Coronavirus Disease 2019 (COVID-19) - Cancer Screening, Diagnosis, Treatment, and Posttreatment Surveillance in Uninfected Patients During The Pandemic - UpToDate

29/11/2020 Coronavirus disease 2019 (COVID-19): Cancer screening, diagnosis, treatment, and posttreatment surveillance in uninfected patients during
ts during the pande…
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Coronavirus disease 2019 (COVID-19): Cancer screening,

diagnosis, treatment, and posttreatment surveillance in
uninfected patients during the pandemic
Authors: Robert G Uzzo, MD, MBA, FACS, Alexander Kutikov, MD, FACS, Daniel M Geynisman, MD
Section Editors: Michael B Atkins, MD, Larissa Nekhlyudov, MD, MPH, Richard A Larson, MD, David I Soybel, MD
Deputy Editors: Diane MF Savarese, MD, Sadhna R Vora, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2020. | This topic last updated: Oct 09, 2020.
INTRODUCTION
Coronaviruses are important human and animal pathogens. At the end of 2019, a novel coronavirus was
identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. It
rapidly spread, resulting in an epidemic throughout China, followed by an increasing number of cases in
other countries throughout the world. In February 2020, the World Health Organization designated the
disease COVID-19, which stands for coronavirus disease 2019 [1]. The virus that causes COVID-19 is
designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); previously, it was referred to as
2019-nCoV.
On January 30, 2020, the World Health Organization declared the COVID-19 outbreak a public health
emergency of international concern and, in March 2020, began to characterize it as a pandemic, in order
to emphasize the gravity of the situation and urge all countries to take action in detecting infection and
preventing spread.
The rapidly expanding COVID-19 acute respiratory pandemic has impacted all areas of daily life, including
medical care. The primary intervention to slow disease spread has been physical distancing, hand and
respiratory hygiene, and staying home as much as possible. (See "Coronavirus disease 2019 (COVID-19):
Epidemiology, virology, and prevention", section on 'Personal preventive measures'.)
Delivering care for patients with cancer during this crisis is challenging given the competing risks of death
from cancer versus death or serious complications from SARS-CoV-2, and the likely higher lethality of
COVID-19 in immunocompromised hosts [2,3]. Many patients with cancer have struggled to receive
treatment for their cancers due to hospitals canceling or delaying surgeries and other procedures,
including chemotherapy and radiation therapy. There is also concern that patients who are otherwise
healthy and have curable cancers that require timely implementation of surgery, chemotherapy, or
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29/11/2020 Coronavirus disease 2019 (COVID-19): Cancer screening, diagnosis, treatment, and posttreatment surveillance in uninfected patients during the pande…
radiation have unfortunately concluded that the risk of contracting COVID-19 may outweigh the benefits
of cancer treatment [4]. Inadequate supplies of personal protective equipment for health care providers,
limited hospital capacity, including intensive care units, and lack of point-of-care testing and
seroprevalence data further complicate the difficulty.
This topic will discuss issues related to balancing the risk from treatment delay versus risks from COVID-
19, ways to minimize the compromise of physical distancing during care delivery, how limited health care
resources can be appropriately and fairly allocated, and reviews the recommendations for cancer
screening, diagnosis, and treatment during the COVID-19 epidemic from expert groups.
Issues pertaining to the risk of COVID-19 in patients with cancer, clinical presentation in patients with
malignancy, and the approach to testing in cancer patients are discussed separately as are the
management of COVID-19 in the general population and issues related to particular patient populations.
● (See "Coronavirus disease 2019 (COVID-19): Risks for infection, clinical presentation, testing, and
management in patients with cancer".)
● (See "Coronavirus disease 2019 (COVID-19): Outpatient evaluation and management in adults".)
● (See "Coronavirus disease 2019 (COVID-19): Management in hospitalized adults".)
● (See "Coronavirus disease 2019 (COVID-19): Critical care and airway management issues".)
● (See "Coronavirus disease 2019 (COVID-19): Management in children".)
● (See "Coronavirus disease 2019 (COVID-19): Pregnancy issues and antenatal care".)
(Related Pathway(s): Coronavirus disease 2019 (COVID-19): Initial telephone triage of adult
outpatients.)
