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\begin{document}

\title{Ensuring the best care to cancer patients in the COVID-19 pandemic era:
insights and challenges.}



\author[1]{Paolo Baldo}%
\author[2]{Sara Cecco}%
\author[2]{Diana Crestan}%
\author[2]{Sara Francescon}%
\author[2]{Elisa Giacomin}%
\author[2]{Liana Dalmas}%
\author[3]{Paola Molin}%
\author[2]{Fabio Puglisi}%
\affil[1]{CRO Aviano Centro Riferimento Oncologico}%
\affil[2]{Centro di Riferimento Oncologico}%
\affil[3]{University of Udine}%


\vspace{-1em}



  
  \date{June 14, 2024}


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\begin{abstract}
On 11/3/2020, the World Health Organization declared that COVID-19 is a
pandemic emergency. In this scenario, cancer patients are to be
considered at higher risk, being fragile and often with disease-related
or treatment-induced immunodepression. Furthermore, this health
emergency generates a harmful psychological impact on these patients,
who fear a lot about losing the continuity of cancer therapy. This fact
must be carefully considered by health personnel, especially in
countries where heavy risk containment and social distancing measures,
the only epidemiological strategies currently considered adequate, are
in force. In short, this is a very delicate challenge for health
professionals engaged in oncology. Here, we report some insights and
challenges that healthcare professionals face daily in caring for cancer
patients.%
\end{abstract}%



\sloppy


Title of the article:

\textbf{Ensuring the best care to cancer patients in the COVID-19
pandemic era: insights and challenges.}

\textbf{Type of paper: Brief Reports}

\textbf{Keywords:} COVID-19; cancer, anti-infective agents;
psychological, adaptation; risk-reduction behavior; epidemiology,
comorbidity.

\textbf{Author list:}

\textbf{Paolo Baldo\textsuperscript{1}, Sara Cecco\textsuperscript{1},
Elisa Giacomin\textsuperscript{1}, Sara Francescon\textsuperscript{1},
Liana Dal Mas\textsuperscript{1}, Diana Crestan\textsuperscript{1} Paola
Molin\textsuperscript{3} and Fabio Puglisi\textsuperscript{2}}

\begin{enumerate}
\tightlist
\item
  Hospital Pharmacy Unit, Centro di Riferimento Oncologico Aviano (CRO)
  -- IRCCS, Italy.
\item
  Department of Medicine, University of Udine; Department of Medical
  Oncology, Centro di Riferimento Oncologico Aviano (CRO) -- IRCCS,
  Italy.
\item
  Child Neuropsychiatric Unit ``Bassa Friulana'', Udine University
  Health Service (ASUFC), Italy.
\end{enumerate}

\textbf{Paolo Baldo\textsuperscript{1}, corresponding author,} Director
of Hospital Pharmacy Unit, Centro di Riferimento Oncologico Aviano (CRO)
-- IRCCS, Italy. Research support: concept, writing, team coordination,
submission

\textbf{Sara Cecco,} Hospital Pharmacy Unit, IMS Investigational
Medicines Service, di Riferimento Oncologico Aviano (CRO) -- IRCCS,
Italy Research support: writing, search on the web and oncology websites

\textbf{Diana Crestan} , Hospital Pharmacy Unit, IMS Investigational
Medicines Service, di Riferimento Oncologico Aviano (CRO) -- IRCCS,
Italy Research support: writing, search on the web for experimental
drugs in clinical trials

\textbf{Sara Francescon} , Hospital Pharmacy Unit, Centro di Riferimento
Oncologico Aviano (CRO) -- IRCCS, Italy Research support: writing,
search on the web for experimental drugs in clinical trials.

\textbf{Elisa Giacomin} Hospital Pharmacy Unit, Centro di Riferimento
Oncologico Aviano (CRO) -- IRCCS, Italy. Research support: writing,
search on the web and oncology websites

\textbf{Paola Molin} , Child Neuropsychiatric Unit ``Bassa Friulana'',
Udine University Health Service (ASUFC), Italy. Research support:
initial idea, concept: the psychological iimpact of the pandemic
scenario on cancer patients; writing,

\textbf{Liana Dalmas} , Hospital Pharmacy Unit, Centro di Riferimento
Oncologico Aviano (CRO) -- IRCCS, Italy Quality and data control, tables
editing

\textbf{Fabio Puglisi} Department of Medicine, University of Udine;
Department of Medical Oncology, Centro di Riferimento Oncologico Aviano
(CRO) -- IRCCS, Italy. Research support: general support, writing the
point of view of the clinical oncologist and insights needed.

