key: cord-0944862-4pvk3fqn authors: Indini, Alice; Aschele, Carlo; Bruno, Daniele; Cavanna, Luigi; Clerico, Mario; Fiorentini, Giammaria; Fioretto, Luisa; Giordano, Monica; Montesarchio, Vincenzo; Ortega, Cinzia; Pinotti, Graziella; Scanni, Alberto; Zamagni, Claudio; Blasi, Livio; Grossi, Francesco title: Reorganization of Medical Oncology Departments during COVID-19 Pandemic: a Nationwide Italian Survey date: 2020-04-06 journal: Eur J Cancer DOI: 10.1016/j.ejca.2020.03.024 sha: d14da333bb8dc75ec869200ade23bf5e60e9329c doc_id: 944862 cord_uid: 4pvk3fqn The novel severe acute respiratory syndrome coronavirus-2 (SARSCoV-2) pandemic is a global health problem, which started to affect China by the end of year 2019. In Europe, Italy has faced this novel disease entity (named COVID-19) first and severely. COVID-19 represents a significant hurdle for public health services and a potential harm for patients with cancer. The Collegio Italiano dei Primari Oncologi Medici (CIPOMO) is an Italian association of head physicians in oncology departments, which promotes working and research activities in oncology on a national basis. In the midst of the epidemic in Italy, the CIPOMO promoted a national survey aiming to evaluate the impact of COVID-19 on clinical activity of oncologists and the implementation of containment measures of COVID-19 diffusion. Overall, 122 head physicians participated in this survey, with a homogeneous distribution on the national territory. Results show that the following measures for oncologic patients have been promptly implemented through the whole country: use of protective devices, triage of patients accessing the hospital, delay of non-urgent visits, and use of telemedicine. Results of this survey suggest that Italian oncology departments have promptly set a proactive approach to the actual emergency. Oncologists need to preserve the continuum of care of patients, as the benefit of ensuring a well-delivered anti-cancer treatment plan outweighs the risk of COVID-19 infection. International cooperation is an important starting point, as heavily affected nations can serve as an example to find out ways to safely preserve health activity during pandemic. On March 11 th 2020, the World Health Organization (WHO) declared the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) outbreak a pandemic [1] . By the end of February 2020, Italy was experiencing the rapid spread of the virus, which started to affect the North of the Country with a daily increase in the number of cases and consequent deaths [2] . In Italy, data regarding the diffusion of the novel coronavirus disease (COVID-19), caused by SARS-CoV-2 confirmed its higher lethality compared to that observed in China and worldwide (9% vs 4.3%) [3] . Following the Chinese model, containment measures to reduce the risk of COVID-19 in Italy have been promptly activated and implemented. The first national decree, issued on March 8 th , instituted a containment zone concerning the most affected areas of the Country (the so-called Red Zone, which at that time included 3 regions in the North of Italy: Lombardia, Emilia Romagna, and Veneto). In the following days, a series of decrees have extended increasingly strict measures to the whole national territory. The main provisions included: forbidding all gatherings of people; restricting movements of people within and outside the hometown, except for circumstances of necessity; encouraging employees to work from home. In this circumstance, health workers cannot take any leave, and are asked to suspend all non-urgent activities. All planned surgeries are postponed, to give over intensive care beds to the treatment of patients with COVID-19, and hospitals had to create new intensive care places by converting operating and anesthetic rooms. This pandemic represents a significant harm for patients with cancer, who are at high risk of infections due to several predisposing factors [4] . Moreover, most treatment procedures in oncology cannot be delayed without compromising the efficacy of treatment itself. In Italy, specific indications on oncologic patients' management were given on March 10 th , mainly regarding caution measures to reduce the risk of infection (i.e. use of personal protective equipment, practice social distancing). While encouraging physicians to postpone follow up visits, indications were given to guarantee oncologic services even within the Red Zone, in order to maintain the continuum of care. At the present time, data regarding diffusion and management of COVID-19 in oncologic patients are scarce [5, 6] . Such emergency has led Italian oncologists to join forces, with the aim to find a way not to compromise the continuum of care of patients and to preserve safe everyday clinical Here we present the results of this survey, providing an overview of COVID-19 epidemic in Italy and assessing potential interventions to overcome this critical situation. The survey includes a total of 27 questions, which are divided in 3 sections: the first section assesses the routine use of preventive measures (e.g. vaccinations) in oncologic patients; the second contains questions regarding COVID-19 diffusion containment measures adopted before the enactment of national decrees in this regard; the third and last section assesses the diffusion of COVID-19 in oncology units and its impact on working activity, after