GENERAL CONSIDERATIONS
Delivering cancer care during the COVID-19 crisis is challenging given the competing risks of death from
cancer versus death or serious complications from infection, and the likely higher lethality of COVID-19 in
immunocompromised hosts, including those with cancer. Other challenges include cancellations of in-
office visits; delays in routine cancer screening leading to significant declines in the number of patients
with newly identified cancers during the pandemic [5-7]; surgery postponements or cancellations; physical
distancing in the office, clinic, and infusion rooms; and the transition to telemedicine for many visits. (See
'Minimizing the compromise of physical distancing during cancer care delivery' below.)
There is no "one size fits all" approach to delivering cancer care during the COVID-19 pandemic, and no
international guidelines. Treatment decisions must be made on a case-by-case basis. Relevant issues are
expanded upon in the following sections. Conceptual frameworks for balancing cancer risk versus
infection risk, and practical approaches for managing cancer patients during the pandemic are presented
below. (See 'Conceptual framework for balancing competing risks' below.)
Providing safe care for outpatients — The American Society of Clinical Oncology (ASCO) suggests the
following guidance for general care from the United States Centers for Disease Control and Prevention
(CDC), as described in the links below:
● General health care facility and health care professional guidance

● Clinical care guidance
● Home care guidance
● High-risk subpopulation guidance
In addition to general guidance provided by the CDC for universal pandemic precautions, the following
points have been emphasized in the ASCO recommendations [8]:
● All patients with cancer should be informed regarding the symptoms of COVID-19, and trained in
proper handwashing, hygiene, and minimizing exposure to sick contacts and large crowds.
● Patients and clinicians are urged to follow the CDC's general recommendations on mask wear, which
now recommend that everyone should wear a cloth face cover when they go out in public, as well as
guidance from local health authorities.
There is no guidance or evidence to suggest that N95 masks are required for cancer patients.
However, most institutions and clinical practices are requiring health care workers, patients, and all
visitors to wear a surgical face mask within the facility, regardless of symptoms, to help prevent
transmission from infected individuals who may be asymptomatic. (See "Coronavirus disease 2019
(COVID-19): Infection control in health care and home settings", section on 'Universal use of masks'.)
● In general, as recommended by the CDC, any clinic visits that can be postponed without risk to the
patient should be postponed. This includes routine surveillance visits to detect cancer recurrence. In
many cases, the recommended frequency of these visits is already considered a range (eg, three to six
months), so extending the time between evaluations may still be within the recommendations. (See
'Minimizing the compromise of physical distancing during cancer care delivery' below.)
● Prescreening via telephone calls or digital platforms for COVID-19 symptoms and exposure history
from 48 to 72 hours prior to planned in-person clinic visits, or each new cycle of therapy is
recommended, if possible [9]. For cancer patients with fever or other symptoms of infection, a
comprehensive evaluation should be performed, as per usual medical practice. (See "Coronavirus
disease 2019 (COVID-19): Risks for infection, clinical presentation, testing, and management in
patients with cancer", section on 'Testing issues specific to cancer patients'.)
Screening clinics should be developed to allow for patients with symptoms to be evaluated and tested
in a dedicated unit with dedicated staff. ASCO guidelines suggest that patient screening status and
COVID-19-positive status should be documented prior to the patient entering the facility [8].
Cancer patients with fever or lower respiratory findings (eg, cough, dyspnea, hypoxia) are a highest
priority for COVID-19 testing, and testing is also recommended for those with an exposure to
someone with confirmed COVID-19. (See "Coronavirus disease 2019 (COVID-19): Diagnosis", section on
'Whom to test'.)
Further information is available within UpToDate on the evaluation, diagnosis, and screening for COVID-19
that are not specific to cancer patients. (See "Coronavirus disease 2019 (COVID-19): Outpatient evaluation
and management in adults", section on 'Initial evaluation' and "Coronavirus disease 2019 (COVID-19):
Diagnosis", section on 'Diagnostic approach' and "Coronavirus disease 2019 (COVID-19): Clinical
manifestations and diagnosis in children".)
Cancer diagnosis and staging — Recommendations about cancer screening and diagnostic testing are
evolving and should be based on the state of COVID-19 in an individual community as well as the
availability of resources. In areas where infection is still an ongoing issue, in general, any clinic visits that
can be postponed without risk to the patient should be postponed, according to the CDC. In areas where
infection has been controlled, many screening programs and clinic visits have resumed, and clinicians
should follow specific local guidance, maintaining full adherence to guidelines for limiting the spread of
SARS-CoV-2 infection.
