key: cord-0805803-8xda78sn
authors: Alom, Samiha; Chiu, Chun Ming; Jha, Ashwarya; Lai, Sheung Heng Daniel; Yau, Thomas Ho Lai; Harky, Amer
title: The Effects of COVID-19 on Cancer Care Provision: A Systematic Review
date: 2021-02-26
journal: Cancer Control
DOI: 10.1177/1073274821997425
sha: 59254a3d68bc95e9c9c219490bf04d7b9546653c
doc_id: 805803
cord_uid: 8xda78sn

This systematic review aims to gather primary data from cancer institutions that have implemented changes to cancer service provision amid the COVID-19 outbreak to inform future intervention and health care facility response strategies. A comprehensive literature search was done on Global Health Medline and EMBASE using pertinent key words and MeSH terms relating to COVID-19 and Cancer service provision. A total of 72 articles were selected for inclusion in this systematic review. Following the narrative synthesis that was conducted of the literature, 6 core themes that encompassed common cancer service intervention adopted by institutions were identified: (1) Testing and Tracking, (2) Outreach and Communication, (3) Protection, (4) Social Distancing (5) Treatment Management, (6) Service Restructuring. Since cancer patients are a high-risk population amid the COVID-19 pandemic, these areas of targeted intervention can be used to inform necessary actions in institutions facing similar risks, based on previous learning from numerous cancer centers globally.

In December 2019, COVID-19 / Coronavirus / SARS-CoV-2 emerged in Wuhan, China, and has subsequently infected over 53.7 million people and caused over 1.3 million deaths globally (as of 15 November 2020). 1 As these numbers are continually increasing, healthcare services worldwide have been subject to immense strain to cater to influx and demands of patients. 2 To combat this, service provision in healthcare institutions have subsequently been reorganized in order to cope with COVID-19 related challenges. 3 The impacts of the COVID-19 outbreak have been particularly evident for cancer services, with many patients experiencing delays in cancer diagnosis and treatment. 4 For example, in the United Kingdom national cancer screening programs have been suspended and patients who are referred may be subject triage before being able to receive treatment. 5 Common stressors on healthcare facilities have been due to the shortage of intensive care beds, as well as the inability to protect healthcare staff due to shortages of personal protective equipment (PPE). 5 To combat the disruptions, cancer care facilities have had to adopt drastic service configurations in order to maintain timely and effective care. 3 These changes have been vital as cancer patients are at high risk of complications from viral infections and are likely to experience adverse outcomes. A Chinese cohort study reported that cancer patients with COVID-19 are at higher risk of severe events, including intensive care unit admission, invasive ventilation and death, compared to patients without cancer (39% vs 8%, p ¼ 0.0003). 6 In light of this, the disproportionate vulnerability highlights the need for implementation of effective strategies that safeguard and protect oncology patients during this time.

In summary, the continual fluctuation of caseloads and the evolving nature of the pandemic require flexible and adaptive care to ensure the safety of patients and staff. As a result, there is a need to study and evaluate whether current adaptations to cancer care have been yielding consistent and positive outcomes for health systems worldwide. This systematic literature review aims to gather primary data from cancer institutions that have implemented changes to cancer service provision amid the COVID-19 outbreak to inform future intervention and health care facility response strategies.

A comprehensive literature search was done on Medline, Global Health and EMBASE to identify articles relating to cancer service provision during the COVID-19 pandemic. This was done in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Grey literature was also included and obtained through snowballing. The search was deconstructed into 3 categories that comprised relevant keywords and MeSH headings relating to (1) COVID-19,

(2) Cancer and (3) Service Provision (Table 1 ). All the relevant articles were identified and screened by 3 authors.

Inclusion and Exclusion Criteria:

The inclusion and exclusion criteria are outlined in Table 2 . Studies were included if they contained primary data on cancer service provision amid the COVID-19 pandemic (Table 2) .

A quality assessment for the included articles was carried out using the NIH quality assessment tool for the appropriate studies. No articles were excluded based on their quality score.

All the relevant articles were screened and selected for inclusion by 3 authors and any disagreements were resolved through consensus and vote. Data extracted from the included articles were tabulated and then a narrative synthesis was undertaken to identify key themes in the literature.

A total of 72 articles were selected for inclusion in this review following screening and duplicate removal ( Figure 1) . A narrative synthesis was conducted following the analysis of the data to identify recurrent and common themes of intervention that were frequently mentioned. Following this, we categorized the data into 6 themes of core cancer service interventions: (1) Testing and Tracking, (2) Outreach and Communication, (3) Protection, (4) Social Distancing, (5) Treatment Management, (6) Service Restructuring (Table 3) . These themes encompass the comprehensive interventions adopted by various cancer departments/institutions during the pandemic. The characteristics of the included articles are summarized in Table 4 and have been explored in a narrative manner in the main text. A large proportion of the studies were conducted in China, Italy, Singapore, United Kingdom (UK) and the United States (US) and included various oncological sub-specialisms.

The literature highlighted 6 common key areas for focused intervention that were adopted by many cancer institutions. A detailed summary of each theme is described below so that we can better apprehend how such measures enabled cancer care continuity, while also mitigating viral spread and protecting staff and patients.

(1) Testing and Tracking

Testing played a huge role in various studies, with many hospitals enabling patient screening for COVID-19 symptoms upon hospital entry or pre-operatively. 3, This involved recording body temperature, checking respiratory symptoms, and taking blood tests and nasal swabs. 3 Category COVID-19 AND "Coronavirus," OR "nCoV*," OR "2019-nCoV,"

OR "COVID*" OR "SARS-CoV*" Cancer AND "Cancer" OR "carcinoma" OR "malignancy" OR "metastasis" OR "Neoplasm" Service Provision "Service" OR "service provision" OR "Care provision" OR "Care" OR "Care organisation" OR "Healthcare provision" In the English language tests results were positive, patients were either disallowed treatment, asked to isolate/quarantine or were directed to COVID-19 outpatient clinics/admitted in to dedicated COVID-19 wards. 33, 36, 40 These interventions helped to prevent the on-site transmission of the virus. In addition, Ngoi et al describes the use of 2 checkpoints within the hospital, where patients and their accompanying visitors had to fill out a health questionnaire and were screened via a thermal scanner for their body temperature (Singapore). This intervention was deemed effective, as results showed that within a 1-month period of adopting this screening method, only 1 person within the hospital was found to be COVID-19 positive out of 70 people tested. 41 As part of patient triaging pathway in some cancer centers, symptomatic patients would have to attend fever clinics before their appointments with their oncologists (UK and China). 21, 42, 43 Staff testing was also mentioned in some articles, with Tan et al and Tey et al reporting that all staff temperature readings were taken twice daily to reduce healthcare worker-patient transmission and safeguard patients and staff. 7, 10, 23, 42, 44, 45 A dedicated tracer team that monitored all patients under investigation allowed for active tracing of all clinical staff that were at potential exposure risk, through using a patient points-of-contact framework. This allowed for staff to be notified of infection risk immediately and enabled rapid instruction regarding the need for quarantine. 46 In addition, contact tracing was highlighted as a tracking method to identify potentially infected patients worldwide. 34, 42, 43, [45] [46] [47] Wang et al demonstrated that the use of documentation of all contact and travel histories was imperative for permitting visitors into the facility (China). 34 Similar contact tracing tactics were deployed in Korea which required mandatory quarantining of COVID-19 patients and any identified personnel who were in close contact with them. 47 A nation-wide program was implemented in China where health QR codes were issued to track case numbers in residential and high-risk areas. This large-scale surveillance system was informative for high-risk patients as they could make the decision to shield themselves if residing in a high-risk area. 43 The benefits of tracking were also evident in a study conducted by Ning et al who reported that active tracking reduced adverse effects that can occur from treatment delay and workforce incapacitation 46 (2) Outreach and Communication