national decrees on containment measures were adopted. A complete original version of the survey is provided in Supplementary Material 1. The survey was launched online on March 12 th 2020, and closed on March 15 th 2020. Figure 1 Results of Section 1 show that the overall tendency throughout Italy is to perform preventive vaccination in oncologic patients ( Table 2 ). Most vaccinated patients are either receiving active systemic treatment (chemotherapy, immune-therapy, and hormonal or targeted therapy), and/or present one or more predisposing risk factors (i.e. age ≥ 75 years, cardiovascular and/or respiratory disease, chronic infections, diabetes, obesity, immune-suppressive therapies). The most widely adopted vaccination is for seasonal flu, however more than 30% of oncologists suggests also performing pneumococcal vaccination in those patients. Seasonal flu cases are not usually reported by medical oncologists to the dedicated national registry, rather this is commonly a duty of family doctors. Answers to the questions in Section 2 clearly show that, even if by the time of the survey COVID-19 represented an emergency mainly in the North of Italy, diagnostic measures for all patients accessing oncologic services were immediately activated in the whole country ( Table 3) . Triage of patients included vital signs monitoring before entering the hospital (body temperature, SpO2, respiratory rate), but also questioning patients on the presence of symptoms during the 15 days before the visit, and possible contacts with subjects affected by COVID-19 or coming from high-risk areas. In more than 65% of cases, triage procedure was followed by preventive isolation and diagnostic work up of symptomatic patients, consisting in chest X-ray and rhino-pharyngeal swab to rule out the presence of SARSCoV-2. After the very first reports of COVID-19 in Italy, measures to reduce hospital accesses for oncologic patients were taken almost throughout the country. Such measures consisted mainly in delaying visits not considered to be urgent (i.e. patients in follow up after surgery and/or radiotherapy, and/or patients with breast cancer receiving adjuvant hormonal treatment after surgery), even more so if the patients presented risk factors (i.e. age > 85 years, presence of comorbidities). Alternative ways to get in touch with patients have been widely used: most patients underwent telephonic interviews with interpretation of laboratory and radiologic exams report, while in other cases family doctors were delegated to inspect the results of follow up exams. Access to oncologic structures was likewise limited and/or denied for visitors and caregivers, either for outpatient visits, day hospital and ward admissions. With the enactment of the decree on March 9 th and subsequent decree on March 11 th , containment preventive measures became effective in the Red Zone before, and on the whole Italian territory thereafter. However, by that time most oncologic units had already activated measures to contain accesses, under regional or internal (hospital Medical Direction) orders. As so, more than 50% of oncologic structures did not have to modify the measures they implemented to reduce the risk of infections, in view of the actual legislation. Due to such measures, more than 20% of structures had reported a significant reduction in their routine activity, while 60% had only a negligible reduction and 9% had not substantially changed their activity. Answers to the questions in Section 3 show that almost one third of oncologic structures had to employ their oncologists for guard duties in Internal Medicine ward and/or Emergency Department; in 23% of cases, guard duties in COVID ward were included (Table 4 ). This percentage was understandably higher in the North of the Country, reaching 51% and 38% of oncologists employed for Internal Medicine/Emergency Department and COVID wards guard duties, respectively, in the Red Zone. Twenty-four percent of Italian oncology departments had at least one patient diagnosed with COVID-19, with a higher rate in the Red Zone (46%) and no diagnosis at all in the South of Italy and in islands. Examining reports from the Red Zone, it emerges that most patients accessed Emergency Room presenting with fever and/or respiratory symptoms (23%), while a significant proportion of patients was diagnosed after a triage procedure (18%) and/or a medical interview regarding possible contacts with subjects at risk (18%). Results of this survey deserve several considerations. Some effective points emerge from this survey, which partly have been also raised in the comment recently released by the European Society for Medical Oncology (ESMO) [7] . First, oncologists face the need to preserve the continuum of care for most of their patients, as the benefit of ensuring a well-delivered anti-cancer treatment plan outweighs the risk of COVID-19 infection. However, the risk from COVID-19 exposure varies significantly from patient to patient, making treatment tailoring important now more than ever. Second, physicians have to get used to a new working activity, which implies the use of tele-consultation services when feasible, and reducing the number of visits by means of customizing treatment delivery (three or two-weekly as opposed to weekly, oral or subcutaneous alternatives as opposed to intravenous administration). Also, in view