COVID-19 has had a significant impact on the number of patients undergoing cancer screening, diagnosis,
and staging. A few expert guidelines for the management of cancer screening during the pandemic are
available [10-16]. (See 'Guidance from expert groups' below and 'Patients with lung cancer' below.)
As of August 2020, ASCO guidelines recommend postponing most cancer screening procedures (eg,
screening mammograms and colonoscopy) to conserve health system resources and reduce patient
contact with health care facilities, unless a clinically relevant cancer is suspected [17]. However, there has
been concern about the halt in national screening programs during the pandemic and its impact on future
cancer mortality [5,18-24]. As such, in areas where infection has been controlled, many screening
programs have resumed, and clinicians should follow specific local guidance, maintaining full adherence
to guidelines for limiting the spread of SARS-CoV-2 infection.
Importantly, the global lockdown and curtailed screening for cancer has led to a backlog of patients with
symptoms needing urgent assessment, and existing services may not have the capacity to manage these
patients, even if they return to prepandemic levels [25,26]. Cooperation between primary care and
subspecialty clinicians and health systems is essential to prioritize and safely investigate patients at
highest risk and regain lost progress in cancer control [27].
In a patient newly diagnosed with cancer, it is reasonable to limit staging procedures and pretreatment
evaluation only to those that are most necessary to inform development of the initial care plan, but this
needs to be individualized and is dependent on the local COVID-19 burden and service availability.
Posttreatment surveillance — As of June 2020, during the period of active ongoing SARS-CoV-2 infection,
ASCO suggests that any clinic visits that can be postponed without risk to the patient should be
postponed. This includes routine surveillance in patients who have completed treatment or those on active
surveillance considered to be at relatively low risk of recurrence or disease progression, and those who are
asymptomatic during the follow-up period. In situations where existing recommendations provide
frequency ranges for interventions (eg, every three to six months), it is reasonable to delay scheduled
interventions to the longest recommended frequency duration. Remote monitoring of such patients using
telehealth may be adopted.
However, recommendations such as these depend on the state of COVID-19 in communities and regions.
In areas where infection rates are declining or under control, clinic visits for posttreatment surveillance are
resuming.
ISSUES RELATED TO ANTICANCER TREATMENTS
Cancer surgery
Delaying elective surgeries — The United States Centers for Disease Control and Prevention guidance
for health care facilities and guidance from the World Health Organization suggests that "elective
surgeries" at inpatient facilities should be rescheduled, if possible. However, clinicians and patients need
to make individual determinations, based on the potential harms of delaying needed cancer-related
surgery; in many cases, these surgeries cannot be considered "elective." Some have distinguished a subset
of nonemergent cancer surgeries as being "essential cancer surgery," including surgical management of
brain tumors, as well as breast, colon, stomach, pancreas, liver, bladder, kidney, and lung resections [28].
These are generally cancers that cannot wait two to three months, and patients have a significant chance
of benefiting from the surgery.
The American College of Surgeons has validated this approach, noting that cases that involve cancers that
may progress without treatment should be performed as resources permit to minimize the need for
emergency procedures, which are often more complicated and more likely to consume limited resources.
In addition, another category of essential surgeries is selective palliative procedures being performed for
acute relief of pain and suffering or acute neurologic deficits that are not manageable by other means
[28]. However, if a surgery will likely require postoperative intensive care, the capacity of available
intensive care units (ICUs) should be considered as part of decision-making.
In some cases, neoadjuvant therapy may be used as a means of delaying surgery. As an example, patients
with rectal cancer may undergo chemoradiotherapy plus upfront chemotherapy (total neoadjuvant
therapy) rather than chemoradiotherapy alone as a means of delaying surgery. (See "Neoadjuvant
chemoradiotherapy, radiotherapy, and chemotherapy for rectal adenocarcinoma", section on 'Total
neoadjuvant therapy for locally advanced tumors'.)
In other situations where neoadjuvant hormonal therapy is not routinely considered (eg, early stage
breast cancer, high-risk prostate cancer), it may be reasonable to offer neoadjuvant therapy or to simply
delay surgery rather than proceeding to upfront surgery. Neoadjuvant hormone therapy is also a safe,
relatively nontoxic alternative for early stage, hormone receptor-positive breast cancer [29]. (See "Initial
management of regionally localized intermediate-, high-, and very high-risk prostate cancer and those
with clinical lymph node involvement", section on 'Neoadjuvant ADT approaches' and "Neoadjuvant
management of newly diagnosed hormone-positive breast cancer", section on 'Neoadjuvant endocrine
therapy'.)