One of the most prominent strategies to ensure the maintenance of care continuity was regular communication between healthcare providers and patients. While use of telehealth and mobile phone technologies has grown in recent years, it has shown to be particularly useful amid the COVID-19 pandemic. Many studies reported the use of telehealth through videoconferencing, telephone, email, mobile phone apps and text message as a means to monitor and counsel patients. 3,7-8,11-12, 15-19,20-22,24,29,30,33-37,39-41,43,45,46,48-65,78 This included screening, symptom checking and side effect monitoring and outpatient care. 8, 22, 29, 39, 45, [52] [53] [54] These modalities of communication were significant in enabling better evaluation and follow-up of patients, as well as facilitating patient triaging and contact tracing. This was demonstrated in an Italian paper, where a "Double Triage Protocol" was put into place involving 2 separate telephone interviews for palliative care patients that require home care. The first interview assessed if COVID-19 symptoms were present in the patient, while the second assessed the severity of their symptoms in order to guide the frequency of home visits. 29 Additionally, de Marinis et al showed that telehealth can be utilized for clinical application and diagnostics, whereby telematic evaluation was utilized for CT scans. 39 The main disadvantage of telehealth for care provision, however, was reduced efficiency as it made appointments longer by an average of 10 minutes. 15 Lobascio et al and Peeters et al also highlighted the use of mobile phone apps to help monitor and manage patient treatment toxicity and nutritional status. 56, 63 In terms of patient acceptability, Van der Lee et al reported interesting patient feedback, with patients showing a preference for virtual consultation due to the ease of accessibility and increased convenience as it reduced the need to travel. 64 Conversely, patients also reported feeling psychologically distant with the doctor as there was reduced non-verbal communication and felt that there was less time for reflection following their call. 64, 65, 78 A Canadian cancer center tried to mitigate this through running a trial to provide patients with daily, self-subscribed supportive text messages for extra psychological support. 11 In light of this, healthcare providers must be astute of the risks posed on the weakened doctor-patient interactions which could have significant impacts on patients' quality of life, 66, 67 Consequently, the psychological impacts of drastic transitioning to tele-oncology should not be overlooked, especially within oncology where adjunctive emotional and holistic care is crucial.

Other forms of patient outreach and education included the dissemination of educational materials through virtual means or via patient information leaflets. 18, 44, [55] [56] [57] In Canada, the Princess Margaret cancer center released core education tools. These tools aided cancer patients with low health literacy to find reliable cancer-related patient education materials and a website (pmcancerclasses.ca) was recommended for online cancer classes for patients and families. 58 These strategies may be an effective way to improve patient compliance with protective measures and inform them of potential risks.

Effective communication of COVID-19-related risks was emphasized in the literature prior to consenting patients for treatments. 19 In West Africa, patients were educated about the possible additional risks of chemotherapy during the pandemic, including the complications associated with contracting COVID-19 and the possibility of experiencing poorer treatment outcomes. 40 Similar practice has been adopted in the UK, where doctors have openly educated patients on COVID-19 related risks before and during surgical treatment. 19 Videoconferencing was also frequently utilized between healthcare staff and multidisciplinary teams in order to streamline healthcare provision, continue staff training and maintain timely diagnosis and treatment. 7 12 Short Report Turkey 1. Floors were marked for enforcement of social distancing while in hospital 2. Follow up appointments were performed over telephone 3. Patient triaging with temperature measurements was done at hospital entrance 4. Only 1 companion allowed per patient 5. Patients were informed to go to palliative care outpatient, rather than emergency department, for treatment-related symptoms 6. All new patients were given same day appointments to avoid delay in diagnosis Harky et al. 61 Letter UK 1. Telemedicine has been widely adopted into current practice 2. Out-of-hours operations have been a viable coping strategy adopted 3. Patients triaged on respiratory symptoms and contact histories Indini et al 33 Cross-sectional (multi-center survey)

Italy COVID-19 diffusion containment measures: 1. Triage of patients (vital sign monitoring at entrance of hospital) 2. Patients questioned on symptoms during 15 days before visit and possible contacts with COVID-19) 3. Triage procedures sometimes resulted in preventative isolation and diagnostic work up of symptomatic patients (nasal swab/ chest x-ray) 4. Non-urgent visits delayed (mainly follow up visits) 5. MDT video conferencing for meetings 6. Patients underwent telephone interviews/counseling 7. Access to oncological hubs was limited/denied for visitors/caregivers (outpatient visits, day hospital and ward admissions 8. Family doctors delegated to conduct follow-ups/carry out home visits 9. Telephone line was set up for emergencies Diffusion of COVID-19 in oncology units:

1. One third of oncological hubs had to employ their oncologists for guard duties in the internal medicine ward/emergency dept. 2. Patients' treatments were redistributed homogeneously throughout the week 3. Doctors on COVID wards waived from oncologic activities to reduce the risk of infection.