\textbf{Running title} : Caring cancer patients in the pandemic era:
insights

\textbf{Disclaimer:} NONE

\textbf{SUPPORT \& FUNDING:} This research did not receive any specific
grant from funding agencies in the public, commercial, or not-for-profit
sectors.

\textbf{Refs of Corresponding Author:}

\textbf{Paolo Baldo}

Hospital Pharmacy Unit, Centro di Riferimento Oncologico Aviano (CRO) --
IRCCS, Italy.

Via F. Gallini, 2 -33081 Aviano (PN) Italy,

Tel +39-0434-659221

Mobile: +39-340-5744979

Mail 1: \emph{pbaldo@cro.it}

Mail 2:\emph{paolo.baldo62@gmail.com}

After the declaration made on 11.3.2020 by World health organization,
concerning the characterization of SARS-CoV2
infection\textsuperscript{1} as a global pandemic, a colossal amount of
scientific studies and research have been published in short times.

To date, published papers are mainly viewpoints or research
letters\textsuperscript{2,3,4} but recently, attention to the problem
was drawn by Van de Haar et al. on Nature Medicine
journal\textsuperscript{5}. First of all, the problem of the
psychological impact caused by fear of COVID-19 infection on cancer
patients should not be underestimated. The devastating threat of a
pandemic looming over the social community risks blocking hospital
efficiency and care. What are the most critical situations encountered
by cancer patients in this scenario?

\emph{Therapeutic continuity or postponing therapies.} In order to
reduce the flow of people, and therefore the risk of spreading the
infection, in Cancer Centers the clinical activities has been reduced to
the essentials. The reason for these measures lies, first of all, in the
particular condition of cancer patients who, due to potential
immunodepression, could be more vulnerable to the contraction of
infection. Furthermore, as documented for other comorbidities, the
co-existence of infection and tumor disease makes patients more prone to
complications and exposes them to a higher risk of death.

But who decides and how do you establish what is essential? The
complexity of the therapeutic choices in oncology, linked to the
different variables that guide the treatments of the different tumor
types, makes it difficult for the same specialists to define the
priority criteria. Furthermore, the uncertainty as to how long the
adoption of rigid measures for the prevention of infection spread can
further complicate decisions on whether or not to postpone or omit
certain therapies. The first report on Chinese cancer patients suggested
postponing adjuvant therapies or elective surgery\textsuperscript{6}.

However, other insights are needed:

1. Definition of the expected benefit of the treatment and of the
possible damage for the patient in case of delay in the administration
(the reduction of efficacy linked to the lack of respect of the dose
density is documented for few clinical situations);

2. The presence of the tumor on site (eg early disease treated with a
neoadjuvant approach or advanced disease) and its biomolecular
characteristics (eg. proliferative index, unfavorable prognostic
factors, etc.) may require more timely treatment;

3. In advanced disease, the treatment line could be a criterion for
deciding whether or not to postpone administrations, but this criterion
alone could be insufficient;

4. Supportive care and palliative care often require hospital management
and, even if they can be delivered at home, they may be subject to
delays due to the lack of health workers.

Therefore, although they may appear rigid, measures that limit hospital
admissions are necessary to protect both patients and healthcare
professionals from the risk of infection. At the same time, these
measures generate a state of isolation for the patient who is facing the
diagnostic-therapeutic path without the support of family members or
caregivers.

\emph{Availability of hospital beds, and information overload by the
mass media.} Right now, everyone, mainly in Europe, is exposed to a
media bombing about the Covid-19 pandemic. Even cancer patients are not
excluded, and it can be very impressive the hypothesis that health
systems may have to choose, next days, whether to reserve care, for
example, to a 70-year-old adult suffering from severe COVID-19 infection
but without comorbidities, who therefore has a more likely to be cured,
or an adult who has other concomitant serious diseases, such as cancer.
This is an issue posed by logistical and economic reasons, but that
implies profound ethical considerations by health organizations.

\emph{Discomfort in having to take interviews and triage.} Continuing to
refer to the restrictions imposed by the Italian government, which are
even stricter starting from 12/3, these require that every person
entering hospital institutions carry out a synthetic triage declaring
the absence of symptoms, i.e. the presence of rhinitis, fever, cough ,
difficulty breathing and a brief interview about the personal recent
history of social contacts or movements. It is essential to remember
that the cancer patient can occasionally be immunocompromised, for
example with the presence of neutropenic fever. This can be confusing
for healthcare professionals who perform triage, but also confusing if
there is a potential hiding of the COVID-19 infection. Certainly, in any
case, the moment of the interview or triage represents an
''appointment'' with fear and anxiety for the cancer patient who sees
the guarantee of the chemotherapy cycle or the follow-up visit
questioned.