The risks of tumor progression with delay in definitive surgery [30,31] should be weighed against the
potential added burden on hospital resources, case complexity, and the risk of exposure to COVID-19.
However, neoadjuvant therapy that requires clinic visits, clinician-patient contact, or that is
immunosuppressive must also be viewed with the potential incremental risks to the patient.
The rationale for delaying elective surgeries is conservation of resources, limitation of viral spread, and
minimizing risks, particularly of postoperative infection. Outcomes from surgery during the COVID-19
pandemic have been described in an observational study of 1128 patients who had surgery between
January 1 and March 31, 2020, all of whom had confirmed SARS-CoV-2 infection within 7 days before or 30
days after surgery [32]. Overall, the 30-day mortality was 24 percent, most of which (83 percent) was due
to pulmonary complications. In adjusted analyses, 30-day mortality was associated with male sex (odds
ratio [OR] 1.8), age ≥70 years or older versus younger than 70 years (OR 2.30), American Society of
Anesthesiologists physical status grades 3 through 5 versus grades 1 and 2 (OR 2.4), malignant (versus
benign) or obstetric diagnosis (OR 1.6), emergency versus elective surgery (OR 1.7), and major versus
minor surgery (OR 1.5). The rate of poor outcomes exceeds that seen in most types of major surgery in the
pre-COVID era, which may be due to the inflammatory and prothrombotic state associated with severe
COVID-19 [33].
Specific guidance for decision-making for cancer surgery on a disease-by-disease basis is available from
the American College of Surgeons, from the Society for Surgical Oncology, from an international Urologic
Oncology Group, and from the National Health Service England.
When should elective surgeries be resumed? — As health care facilities start resuming elective
surgical cases, the American College of Surgeons and other groups have issued the following
recommendations [34,35]:
● SARS-CoV-2 infection rates should be on a downward trend for at least two weeks at the facility's
geographic location.
● Resource utilization, including ICU bed and personal protective equipment, must be carefully
calibrated.
● Testing of patients and employees must be strongly considered.
● Prioritization and scheduling of cases must be managed carefully by all key stakeholders.
Other resources for resuming cases are available [36-39].
Radiation therapy — Some patients receiving radiation therapy (RT) with curative intent or for rapidly
progressive or symptomatic tumors may reasonably proceed with therapy, as the risks of delaying
treatment may outweigh the risks of COVID-19 exposure and infection [40]. Where available, alternative RT
regimens (eg, hypofractionation) should be offered, if appropriate. As an example, an international expert
consensus statement has recommended that neoadjuvant short-course RT be preferred over long-course
chemoradiotherapy for patients with locally advanced rectal cancer during the pandemic [41]. (See
"Neoadjuvant chemoradiotherapy, radiotherapy, and chemotherapy for rectal adenocarcinoma", section
on 'Short-course radiotherapy'.)
Randomized trials support deferring RT across a multitude of cancers by placing systemic therapy first in
the treatment sequence [42]. Examples include initial androgen deprivation therapy for intermediate- to
high-risk prostate cancer [43], induction chemotherapy for nasopharyngeal carcinoma, and upfront
chemotherapy for some grade 2 or 3 gliomas. (See "Initial management of regionally localized
intermediate-, high-, and very high-risk prostate cancer and those with clinical lymph node involvement",
section on 'Timing and duration of androgen deprivation therapy' and "Treatment of early and
locoregionally advanced nasopharyngeal carcinoma", section on 'Induction chemotherapy for select
patients' and "Treatment and prognosis of IDH-mutant, 1p/19q-codeleted (grade II and III)
oligodendrogliomas", section on 'Order of therapy'.)
For those receiving RT for symptom control, or for whom an alteration of schedule is unlikely to
significantly impact outcome, treatment should be delayed or adjusted. If hypofractionated schedules are
appropriate for a given condition, they should be considered [44,45], and this approach is consistent with
guidelines from the American Society for Radiation Oncology (ASTRO). An important point is that the
evidence to support such recommendations for change in radiation fractionation schedules across major
disease sites during the pandemic is variable, and the quality of the evidence may be lower than that
routinely used to justify changes in fractionation schedule outside of a pandemic [46].