Jiang et al 60 Review USA 1. Remote care was established to facilitate anti-cancer medication deliveries 2. 92.8% reported very satisfied with the experience with using clinical video telehealth (CVT) Lee et al 15 Perspective Hong Kong 1. Routine clinic appointments were postponed (only urgent conditions to be seen or reschedules 2. Number of doctors seeing consultations was reduced performing aerosol generating procedures. 3. Reduction of caseload (doctor saw only 10-15 patients per session) allowing time needed for infection control compliance 4. All doctors were given PPE 5. Drug refill clinic was set up to allow stable patients to get repeat prescription without consultation 6. Extra clinic sessions on weekends and evenings were considered to deal with accumulation of rescheduled appointments 7. Telemedicine appointments were implemented (took 10 minutes longer than face-to-face appointment) 8. Preoperative personnel for procedures was kept to a minimum . 9. Video laryngoscopes with a plastic drape to form a barrier between them and the patient's airway to decrease aerosol spread were used by Anaesthetists 10. Only experienced surgeons were selected for airway operations in order to reduce contact time and risk. 11. Reduction of operation theater service (only emergency and priority elective operations go ahead) Lee et al 47 Editorial Korea 1. Aggressive contact tracing and quarantining of COVID-19 positive patients and any personnel in close contact 2. Patient triaging by telephones a day before appointments were done 3. COVID-19 testing was offered to patients attending chemotherapy infusion 21 Reportage China 1. Patients and healthcare workers in the hospitals were screened (via nucleic acid and antibody tests in combination with CT scans) 2. An isolation ward was created with an increased prevention level compared to the rest of the hospital 3. Telemedicine was used to follow up on discharged patients and medicine was mailed to patients 4. Confirmed patients were isolated and visits were prohibited 5. Wearing of masks and hand sanitization by staff and patients were made mandatory 6. To combat shortage of staff, 50 doctors and nurses were redeployed and temporarily relocated from other not-in-service departments to oncology departments (which also consisted of specialists in serious infections and management of respiratory tract diseases 7. COVID-19 confirmed and suspected cases were redirected to other hospitals 8. Careful evaluation of cancer patients was undertaken before admission with an emergency department for serious care 9. Elective patient admissions were postponed 10. Chemotherapy-free alternatives were given when possible. 11. Chemotherapy protocol was adjusted/postponed 12. Free-of charge online fever clinic was set up Mendoza et al 23 Editorial Philippines 1. Pre-scheduling and pre-screening of all patients was done for outpatient consultations and admissions 2. Referrals were coordinated to local oncologists for patients with travel restrictions 3. Patients receiving systemic cancer treatment were prioritized 4. The outpatient clinic was restructured physically and procedurally 5. hand hygiene and social distancing was observed in hospital Personnel working in COVID-19 areas were segregated 6. Medical supplies were secured by working with non-governmental organizations 7. Centralized inventory system for medical consumables was made (continued) 41 Editorial Singapore 1. All staff belonging to the National University Cancer Institute, Singapore (NCIS), with clinical and non-clinical roles, were separated into 2 teams to prevent full departments from being quarantined in the case of COVID-19 2. Each outpatient part was segregated from the others, with their own registration desks and triage systems to help enable contact tracing 3. Cancer services running within the community were canceled, such as home chemotherapy 4. All face-to-face meetings were canceled, and all departmental meetings were conducted via video calling 5. Telemedicine consultations were conducted 6. Home delivery of prescribed medications was used 7. All patients and visitors to outpatient clinics were screened at 2 points in the hospital via a thermal scanner and health questionnaire. Outcomes: During the 1-month period in which this team segregation method was carried out, 70 COVID-19 testing kits were utilized in the outpatient and inpatient clinics. There was only 1 case of COVID-19 found in the entire unit Ning et al 46 Prospective cohort study USA 1. Routine appointments were deferred by 2 months 2. Transitioning to telemedicine as implemented 3. Patients were outsourced to local oncology providers 4. Designated contact tracing team were formed to identify staff who are exposed to patients who was tested positive for SARS-CoV-2, which subsequently leads to quarantining of staff 5. Staff were screened for fever and respiratory symptoms and offer staff testing if symptomatic 6. Dual PPE policy was implemented-Patients and clinicians had to wear surgical masks while on site is delivered in more than 90% of cancer centers 3. Clinical areas were frequently sterilized in 85% of centers 4. Telemedicine was adopted in 76% of centers 5. 65% of centers required COVID-19 swab tests before admission 6. 50% reduced palliative care admission Ong et al 72 Letter Singapore 1. Team segregation was used to ensure continuity of care 2. Outpatient load was decreased and non-urgent cases were deferred to ensure sustainability 3. High patient load was maintained through efficient deployment of manpower within the SPRinT team. Oualla et al 22 Article Morocco 1. Crisis management team was formed 2. Training was given to all staff in the Oncology department 3. Patients were tested before admission and only those who were COVID-19 negative were admitted 4. Face mask-wearing was mandatory for patients and staff 5. Temperature monitoring of patients and staff was implemented 6. Alcohol hand rubs were provided in hospital 7. Reception area and clinical rooms were disinfected 8. The number of accompanying family members was limited 9. All clinical follow-ups were postponed 10. Transition to web-based consultations was implemented 11. Stopping or changing treatment was considered if absolute benefit of treatment regimen is low; Reduce invasive procedures that requires ICU admission 12. For patients with metastatic disease were discussed on case-by-case basis. Discussions considered patients age and comorbidities, considered treatment breaks/oral treatment for indolent and stable disease 13. Palliative care was managed with telephone consultations with home services in patients with high palliative care needs Patel et al 16 Perspectives USA 1. Preoperative COVID-19 testing was offered in 79% of institutions 2. Telemedicine was implemented in most head and neck cancer units implemented 3. Clinical visits were limited through triaging of patients 4. Resident involvement in surgery was limited 5. N95 masks were used for all high-risk procedures in patients who tested negative 6. Treatment decisions were reviewed by multidisciplinary committee Peeters et al 63 Editorial Belgium 1. Mobile phone apps were developed to monitor treatment toxicity in patients and identify individuals who are at risk of COVID-19 infections Peng et al 43 Comment China 2. Nation-wide program issued each personnel a health QR code showing a 2 tier contagion risks, which was determined by the number of cases in the area of residency. Medical isolation is required for "high-risk" patients, unless in an emergency 3. Face coverings were required in hospitals 4. Temperature monitoring of patients and staff was implemented 5. Visitors were prohibited in the wards 6. Fever clinics were used to screen patients with suspected COVID-19

