Blood cancers

Cancer units should prepare for the next transmission phase: experts


Haematologists will need to make hard calls about delaying some cancer therapies, moving to shorter treatment regimens and prioritising treatment to only those most at risk if community acquired COVID-19 transmission rates start to climb, according to new clinical guidance.

During a SARS-COV-2 (COVID-19) webinar sponsored by Janssen-Cilag to discuss the management of cancer patients during the pandemic, Dr. Robert Weinkove, Clinical Director at the Malaghan Institute of Medical Research and a consultant haematologist at the Wellington Blood and Cancer Centre in New Zealand, said haematology and oncology units should start to prepare to introduce stricter measures to minimise the risk of hospital transmission.

“We’re never going to be able to completely prevent the possibility of nosocomial outbreak – our wards are anathema to the kinds of social distancing that we’re recommending people maintain in the community – but there are some things we can try to do to minimise the risk as best we can,” said Dr. Weinkove who co-authored the guidance1 along with other experts.

Topping the raft of measures recommended to prevent nosocomial transmission Dr. Weinkove said retraining in basic infection control measures, such as hand washing and auditing its practice, was the most important defence.

Recounting the experience of his own unit Dr Weinkove said: “We found that our nurses are excellent at doing this; it was the medical staff that were far less good – particularly the senior medical staff.”

Transmission phases A, B and C

The clinical guidance1 covers three transmission phases: phase A where there is no community level transmission; phase B, where Australia and New Zealand currently sit, which signals sporadic community level transmission but not enough to overwhelm healthcare provision; and phase C, a worse-case scenario where there is community level transmission and healthcare capacity has been exceeded.

Dr Weinkove noted that the recommended actions in the guidance are “potentially cumulative” but each hospital’s local, statewide or national regulations should take precedence.
“These are cues for haematology and oncology departments to think about, these are not the only measures that you should be looking at,” he told webinar participants.

The goals of phase B, where there is some evidence of community transmission but the majority of healthcare can still be carried out, are to minimise the risk of nosocomial spread and to support population-wide distancing measures, Dr. Weinkove explained.

For example, screening all patients for COVID-19 symptoms before they come in to hospital for clinics and using tele-health and remote consultations as much as possible would minimise the risk of patients coming into contact with other healthcare workers and patients, Dr. Weinkove said.

And in some circumstances, it might be appropriate to move clinics away from acute care facilities, as while larger cancer centres may already have isolation areas, smaller outreach clinics may share space with respiratory clinics.

“That situation is not ideal… so it may be appropriate to start making use of some alternative clinic facilities or even private facilities to keep patients away from areas where they might come into contact with high risk groups,” he said.

Impact on inpatient care

As a way of reducing the number of inpatient contacts the guidance recommends that visitors are restricted, the number of students on the wards are reduced and that consideration is given to the deferral of non-urgent cases and tests.2

“You might be able to minimise some admissions altogether – look at early discharge and through that enhance community care. Obviously if you’re doing community care you’re still potentially sending a nurse into the patient’s home but that might be one contact for the day as opposed to 20 or 30 contacts,” Dr Weinkove said.

He also stressed that while patient visitor restrictions were in place it was important to look at the goals of care.

“Visitor restrictions can have a dreadful impact on end of life care and units should have exemptions around those situations…you may not be able to get visitors in at short notice to have face-to-face discussions about resuscitation or intensive care suitability and this might be really important to document as well as you can early on,” Dr. Weinkove said.

He added that there should be ‘vigorous measures’ for patient isolation if respiratory symptoms developed but it was important that all hospital staff were trained to pick up symptoms.

“It’s really critical that we train everyone on that. In my own centre for example I’ve noticed that [development of respiratory symptoms] tends to be [picked up] on the consultation ward round … it should be the responsibility of everybody in that hospital ward to identify when a patient has symptoms and to put them into isolation until we’ve got a negative respiratory viral swab.”

Doctors may also need to consider a more restrictive transfusion policy, he suggested, which has been shown to reduce the need for red cell transfusion which might reduce the number of physical interactions that patients have with staff and other patients3.