of a visit a telephonic "previous day" triage could help, in order to avoid the access of symptomatic patients to oncologic wards. Third, protection of patients and physicians is paramount in order to keep providing the best service in a safe way. This last issue raises the question on how to optimize oncologic resources for COVID-19 emergency. Due to both clinical characteristics of oncologic patients, which are frail and at high risk for infections, and features of oncologic services, which often cannot be postponed, how can oncologist reasonably help in this emergency without compromising patients' continuum of care? To date, no clear indications have been provided to health care providers in oncology, making it difficult to create a common line of action. In conclusion, results of our survey suggest that Italian oncology departments have promptly set a proactive approach to the actual emergency. Together with indications provided by national decrees and internal dispositions, several individual initiatives have contributed to reorganize working activity in the actual condition. The medical community worldwide is facing a difficult situation, and oncologists in particular require several extra precautions to protect the patients first and their activity thereafter. International cooperation is an important starting point, as heavily affected nations can serve as an example to find out ways to safely preserve health activity during pandemic. The Municipal Health Services in Wuhan (China) report to the WHO a cluster of patients with pneumonia of unknown etiologic agent in the city of Wuhan, in the Chinese province of Hubei. January 9 th 2020 Chinese authorities make a preliminary determination of a novel (or new) coronavirus (SARSCoV-2), as the causal agent of the severe acute respiratory syndrome, named COVID-19. Chinese investigators conduct gene sequencing of the virus, using an isolate from one positive patient sample, making diagnostic tests promptly available worldwide. The Italian Ministry of Health sets up a task force to coordinate interventions on the Italian territory, together with international responsible institutions. A surveillance system for suspected cases is established. January 30 th 2020 Two Chinese tourists hospitalized for respiratory tract infection, in Rome, are the first confirmed cases of COVID-19 detected in Italy. Regional Health Authorities implement measures to track contacts of the two subjects. All contacts resulted negative for COVID-19. Italian government decides to interrupt all air connections with China. The WHO declares COVID-19 diffusion in China a public health emergency. The Italian Council of Ministers declares national public health emergency condition. February 21 st 2020 The Italian National Institute of Health confirms the first case of local transmission of COVID-19 infection in a 38-year-old patient in Codogno. February 28 th 2020 The WHO raises the threat definition for COVID-19 epidemic at a "high level" of threatening for the global health. March 8 th -9 th 2020 A national decree institutes a containment zone concerning the most affected areas of the Country, located in the North of Italy (Lombardia, Emilia Romagna, and Veneto). The main provisions include: forbidding all gatherings of people; restricting movements of people within and outside the hometown, except for circumstances of necessity; encouraging employees to work from home. Health workers cannot take any leave, and are asked to suspend all non-urgent activities; all planned surgeries are postponed, to give over intensive care beds to the treatment of patients with COVID-19. March 10 th 2020 The Italian Ministry of Health issues recommendations for oncologic and oncohematologic patients, providing protective measures for off-therapy patients and those receiving systemic treatment. Oncologists are required to postpone follow up visits, in order to reduce patients' access to hospitals. Patients with thoracic tumors and those who underwent pulmonary resection are to be considered a subgroup of high risk patients. March 11 th 2020 The Italian Council of Ministers urgently sets increasingly strict containment measures, to the whole national territory. The WHO declares the novel SARSCoV-2 outbreak a pandemic. March 13 th 2020 Three Italian scientific associations (AIOM, CIPOMO and COMU) release an official document for the management of oncologic and onco-hematologic activities during COVID-19 pandemic. The WHO declares Europe is becoming the new epicenter of COVID-19 pandemic. Abbreviations: AIOM, Associazione Italiana di Oncologia Medica; CIPOMO, Collegio Italiano dei Primari Oncologi Medici Ospedalieri; COMU, Collegio degli Oncologi Medici Universitari; COVID-19, novel coronavirus disease; SARSCoV-2, severe acute respiratory syndrome coronavirus-2; WHO, World Health Organization. The World Health Organization (WHO) website COVID-19 in Italy: momentous decisions and many uncertainties The World Health Organization (WHO) Health Emergency Dashboard Diagnosis, Treatment, and Prevention of Influenza Infection in Oncology Patients Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China SARS-CoV-2 Transmission in Patients With Cancer at a Tertiary Care Hospital in Wuhan, China The authors they have no conflicts of interest to declare for the present paper. All authors have no conflict of interest to disclose.