symptoms. If cancer patients presented to the hospital with fever, they were attended by an infectious disease specialist before they were seen by oncologists 7. Online consultations were performed Home drug deliveries were done 8. Special programming model was used to aid scheduling of radiotherapy to minimize patients' waiting time at hospital (continued) Urologists who tested negative resumed oncological cancer service on a biweekly rotation 2. Patients who were exposed to infected personnel were found by extensive contact tracing and subjected to strict quarantine. These patients were advised to monitor their symptoms with a symptom diary 3. Symptom checking and side effects monitoring was done through telemedicine; multidisciplinary team meetings were conducted using teleconferences 4. Enrolment in clinical trials was suspended; Study follow-ups were done under virtual care 5. Treatment de-escalation: Immunotherapies were given at prolonged intervals; chemotherapy was subjected to dose reductions 6. Patients were triaged prior to hospital visits; patient companions during visits were prohibited 5. Patients visiting the hospital for systemic treatment were advised to wear surgical masks and were taken to a single room on arrival. Silvestris et al 35 The number of patients in clinics was reduced and appointment times were spaced out 3. Cross-covering of satellite clinics in cluster hospitals was suspended 4. Multi-disciplinary meetings were conducted via email/teleconferencing 5. Teams were divided to service each treatment site when full segregation of services activated 6. Temperature was checked and logged twice/day on database (staff) 7. Only one person was allowed to accompany patients 8. Declaration form for patients had to be signed at hospital entrances before triage 9. Thermal Scanners were placed at hospital entrance 10. Visitors had to wear surgical masks 11. Non-essential appointments were postponed (continued) Tey et al 10 Perspective Singapore 5. Strict visitor screening was implemented 6. Patient triaging with questionnaire and temperature measurement was implemented 7. Universal masking of all visitors was implemented 8. Twice daily temperature monitoring of working staff was done 9. Weekly reviews of availability of medical supplies was conducted 10. Radiotherapy was continued if it has already been started, but new elective new referrals were reduced to high maintenance services (E.g. Brachytherapy) 11. Staff segregation-movement between hospitals was restricted 12. Care teams were formed so 1 team could ensure continuity of service if 1 team requires quarantine 13. Workplace segregation was adopted-2-meter distance between work desks 12. Separate areas for meals were allocated for different clusters of staff Valenza et al 37 Observational Italy 1. Filters were applied to and within the hospital, the institution of a surveillance zone to serve both in-hospital and out-of-hospital individuals suspected of having COVID-19, and filters for patients about to undergo surgery. 2. Text messages were sent to those with appointments to contact their doctor if influenza-like symptoms displayed 3. Text messages were sent to those with hospital appointments, asking them to contact their doctor upon experiencing symptoms 4. Those at hospital entrance were filtered out by symptoms and temperature measurements. 5. Surgical masks were distributed 6. Surveillance zones (serve both in-hospital and out-of-hospital patients suspected of having COVID-19 or in need of a differential diagnosis to continue with cancer treatment) was chosen according to -Logistics: Room isolation was considered based on transfer time and distance within the hospital to access CT scanner). Closed-circuit video cameras installed in high care and triage rooms to limit number of nurse visits -Pathways of diagnosis and treatment: pathways and treatment were designed for categories of patients (admitted and at home (under active treatment)). 8 Perspectives Germany 1. A multidisciplinary leadership task force was established to discuss treatment plans on a case-by-case basis 2. Outpatient care was replaced with telemedicine 3. Staff and patients were trained to practice social distancing at outpatient departments 4. Elective surgeries were reduced to make way for necessary cancer surgery 5. Frequent staff testing was provided for those with suspected contact with COVID-19 patients 6. Physicians were assigned a designated replacement staff in case of quarantine Outcome:Reduction in outpatient visitors by 40-50% per week 6 cancer patients and 5 staff members were tested COVID-19 positive Wilkinson 42 Editorial UK 1. COVID-19 free cancer center was established 1. Patients were quarantined and tested before surgery 2. Clear guidance was issued on patient prioritization (3 tier system arranged according to urgency of treatment) 3. Phlebotomy service allowed patients to wait in their cars for their turns 4. Treatment adaptation: immunosuppressive treatments were reduced 5. Regular weekly staff testing was implemented 6. Phone calls prior to appointments were made for patient reassurance 7. Rapid diagnostic clinics were held virtually to deal with new referrals Wilson 30 Report (gray literature) UK 1. Single point entry to the hospital was instated, where all patients and visitors were screened 2. Oncology and hematology wards on separate levels were repurposed into a clean ward for patients who had tested negative and a second ward for patients awaiting test results 3. face to face outpatient clinic appointments were almost entirely replaced by to telephone-based consultations almost entirely 4. All intravenous anti-cancer treatments were moved off-site

Dharmarajan et al reported that instating virtual multidisciplinary conferencing facilitated MDT evaluation, referral coordination and reduced diagnosis, treatment delays and travel burdens on patients and staff. 38 Utilization of this modality was also well accepted among the users as many found it comparable to in-person meetings. 51 In Lebanon, virtual MDT also allowed for patient data to become centralized on a single electronic system, which facilitated efficient virtual meetings and allowed for more participants to be included than in normal face-to-face meetings. 59 However, one study reported that the duration of MDT case presentations had also increased and there were greater delays in receiving supporting information such as imaging and pathology slides. 78 Although speed and efficiency were marginally hindered compared to "business as usual," videoconferencing should be considered by institutions as a method to reduce unnecessary physical contact between managing team members. In summary, the adoption of telemedicine into modern practice has been well received by both healthcare professionals and patients. 26, 44 (

This theme encompasses measures that aim to mitigate the spread of the virus to protect both staff and patients. Use of PPE by staff was adopted by almost all institutions. 7,11,15-17, 19-21,24,30,35,37,40,43,44,46-49,55,68-70 For example, in a head and neck cancer center in the UK, staff were required to wear full PPE intra-operatively and surgical staff were instructed to change clean scrubs after entering hospital. 19 Patients and visitors were also sometimes asked to wear masks, especially if they displayed symptoms. 7, 10, 20, 21, 24, 34, 36, 37, 43, 45, 46, 70 While PPE was endorsed as a necessity within many healthcare institutions, some studies reported shortages. For example, in the US, a 35% shortage in protective gear was reported. 16, 21 Tey et al, however, stated that their institution in Singapore undertook weekly reviews for the medical supplies, a potential way to ensure PPE shortages can be mitigated. 10 Similarly, at the National University Cancer Institute of Singapore, to further reduce the use of N95 masks and gowns in cancer wards, Treatment adaptations 5. Standard prescription length for some oral medications was increased to reduce appointments 6. Medications including oral anti-chemotherapy were sent to patients' home addresses 7. Patients established on immunotherapy were switched to longer regimens Team restructuring:

8. Separate staffing was adopted for clean, potential positive and confirmed positive areas 9. Separate consultants provided inpatient cover to clean and positive areas 10. Junior doctors covered all inpatient areas onsite 24 hours a day 11. Shadow rota was implemented to cover sickness or self-isolation 12. Task groups were set up between registrars, consultants, senior nursing staff and management to facilitate rapid decisions and communication Wu et al 44 Perspectives China 1. Patient and healthcare worker screening was undertaken 2. Health education for patients: patients signed a consent form before therapy and were informed of the risk of cross-contamination during treatments and the zoning design of center. 3. Staff were trained on personal hygiene, prevention and protection. 4 . Staff learned about the appropriate personal protection for the role 5. Special radiotherapy workflow was adopted to avoid patient-patient contact and minimize patient-staff interaction time. 6. Departments were divided into zones according to different contamination levels Yusuf 13 Editorial Pakistan 1. Well-developed textile companies were enlisted to help speed up the production of protection gowns and N95 masks 2. Only essential imaging studies were performed. Elective imaging and endoscopy surveillance were stopped 3. All hospital visitors were triaged to quickly screen for respiratory symptoms at hospital entrance. High-risk patients were transferred to temporary triage areas 4. Outpatient services were continued virtually 5. Treatment adaptation: Oral medication was preferred over ablative procedures for hepatocellular carcinoma to minimize hospital visits all COVID-19 positive patients were admitted to a designated COVID-19 ward. 41 Another approach taken in Zambia was the tiering of PPE protocol, which reserved various types of PPE depending on patient type and status. 68 Interestingly, Morrison et al from the USA reported extending the use of N95 respirators through reprocessing under UV light radiation and vaporized hydrogen peroxide. 69 On the other hand, Philippines and Pakistan ensured that demands were met through increasing the supply of PPE through working with manufacturers and external charities. 13, 23 To ensure correct use, one study also conducted a refresher course on PPE and Powered Air Purifying Respirator (PAPR) so that staff knew how to use their PPE properly. 7 Disinfection was also an important priority for some healthcare centers with hand sanitizers being widely distributed and hand sanitation/washing being made compulsory. 11, 18, [20] [21] [22] 34, 71 Clinical environments and equipment were also frequently sterilized, such as the disinfection treatment of beds and surrounding areas during treatment intervals. 18, 20, 22, 24, 44, 71 Anesthetists also undertook protective measures whereby intubation procedures were conducted via the use of video laryngoscopes with a plastic drape in order to reduce aerosol spread (Head and Neck Cancer Services, Hong Kong). 15 

Social distancing measures were put in place to enforce physical distance to help limit contamination and spread. To minimize contact among patients, some facilities enforced limits on the number of patients who were permitted onsite at a given time for clinical visits. 16, 33 Stringent restrictions on visitation for visitors/caregivers were applied and waiting rooms were closed in centers to reduce unnecessary congregation of people within a confined space. 12, 14, 16, 18, 20, 22, 35, 40 In some cases, visitors were able to accompany patients, given that health checks were enacted upon arrival. 7, 10, 34, 41 To ameliorate the social impacts of this, cancer care providers from Singapore tried to establish communication with family members through conducting remote meetings. 14 Another social-distancing measure to avoid physical proximity was adopted in a cancer center in Bermuda, where patients were asked to wait at car-parks until they were collected for their appointment. 26 Similarly, in the UK, phlebotomy services adopted similar approach where patients were asked to wait in their cars until their turn. 42 Peng et al also described the use of a special programming model in China which aided the scheduling of radiotherapy, in an attempt to minimize waiting time and hence cross-infection risk for patients requiring in-hospital treatment. Similarly, an online booking system was utilized in Wang et al to improve efficiency and limit the number of patients on-site. 34 Clinical space reconfiguration was also undertaken, as some centers attempted to modify their physical environment to better facilitate social distancing through freeing up physical space or marking floors and/or seating. 11, 12, 23, 26, 68 For example, a breast cancer center in Italy reorganized working spaces and schedules in radiology and outpatient clinics to minimize patient flow and increase physical distance. 21 Another study also ensured that work desks had a 2-meter separation between them to ensure adequate spacing. 10 Staff and healthcare workers were also subject to intervention to minimize staff-staff/patient-staff contact. 7, 10, [14] [15] [16] [17] 19, 20, 23, 24, 36, 41, 44, 47, 72 In Singapore, staff-to-staff transmission was avoided by separating areas for mealtimes for different clusters of staff. 10 Additionally, in surgical settings, the presence of staff during high-risk procedures was minimized when possible in order to reduce staff-staff contact and protect them from aerosol generating procedures. 19 For example, in head and neck surgery, intubation was performed with only essential members of the anesthetic team, while in Hong Kong the number of staff required to be present was reduced preoperatively and intraoperatively. 15 In the USA, Patel et al also noted that several Head and Neck cancer centers limited resident participation in high-risk surgeries. 16 Staff-to-patient transmission was mitigated through implementing "staff segregation systems," in which oncological staff were often separated into 2 teams or had back-up staff to ensure care continuity in the case of staff infection and subsequent need for quarantine. 7, 10, 13, 17, 23, 27, 30, 36, 41, 72 In Singapore, Ngoi et al discussed the utilization of a "Team-Segregation Pandemic Strategy" where departmental teams were restricted to one ward and cross-transfer of staff between hospital facilities was forbidden to avoid cross-contamination. The outcome for these measures were favorable as within a month of employing staff segregation, only 1 confirmed case of COVID-19 was reported among staff and patients. 41 Wu et al also instated the zoning of departments according to different levels of contamination in a center in China. 44 Social distancing was additionally enforced through physical isolation of COVID-19 wards and closure of common areas to prevent viral spread (Italy). 35 Rodler et al reported the isolation of new patients in a single room upon arrival (Uro-oncology, Germany), while in Mei et al, an isolation ward was created and had an increased prevention level compared to the rest of the hospital so that patients who tested positive could not be visited (Wuhan, China). 21, 45 Valenza et al similarly described the creation of a surveillance zone to house COVID-19 patients, whereby isolation rooms were selected based on transfer time and distance from the hospital CT scanner and contained installed video cameras to limit the number of nurse visits (Italy). 37 In addition, COVID-19 patients in need of urgent surgery were operated on when no regular cases were underway in a dedicated COVID-19 theater. 37 Attempts were also made to instate COVID-19 free cancer-dedicated centers/hospitals, in order to segregate them from institutions treating COVID-19 cases to prevent viral spread. 10, 19, 35, 42, 44, 70 In Van der Haar et al, cancer patients were transferred from general hospitals dealing with COVID-19 patients to dedicated cancer centers aiming to stay COVID-19 free. 3 However, this study also noted that complete segregation is difficult for cancer centers built within general hospitals as they still ended up treating COVID-19 positive patients. 3 It should be noted that factors such as widespread use of PPE and good ventilation are key factors that should be considered in order to mitigate aerosol transmission when segregation measures have been implemented within one building. 79 Finally, training staff and patients on social-distancing practice proved to be beneficial in improving behaviors conducive to maintaining physical separation. 8 Education on good social-distancing practice may be beneficial in ingraining habits that are essential for staff and patients who have high exposure to the virus due to their clinical surroundings.