Doctors should also look for opportunities to optimise prophylaxis of infection to reduce the risk of infection requiring inpatient therapy.

“Is that patient suitable for prophylactic antimicrobials, for example, can you reduce the chance of those emergency admissions to hospital where you may be putting patients at additional risk?”

Changes to treatment need a regular review

Meanwhile, using shortened, or oral or less immunosuppressive treatments, if appropriate, might also be considered but at this point only if it’s therapeutically equivalent, Dr. Weinkove noted, stressing that measures should be ‘proportionate’ to the threat of COVID-19 disease which will change periodically4,5.

“Doctors must be fair and equitable as well as transparent in their treatment decisions. Our own unit has gone through a phase of thinking we’re going to be on the cusp of being like Spain or Northern Italy but through rigorous public health measures we’re not quite facing that – at least not right now – and so we postponed some treatments but we’ve now been reviewing that and resuming those treatments as those threats have eased off,” he said.

“As the pandemic continues, doctors may have to move between phases and will have to review these measures regularly…we need to make sure we’re not under treating our cancer patients for what is, at the end of the day, more likely to kill them in many situations than COVID-19 disease if there’s not a great deal of community spread,” he added.

Learning from the COVID-19 and cancer experience overseas

Reflecting on experiences with COVID-19 and cancer overseas, Dr. Weinkove said overwhelmed emergency departments and ICUs had meant many of his colleagues had changed the way they treat cancers altogether.

Australia and New Zealand are ‘fortunate’ not to have reached that stage, but if a future wave did hit locally, doctors would have to modify cancer treatments to minimise the chance of emergency department attendance, Dr. Weinkove said.

“That might involve changing to oral therapies rather than parenterally administered treatment, maybe you can tide those myeloma patients over with oral therapy instead of bortezomib while using less myelosuppressive regimens where appropriate and using abbreviated treatments or even deferring elements of treatments entirely such as prophylactic high dose methotrexate,” he suggested.

Moving deeper into a Phase C scenario, Dr. Weinkove said it may get to the point where therapy will have to be ‘completely prioritised’.

“Perhaps doctors can bide some time by looking at alternative treatment deliveries such as using private hospitals as key areas for oncology patients who don’t have COVID-19 but, once therapy has to be completely prioritised, it’s critical that oncology units have a transparent and fair process for classifying patients,” he warned.

“One of the issues is how do you prioritise therapies when you’re dealing with multiple diseases, multiple different modalities of treatment, multiple different specialists involved. It’s really important that you document and review [that process] once your capacity constraints resolve,” he said pointing to recent NICE guidance which he said provided a “fairly straightforward” way of prioritising therapies that should be applicable across the whole of haematology and oncology.

“For example, if you’re looking at frontline treatment for an aggressive lymphoma you would classify this as a very high priority of treatment. What might get more difficult is if you’re trying to compare an adjuvant therapy for a particular disease with third line treatment of lymphoma. This NICE guidance – and it’s not perfect – does provide a framework for doing that in a reasonably fair way and I think it’s critical to have some sort of system like that ready to go if we do get to that situation in the future.”

You can find the full guidance here.

If you would like to view a recording of the event when it is available online, please notify Janssen here.

References

  1. Robert Weinkove, Zoe McQuilten, Jonathan Adler et al. Managing haematology and oncology patients during the COVID-19 pandemic: interim consensus guidance. Med J Aust. Published online: 20 March 2020
  2. https://www.safetyandquality.gov.au/our-work/comprehensive-care/essential-elements-comprehensive-care/essential-element-2-identifying-goals-care
  3. Carson JL, Stanworth SJ, Roubinian N, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2016;10(10):CD002042. Published 2016 Oct 12. doi:10.1002/14651858.CD002042.pub4 https://pubmed.ncbi.nlm.nih.gov/27731885/
  4. https://www.hematology.org/covid-19#faqhttps://www.eviq.org.au/WWW_eviQ/files/4f/4fb20301-bc71-4456-a8a5-1b14d7927414.pdf
  5. NICE Guidance: https://www.nice.org.uk/guidance/ng161/chapter/6-Prioritising-systemic-anticancer-treatments

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