Nevertheless, the International Lymphoma Radiation Oncology Group has issued guidance on alternative
radiation treatment schemes in blood cancer during the COVID-19 pandemic, and an international group
has offered recommendations for use of shortened RT durations in the management of patients with
gastrointestinal malignancies [47]. Joint practice recommendations for risk-adapted head and neck cancer
RT during the pandemic are also available from ASTRO and the European Society for Therapeutic Radiation
Oncology (ESTRO) [48].
For patients who are actively undergoing RT with established treatment plans, the decision to continue
requires careful consideration of indications, dose already delivered, and risks and benefits. ASTRO
suggests that cancellation or delay in cancer treatment may be an appropriate option for patients with
COVID-19, after a reassessment of the patient's goals of care. Recommendations are also available from an
international Radiation Oncology Group called the Global Radiation Oncology Targeted Response. The
National Institute for Health and Care Excellence (NICE) has published a rapid guideline on the delivery of
radiation in cancer patients both with and without known COVID-19. (See "Coronavirus disease 2019
(COVID-19): Risks for infection, clinical presentation, testing, and management in patients with cancer",
section on 'Management of cancer therapy'.)
Systemic anticancer treatments — There is no direct evidence to support changing or withholding

chemotherapy or immunotherapy in patients with cancer [49], and routinely withholding critical anticancer
or potentially immunosuppressive therapy is not recommended for those who do not have COVID-19. The
approach to patients who have a positive test for SARS-CoV-2 is discussed separately. (See "Coronavirus
disease 2019 (COVID-19): Risks for infection, clinical presentation, testing, and management in patients
with cancer", section on 'Approach to SARS-CoV-2 positive patients'.)
There is evidence that a considerable proportion of patients have experienced changes to their cancer
treatment as a direct result of the pandemic, both for those receiving potentially curative and palliative
intent treatment [50,51]. The balance of potential harms from delaying or interrupting treatment versus
the benefits of possibly preventing SARS-CoV-2 infection remains uncertain. The available evidence to date
does not support a higher risk of complications from COVID-19 in those receiving active anticancer
treatment, although the data on patients receiving active immunotherapy is conflicting. (See "Coronavirus
with cancer".)
The American Society of Clinical Oncology (ASCO) recommends that clinical decisions be individualized,
and consider factors such as the curability of the cancer; the risk of cancer recurrence with treatment
delay, modification, or interruption; the number of cycles of therapy already completed; existing
comorbidities; and the patient's tolerance of treatment. The local incidence of viral infection and
availability of necessary resources, and whether testing for SARS-CoV-2 has been performed are also
considerations.
NICE has published a rapid guideline on delivery of systemic anticancer treatments. Practical
considerations for the use of systemic anticancer treatments and supportive care in the adjuvant and
metastatic disease settings for a variety of cancer types are also available from an international group of
medical oncologists [52]. However, guidelines such as these are opinion-based and not evidence-based.
Chemotherapy — Administration of chemotherapy is determined on a case-by-case basis. In general,

adjuvant therapy with curative intent should likely proceed, despite the threat of SARS CoV-2 infection
during therapy. Shorter treatment duration should be considered, where feasible. Data regarding impact
of recent chemotherapy on COVID-19 outcomes are discussed separately. (See "Coronavirus disease 2019
(COVID-19): Risks for infection, clinical presentation, testing, and management in patients with cancer".)
For patients receiving palliative therapy for metastatic disease, the decision to continue requires careful
consideration of indications, response to treatment already delivered, and risks and benefits of continued
treatment. In some cases, treatment delays may lead to worsening symptoms and performance status
and the loss of the opportunity to treat [53]. Considerations should include whether such delays require
hospital admission for palliation of symptoms, which would further stress available resources. Shared
decision-making is paramount.
Considerations for chemotherapy treatment during the COVID-19 pandemic set forth by ASCO include the
following:
● For patients in deep remission who are receiving maintenance therapy, stopping chemotherapy may
be an option. Similarly, for those in whom the benefit of adjuvant chemotherapy is expected to be
small and where nonimmunosuppressive therapies are available (eg, hormone therapy for hormone
receptor-positive early breast cancer or prostate cancer), it may be reasonable to omit chemotherapy
in consideration of the risks of COVID-19.
● Oral chemotherapy and home administration of chemotherapy drugs (if logistically feasible) may be
options for some, but require coordination with the oncology team to ensure that patients are taking
their treatments correctly.