With aims to minimize non-essential hospital visits and additional risks of treatment-induced complications, many health care providers adapted individual treatment plans during the COVID-19 pandemic. 8, 21 Careful assessment before treatment continuation/initiation and reviewing of hospitalization proposals were conducted to priorities patients requiring necessary and urgent intervention. 19, 35 De-escalation of treatment regimens was commonly adopted by many institutions, with some making changes to treatment type, intervals or dosage. 11, 13, 16, 24, 25, 30, 33, 36, [40] [41] [42] 73, 74 Several healthcare providers routinely considered replacing intravenous regimens with oral or subcutaneous agents and prolonging treatment intervals for intravenous treatment. 8, 10, 34, 35, 62, 73, 74 Interestingly, in Germany, this was accompanied by dosage increase in immunotherapy but reduction in chemotherapy to minimize risk of leukopenia. 45 In the UK, some patients with hematological cancers were denied stem cell transplantation and received radiotherapy instead, while patients with locally advanced colorectal cancer, were offered a short course of radiotherapy prior to radical surgery rather than the standard long-term chemotherapy prior to radical surgery. 42, 73 In Italy, oncologists adopted regimens that deviated from orthodox first line therapy for breast cancer in the metastatic setting. Preferred adaptions included switching of oral treatment in patients eligible for chemotherapy administration (n ¼ 139; 84.2%) compared to the standard intravenous agents (n ¼ 26; 15.8%). A significant deviation of treatment therapeutics was also observed, whereby the administration of CDK4/6 inhibitors to endocrine therapy for luminal tumors with less-aggressive characteristics was reduced during the pandemic than before the emergency (n ¼ 92; 55.8% vs n ¼ 132; 80.0%). 74 In Tagliamento et al, concerns over the potential interference with immune checkpoint inhibitors (ICI) and SARS-COV-2 was highlighted. Despite this, 97.1% of Italian physicians in the survey reported that they would not deny ICI's as a treatment option, while 31.7% of the respondents did not modify the choice of the ICI and the schedule of administration in order to reduce the number of hospital visits. 25 With the ambiguity surrounding the interaction between ICIs and the pathogenesis of the virus worsening hyperinflammation with cytokine release syndrome, is it essential that parallel efforts are made to reduce the risk of contracting COVID-19 among patients taking this medication. 25 Delivery of this drug should be evaluated on a case-by-case basis and should take both efficacy and safety into consideration. 25 Similarly, treatment de-escalation was made in radiation oncology and nuclear medicine, in compliance with a proposed the 4R's system by a Canadian group, including (1) viRtual care, (2) Ration radiation, (3) deFer radiation and (4) hypofRactionate radiation. 10, 18, 36, 41, 50 Hypofractionating radiation in selected patients (i.e. escalation in dose of radiation, but reduced treatment frequencies) was thought to be a viable strategy to shorten treatment schedules in radiotherapy. 18 Interestingly, a retrospective cohort study following 800 cancer patients with symptomatic COVID-19 infection found no significant association between mortality and the receipt of cytotoxic chemotherapy, radiotherapy and immunotherapy. This suggests curative treatment should not be delayed in cancer patients while trying to shield cancer patients from exposure to the virus. 27 Curative cancer surgeries were also subject to change, delays or cancelation due to safety concerns or lack of resources. 9, 38, 40, 48, 66 Surgical oncologists often considered referral to non-surgical options such as radiotherapy or switching to a less risky surgical technique. 3, 9, 15, 75 For instance, one study reported that cordectomies were performed for vocal cord malignancy using a sharp technique, instead of the laser technique to prevent aerosolization of viruses. 49 In addition, attempts to switch from general anesthesia to local or regional anesthesia were observed during sentinel lymph node biopsies and breast cancer surgery in some UK centers. 42, 76 In the US, robotic technique was preferred over open surgery when managing urological cancers, while some others reported use of enhanced recovery programs after surgery protocols to minimize hospital stay. 14, 70 Patients who were also candidates for supportive therapy alone or eligible for alternate non-surgical treatment were excluded from hospitalization. 35 In summary, many centers judiciously considered risks and benefits for treatment continuation or initiation for patients, such as treatment-related complications and intensive care availability. 3 Although downscaling treatment plans in cancer patients was a significant intervention in this review, Poggio et al expressed their concern over potential undertreatment of cancer patients as a result of these treatment changes. 74 The general consensus was that each patient should be assessed on a case-by-case basis by multidisciplinary teams and that delaying treatments for curable cancer was not recommended. Tumor stage, histology, age, treatment type, comorbidities, patients' general well-being and history of recent pneumonitis were taken into account when assessing the risks and benefits of cancer treatments. 39 Documentation of treatment variation into trust databases and regular auditing of clinical activity was also deemed crucial in maintaining standard of care during COVID-19 pandemic (Head and Neck Surgery, UK). 19 (6) Service Restructuring Due to resource scarcity, staff shortages and interruptions to care continuity and accessibility, service provision was often adapted to combat the pressures inflicted on healthcare institutions. Service restructuring through role allocation, outsourcing and patient transfers were common methods used to help mitigate the strain. For example, healthcare providers outsourced investigations (blood tests) or transferred patients externally to private sectors/local providers to help alleviate burdens. 3 , 17,46 Some studies made referrals to family doctors and centers closer to the patient's home in order to maintain care continuity and conduct follow-ups, while also minimizing patient travel. 33, 39 Good organization and role allocation of healthcare staff proved to be pivotal in streamlining cancer care. 11 A case from the epicenter of the outbreak in Wuhan outlined the redeployment of 50 doctors and nurses to oncology departments who were part of departments that were not in service when cases of COVID-19 started exponentially rising. 21 Ong et al also ensured that there was efficient deployment of manpower to maintain high patient loads. 72 The importance of COVID-19 dedicated teams in Europe was also highlighted, whereby Valenza et al also described how setting up a "surveillance team" (including one nurse specializing in respiratory care) meant that COVID-19 patients could continuously be monitored (Italy). 37 In addition, in the UK, junior doctors also provided effective 24-hours cover for all inpatient areas onsite. This was made possible via an implemented shadow rota to cover sickness or self-isolation absence. 30 In the context of surgery, the importance of surgeon selection was also mentioned, with one study reported using only highly experienced surgeons who were selected for airway operations as a means to reduce contact time and risk as they were able to carry out surgeries at a quicker pace. 15 These examples demonstrate how assembly of a team with dedicated responsibilities and selection of staff based on their skills and competencies can contribute to increased safety and better quality of care.