\emph{Indirect consequences: emotional and psychological costs on the
families of cancer patients} . In addition, primarily in Italy,
government restrictions impose an almost total absence of movement
outside one's home, at least until the end of March. The indirect
consequences are social isolation due to possible
quarantine\textsuperscript{7}, reduction of assistance and closeness of
the family members to cancer patients, who however cannot and must not
feel ''alone'' to face the most critical phase of their life: coping
with cancer, let's not forget it.

\emph{The position of Scientific Societies of Oncology and
Haematology\textbf{.}} In the present, unpredictable scenario, which has
found the medical world unprepared, the position of representative
Scientific society in oncology field may be differently oriented. Some
scientific societies are mainly oriented to give information to
associates that all events, conferences, meetings or training courses
are postponed or canceled; others include in the website homepage
special sections about the COVID-2019 pandemic emergency, expressing the
Society's point of view and behavioral indications.

For example, AIOM , the Italian Association of Medical Oncology
(\emph{www.aiom.it}), is informing patients in the website homepage that
it might be necessary to defer part of the planned activity, access to
pharmacologic treatment and to postpone follow-up, non urgent visits.
The advice is also to evaluate and discuss case by case any access to
the treatment, based on the relationship between the risks (for the
individual and for the community) related to hospital access and the
benefits expected from the treatment itself. On March 13, 2020, AIOM
released the document: ``Infectious risk from Coronavirus COVID 19:
indications for Oncology''. In this document, AIOM considers it
appropriate to postpone the outpatient activities of follow-up for
disease-free patients (e.g. follow-up at 6-12 months) partially,
providing for a telephone call and conversation. At the same time, to
avoid overcrowding of waiting rooms, it is advised that access of the
accompanying persons in the rooms where therapy is administered or
within surgeries, will be limited to one for each
patient.\textbackslash{}sout. \emph{\textbf{ASCO},} the American Society
of Clinical Oncology
(\emph{https://www.asco.org/asco-coronavirus-information}) is presenting
in the website homepage the ``ASCO Coronavirus resources'', consisting
in essential links for information about the new Coronavirus disease for
health professionals involved in cancer care; the society has also
developed a guidance for patients, based on questions received from ASCO
members and the internal COVID-19 Clinical Questions Advisory Group.

ESMO, the European Society for Medical Oncology,
(\emph{https://www.esmo.org}) proposes rich, informative material for
oncology professionals and cancer patients; in parallel, ESMO has
launched a collaborative project, the~\emph{ESMO-CoCARE Registry} , to
share data and information among healthcare professionals about
treatment approaches on cancer patients who are suspected or confirmed
to have the novel coronavirus disease (COVID-19). The aim is to
understand better the unique effects of COVID-19 on patients with cancer
and cancer survivors. By pooling real-world data with updated
information coming from clinical and pharmacological research, ESMO
hopes to assist cancer patients at best.

LLS - Leukemia \& Lymphoma Society
(\emph{https://www.lls.org/blog/4-things-cancer-patients-need-to-know-about-the-coronavirus})
is perhaps the more closest to the spirit of this paper, declaring in
its homepage that one of its highest priorities is ``\emph{Helping Blood
Cancer Patients Adjust to the New Normal} '' telling about the new
COVID-2019 pandemic. LLS priority is the well-being of the patients -
especially as many blood cancer patients are immunocompromised,
suggesting the ``\emph{4 things cancer patients need to know about the
Coronavirus disease} ''.

It is of paramount importance that all the scientific societies indicate
patients to follow the directives of the national regulatory authorities
and the other competent authorities, for example, the Centers for
Disease Control and Prevention (CDC) or World Health Organization (WHO)
guidelines, in order to protect the health of all of us and the general
population\textsuperscript{8}. All healthcare professionals can have
access to electronic \emph{directories} ~reporting links to the clinical
reference guidelines\textsuperscript{9,10,11}. Finally, in the homepage
of clinicaltrials.gov
(\emph{www.clinicaltrials.gov})\textsuperscript{12}, a direct filter
strategy available links us directly to all the clinical trials
activated for COVID-19 research, a list that on 13.5.2020 reached the
number of 1.450 registered studies in the world.

In conclusion, while the various countries are waiting to see a drop in
the number of infections and deaths caused by COVID-2019, a great effort
by all health professionals is needed to do their best to help in this
new healthcare scenario. Healthcare professionals dealing with cancer
patients must also avoid any form of distraction and concentrate their
efforts on communication to transmit messages of trust and hope,
especially needed in these critical times.

\textbf{CONFLICT OF INTEREST STATEMENT}

\textbf{None to declare}

\textbf{SUPPORT \& FUNDING:} This research did not receive any specific
grant from funding agencies in the public, commercial, or not-for-profit
sectors.

\textbf{REFERENCES}

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