing Telehealth: Virtual Sessions
      • Deferring non-essential face-to-face follow up
      • Using community/home delivery services for medicines if capacity allows
      • Using local services for blood tests if possible.
      • Hospitals should consider off-site or physically separate phlebotomy services for cancer patients on SACT treatment not requiring dayward attendance
    • Minimise time in the dayward waiting area by:
      • Careful scheduling
      • Encouraging patients not to arrive early
      • Texting patients when you are ready to see them, so that they can wait in a lower risk environment e.g. their car.
    • Consider relocating SACT day wards to a site that can maintain a COVID-19 free environment and has an entrance for patients that is not shared with patients attending other areas of the hospital.
      • Clear governance arrangements should be in place where daywards are relocated or patients treatment location is moved
    • SACT daywards should be reconfigured to maintain the social distancing as advised. It is acknowledged that this may result in a decrease in chairs available for treatment in some cases.
    • Contact patients 24-48 hours prior to their planned SACT appointment to ascertain their COVID 19 exposure status.
    • Consider triaging patients attending for chemotherapy in a separate area to the day ward. This triage should include confirming their COVID-19 exposure status and a temperature check.
    • Day wards should implement options to isolate patients (as detailed in Section 4 Patient and COVID-19 exposure) who are defined as a ‘close contact’ from other patients.
    • Consideration must also be given to the patient’s means of transport to the unit, with shared transport alongside other patients to be avoided during the 14-day ‘close contact’ follow up.
  • Isolation facilities9 should be prioritised for patients:
    • Undergoing SACT treatment with curative intent
    • With significant lymphocytopenia
    • With significant respiratory co-morbidity
  • If a SACT service experiences capacity issues10 due to the COVID-19 pandemic then patients should be prioritised based on treatment intent and the risk:benefit ratio of treatment.   Priority should be given to the continuation of treatment for those with curative intent, including, where necessary, the transfer of a patient to an alternative location to continue treatment.
Staffing and Capacity
  • Hospitals should maintain their cancer services staff to support the running of the cancer service.
References
  1. https://www.hse.ie/cancerinfocovid-19hcp
  2. https://www.hse.ie/eng/services/list/5/cancer/patient/covid-19.html
  3. National Infection Prevention and Control Guidance is available at https://bit.ly/3c9uoBV
  4. CLOSE CONTACTS: Any individual who, within the past 14 days, has had greater than 15 minutes face-to-face (<2 metres distance) contact with a laboratory confirmed case, in any setting. Further details on the definition of close contacts  is available here - https://bit.ly/2SBbSe8
  5. Restricted movements: You need to restrict your movements for at least 14 days if you live with someone who has symptoms of coronavirus, but you feel well; are a close contact of a confirmed case of coronavirus or have returned to Ireland from another country. If the person you live with has had a test and it is negative, you don't need to wait 14 days. You should still follow the advice for everyone - stay at home as much as possible. Further information on restricted movement is available at:  https://www2.hse.ie/conditions/coronavirus/self-isolation-and-limited-social-interaction.html
  6. Note that due to current turnaround time for testing, contacts of suspect cases should be treated as contacts of confirmed cases for this risk assessment, rather than having a focus on the test result.  This will be kept under review.
  7. https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/
  8. Patients may have their treatment plan modified to reduce the risk of immunosuppression
  9. Access to isolation facilities to facilitate SACT treatment, particularly in the in-patient setting, may be limited depending on service demands.
  10. Such as limited resources (workforce, facilities, intensive care, equipment)

National Health Library & Knowledge Service. Health Service Executive. Dr. Steevens' Hospital, Dublin 8. Tel: 01-6352555/8. Email: hselibrary@hse.ie

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