In addition, to improve drug delivery, drug-refill clinics were set up to fast-track repeat prescriptions for stable patients who did not require drug reviews in Hong Kong. 15 In other countries, home delivery of medications was introduced to minimize patient travel to pharmacies. 14, 21, 41, 43, 60 One study also reported that patients received a higher volume of drugs at each hospital visit so that patients did not have to keep on returning to replenish their supply. 55 Another significant determiner for service restructuring was the need to accommodate demand, maintain care continuity, and address the accumulation of delayed and canceled appointments. 22, 28, 66, 69 Service restructuring proved to be essential in mitigating these strains. In Italy, a specific outpatient clinic was set up to resolve treatment-related cutaneous and mucosal adverse events53. This allowed for dedicated care for specific issues, while reducing appointment backlogging. Italian cancer designated hubs were also created to deliver necessary curative treatments in regions significantly hit by the virus (Lombardy) to ensure patients in high-risk areas were also able to access adequate care. 55 In Singapore, Ong et al reported that efforts were devoted to review patient lists for clinic sessions in order to decrease outpatient load and defer non-urgent cases. 70 Healthcare providers that limited caseloads to 10-15 patients per session and spaced out appointment times also implemented evening and weekend clinical sessions to reduce the backlogging of appointments. 7, 15 Out-of-hour operations were also adopted to catch up on rescheduled lung cancer surgeries (UK). 75 Finally, various institutions formed leadership teams and committees, who were pivotal in making crucial decisions in regard to various aspects of service restructuring in order to minimize patient contact. 30 For example, Blot et al highlighted the crucial role played by their ethical committee board in assisting physicians with decision making in clinical dilemmas. 77 Additionally, Civantos et al also set up an otolaryngologic triage committee in order to decide patient resource allocation, while in Germany a multidisciplinary leadership task force was created to assess treatment plans on a case-by-case basis. 8, 9 These leadership teams were essential for service restructuring decisions and ensured that care provision could be prioritized and maintained in a safe and efficient way. 9 The Utilization of Tele-oncology for Care Provision Possible financial, social and ethical factors should also be considered as telehealth becomes more integrated into cancer care. In terms of ethics, adequate cybersecurity measures should be in place to ensure patient privacy is protected. 78 Financially, positive economic outcomes for telemedicine usage have been reported highlighting the potential cost-effectiveness for healthcare institutions. 17 Financial support has been demonstrated by some countries such as the USA, where reimbursement for telephone and video encounters has been allowed. 78 However, ambiguity remains in regards to how flow of funds and reimbursement pathways will continue post-pandemic and as well as what constitutes as "chargeable" care. 78 Thus, there is a need for financial regulation and renegotiation of funding models to ensure that the financial implications posed on cancer institutions and oncologists can be minimized.

Despite the numerous benefits of telehealth, the social and structural implications associated are numerous. Internet connectivity, possession of digital devices and technological literacy are factors that can lead to digital and socioeconomic divides. As aforementioned, the virtual pivot may also have significant effects on doctor-patient interactions and rapport building, as well as removing the "social, moral and ritual significance" of in-person communication. 78 Thus, in order to bridge the digital void, acquisition of communication and technological skills within tele-oncology settings are required. 78 In summary, the COVID-19 pandemic has emphasized the benefits of the clinical application of tele-oncology for cancer patients. 80, 81, 82 As many cancer treatments often result in immunosuppression, cancer patients are a prominent risk group in the pandemic due to their increased susceptibility to contracting COVID-19. Thus, a significant benefit identified for tele-oncology is that it reduces the risk of infection through decreasing in-person contact, while maintaining care continuity. Additionally, since previous literature has reported that virtual oncology services are efficient, cost effective and result in good patient satisfaction, the future of tele-oncology is a promising prospect and is likely to be continually adopted post-pandemic in routine clinical care. 75, 83, 84 

The COVID-19 pandemic has placed inevitable psychological implications on cancer patients. Cią_ zyńska et al found that cancer patients often felt stressed due the uncertainty regarding their cancer therapy and the risk of developing COVID-19 symptoms while undergoing treatment. 84 Furthermore, patient wellbeing was also affected due to social distancing restrictions, as patients who would have previously taken their family members to hospital appointments were asked to come alone. 84 While our review focuses on the operational and organizational adjustments to care provision, cancer institutions must also consider the importance of providing emotional support and addressing mental health issues that are prevalent among cancer patients at this time.

Learning from the pandemic has also highlighted the broad impacts of how governmental policies and societal needs have shaped oncological care. It has also emphasized the need for healthcare systems to be dynamic and flexible in order to mitigate the mid and long-term ripple effects that will be reflected in clinical practice and patient outcomes. Broad challenges on oncological care will include: the effects of unemployment and thus the inability to pay for cancer therapies, access to novel treatments and clinical trials as a result of structural impacts, disparities in patient experience due to wider socioeconomic disparities, and enhanced mental health consequences. 78 In light of this, we can foresee that future cancer patient care will be disproportionately affected by the consequences of the COVID-19 pandemic. 78 Available Models of Care Delivery for COVID -19 Positive/Negative Patients COVID-19 Positive Patients. As COVID-19 positive patients may still shed the virus for prolonged periods, care delivery was adjusted in order to maintain cancer care for those requiring it in the interim. For these patients, 2 priorities were prominent within the care models of each institution. Firstly, changes to models of care were made to ensure effective isolation (either at home or in a quarantined area onsite) to minimize viral spread to other patients and personnel while receiving care. While isolation requirements often resulted in the cancelation/delay of treatments, implementation of COVID-19 designated areas in institutions facilitated the continuation of treatment for patients in need of in-patient care. Additionally, since COVID-19 positive were deprived of visitors, models of care should include services that supplement the emotional support that is usually provided through visitation.

Another significant consideration was the type, frequency, and continuation of treatment that was given based on their medical need and severity of cancer. Thus, the opportunity cost of maintaining cancer care in those infected was judiciously considered. The factorization of risks imposed by infection, such as developing severe pneumonia during the disease course and their weakened immune state were significant determinants for the proposed model of care delivery which were decided on an individual basis. The importance of conducting risk-benefit analyses has been particularly emphasised in the context of surgery, due to the substantial risk of mortality and developing postoperative complications in patients with COVID-19. 85 COVID-19 Negative Patients. For COVID-19 negative patients, efforts were predominantly centered around reducing the risk of contracting the virus. As a result, models of care delivery and treatment were adjusted to safeguard and mitigate the possible negative health outcomes patients may experience should they get infected at a later time. To reduce this risk, segregation systems were often instated to ensure COVID-19 negative patient safety. For institutions providing care within the same building, staff segregation interventions were instated so that staff working in COVID-19 designated areas would not mix with staff in contact with non-infected patients. In addition, some institutions implemented transfer procedures to relocate patients from general hospitals dealing with COVID-19 cases to COVID-19 free centers so that treatment could resume in low infection risk settings. Similar to patients who tested positive, the risk of COVID-19 exposure was weighed against the risk of not receiving or de-escalating cancer treatments.

In summary, the literature emphasizes the great importance of multidisciplinary leadership teams studying treatment regimens on a case-by-case basis due to the varying cancer types, prognosis, and needs within the cancer patient population. Moreover, due to their vulnerability to infection, institutions should also priorities effective segregation and isolation measures within their care delivery procedures. Based on these priorities, there is a need for models of care to be catered and flexible to patients according to a detailed risk-benefit criterion.

The purpose of the narrative synthesis conducted in this review was to identify key areas that must be targeted in order to mitigate viral spread while maintaining cancer care provision. In doing so, the themes outlined in the literature can be considered by cancer centers or other institutions containing high-risk patient populations when planning and implementing their own interventions amid the viral outbreak. Table 5 and Figure 2 highlights recommendations based on the findings from this review.

The utilization of common quality improvement tools, such as logic models (to evaluate the effectiveness of interventions), process mapping (to map out staff workflows and patient journeys) and Plan, Do, Study, Act Cycles (to test interventions and incrementally improve them) are recommended for the planning and assessment of new strategies for cancer service provision. These tools will help ensure that any changes to cancer care are thorough, efficacious and efficient.

In search of a better strategy to support cancer patients during the COVID-19 pandemic, research priorities should be directed to the following areas. Firstly, long-term clinical data is required to assess the impact of treatment de-escalation has on patients' outcomes. Secondly, psychological impacts on cancer patients should also be examined with both qualitative and quantitative methods to help guide evidence-based interventions aiming to provide adjunctive holistic and emotional care. Thirdly, though many healthcare institutions have shared their ideas on possible adjustments to be made on an organizational level, quality improvement data is still limited. Sharing of this information should be encouraged as it could provide a Treatment Managements 1. Carry out careful risk-benefit assessment before treatment initiation /continuation 2. Consider de-escalation of treatment regimens/frequency: 1. Consider oral/subcutaneous treatments over intravenous treatments (as well as prolonged treatment intervals for intravenous treatment) 2. Consider defer radiotherapy for less aggressive tumors; Hypofractionating radiation for those who are on radiotherapy to shorten treatment schedules 3. Consider changing to less invasive/immunosuppressive treatments 3. Consider postponing/canceling elective operations 4. Employ surgical techniques with lower risks of aerosolization 5. Minimize length of hospital stay using less invasive (e.g. robotic) surgery or enhanced recovery protocols after surgery 6. Document treatment variation and regularly audit clinical activity to maintain standard of care 7. Consider non-surgical interventions when possible Service Restructuring 1. Consider outsourcing selected clinical investigations (e.g. blood tests) to non-academic centers or the private sector 2. Delegate and refer care provision to family doctors/local centers 3. Streamline drug delivery: set up dug-refill clinics, home delivery, and prescription of medication through telehealth. 4. Limit case load and space-out patient appointments 5. Instate out-of-hour operations to reduce accumulation of delayed appointments 6. Form leadership teams or committees to help advise and streamline care 7. Form shadow rotas to help cover sick or quarantining staff 8. Leadership roles should be given to senior staff members to delegate tasks effectively 9. Select experienced surgeons to perform airway operations to minimize contact time with patient. 10. Redeploy staff from hospital departments that are not in service to oncological wards point of reference for recommended intervention implementation when managing future health crises. Finally, as we anticipate further consequential impacts on cancer care post-pandemic, it is imperative that efforts are made to better understand the mid-and long-term implications imposed on clinicians and patients. In order to strengthen the evidence-base, qualitative methods should be employed to aid primary data collection through surveys/interviews with relevant stakeholders to better comprehend the impacts of COVID-19 on the oncological landscape.

Majority of the articles included in this review were geographically based in high-income/upper-middle income countries. Consequently, relevant learning from low-resource settings may be limited. This was evident in our search, as the majority of screened studies were from China, Italy, Singapore and the United States.

In addition, our search strategy only included publications in the English language, meaning that the review may be subject to geographical bias. Thus, learning from non-English speaking countries (such as high death toll countries like Italy) may have also been forfeited as it can be assumed that a large proportion of studies would have been published in their native language.

While descriptions of interventions were plentiful in the literature, many studies did not report outcomes on whether the strategies were effective in mitigating spread of the virus and facilitating care provision. Therefore, we cannot be certain on how effective the interventions were in yielding positive outcomes and reducing the number of COVID-19 cases in cancer patients and healthcare workers.

Since this review only provides a descriptive list of interventions adopted globally (which were largely adopted due to recommendations encouraged by governments and scientific organizations e.g. testing and triage), it is difficult to form a uniform summary of cancer care changes as different countries have experienced different COVID-19-related challenges. Thus, due to the varying healthcare system contexts and burdens, we are unable to provide definitive recommendations for cancer care provision since there is no one-size fits all solution.

Cancer patients are a high-risk population amid the COVID-19 pandemic. As a result, extensive planning must be undertaken to protect this population from infection and COVID-19related risks, while also maintaining their cancer treatment and care. Many institutions have adopted various strategies to safeguard their patients and staff and streamline service provision, however the extent of success of these interventions is still unknown. This systematic review provides an updated summary of the evidence-base and presents 6 core themes of targeted intervention commonly adopted within numerous cancer institutions globally. The themes can be used as a tool to inform future interventions that can be implemented by healthcare institutions facing similar risks amid the COVID-19 outbreak.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Our study did not require ethics approval because the study did not contain human or animal trials.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Chun Ming Chiu https://orcid.org/0000-0001-8335-0409 Thomas Ho Lai Yau https://orcid.org/0000-0001-5510-6214 Amer Harky, MRCS, MSc https://orcid.org/0000-0001-5507-5841

Consider the ethical and financial challenges of transitioning to telehealth and the psychological impact on tele-oncology on patients

Consider and address the impact of tele-oncology on the doctor-patient relationship 6. Provision of cancer-related education materials online or through leaflets

Development of mobile phone apps for monitoring treatment and/or identifying those at risk of COVID-19

Education about and open discussion on the impact of COVID-19 or additional risks of COVID-19 infection with patients Protection 1. Provide training on PPE and provide PPE to all staff 2. Perform weekly PPE stock checks to mitigate potential shortages 3. Implement a tiered PPE protocol based on patient type and status 4. Staff change into clean surgical scrubs when entering hospital 5. Provide visitors and patients with masks upon entering facility 6. Use of video laryngoscopes and plastic sheaths can be used as a barrier to reduce aerosol spread during intubation to protect anesthetists

Consider using UV light radiation and vaporized hydrogen peroxide to extend the use of N95 respirators

Maintain PPE supply through engaging with external stakeholders (e.g manufacturers and charities) Social Distancing Patients and Visitors

Visitors/caregivers should be given limited access to health facility 2. If accompanying visitors are allowed, health checks should be put in place 3. Limit number of patients on-site

Instate measures to reduce waiting room congregation and waiting time (e.g. online booking systems to reduce waiting time

personnel and staff onsite are kept to a minimum (especially for surgical procedures) 9. Staff segregation systems put into place to reduce intermixing 10. Set up oncological teams focusing solely on COVID-19 patients with cancer

split teams into sub-teams) 14. Use of videoconferencing for multidisciplinary teams and healthcare workers 15. Perform aerosol generating procedures with the minimum number of members of the anesthetic team in the operating theater General 16. Segregation by area (allocate areas for COVID-19 and COVID-19 free rooms/zones) 17. Treatment rooms should utilize cameras to reduce healthcare worker-patient contact 18

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