A shift to parenteral chemotherapy administration at home poses several challenges for United States
oncology practices, although it is routinely provided in other countries [54,55]. United States
oncologists have shared concerns regarding the safety and appropriateness of home infusion for
anticancer drug administration, and generally do not recommend it for most drugs [8]. An ASCO
position statement on this issue states that at-home infusion of chemotherapy, therapeutic
monoclonal antibodies, or other anticancer therapies is not a safe alternative to conventional
outpatient treatment, and cannot be endorsed without evidence of safety protocols or direct
oncologist oversight [56]. This guidance does not apply to continuous infusion of chemotherapy over
multiple hours or days that is both initiated and disconnected within the health care setting. Patient
safety at home must continue to be the first priority, and the decision to administer anticancer
therapy in the home setting can only be made if the treating clinician and the patient agree that it is in
the patient's best interest. Before it can be more widely applied, the safety of home chemotherapy
and immunotherapy will require nuanced changes to the ASCO/Oncology Nursing Society
Chemotherapy Administration Standards to reflect potential hazards associated with drug storage and
disposal at home, training of the administering caregiver, and mandating requirements for patient
education and self-care [57].
Oncologists may reasonably consider home infusion for supportive care, such as hydration or
antiemetics. Others suggest that low-risk drugs that require subcutaneous or intramuscular
administration (eg, fulvestrant, gonadotropin-releasing hormone agonists) could be safely
administered at home [58].
● A toolkit is available from the National Comprehensive Cancer Network to assist in shifting
traditionally inpatient chemotherapy regimens into the outpatient setting, primarily for patients with
hematologic malignancies [59].
● If a particular cancer center is heavily affected by coronavirus infections, it may be reasonable to alter
the chemotherapy schedule so that fewer visits are needed or to arrange infusion at a less affected
cancer center.
The use of prophylactic growth factors is discussed below. (See 'Supportive care' below.)
Issues related to tumor genotyping — Tumor genotyping is becoming an essential step in cancer

management for many solid tumors. The identification of specific molecular targets is increasingly being
used to define optimal systemic treatment for many patients with common solid tumors, including non-
small cell lung cancer (NSCLC) and breast cancer. (See "Personalized, genotype-directed therapy for
advanced non-small cell lung cancer" and "Treatment approach to metastatic hormone receptor-positive,
HER2-negative breast cancer: Endocrine therapy and targeted agents", section on 'Fulvestrant plus
alpelisib for PIK3CA-mutant tumors'.)
Worries about nosocomial contagion, particularly during the COVID-19 pandemic, may limit access to
diagnostic procedures such as tumor biopsy for next-generation sequencing. However, liquid biopsy,
namely cell-free DNA analysis, has already entered clinical practice in advanced NSCLC for epidermal
growth factor receptor (EGFR) mutational testing, and for the diagnosis of PIK3CA mutations in breast
cancer. The growing availability of several commercially available next-generation sequencing platforms
for blood-based comprehensive genomic profiling could extend liquid biopsy use to other settings as well,
perhaps precluding the need for invasive tumor biopsy [60]. However, liquid biopsy will not be useful for
identifying positivity for expression of the programmed cell death-1 ligand-1, which may influence
candidacy for immune checkpoint inhibitor (ICI) immunotherapy. Furthermore, the sensitivity for liquid
biopsies to yield results that predict clinical response to targeted agents ranges only between 60 and 80
percent. (See "Personalized, genotype-directed therapy for advanced non-small cell lung cancer", section
on 'Liquid biopsies'.)
Immune checkpoint inhibitor immunotherapy — There are several concerns that arise with the use
of ICI immunotherapy in the setting of the COVID-19 pandemic, including the possibility that immune
checkpoint blockade may lead to more severe immune system hyperactivation and increased incidence or
severity of the acute respiratory distress syndrome that develops during active infection, the diagnostic
dilemma posed by ICI toxicity, and the implications of COVID-19 for the management of ICI-mediated
adverse effects.
● Effect of immunotherapy on the incidence or severity of COVID-19 – At this time, there are
conflicting data regarding whether ICI therapy affects the severity of COVID-19. Available data are
discussed elsewhere. (See "Coronavirus disease 2019 (COVID-19): Risks for infection, clinical
presentation, testing, and management in patients with cancer".)
● Effect of COVID-19 on diagnosis and treatment of side effects from immunotherapy – In addition
to concerns that ICI therapy may exacerbate the clinical course of COVID-19 because immune
responses are enhanced by these treatments [61], there are also concerns that COVID-19 may impact
the diagnosis and treatment of ICI-related side effects [62,63]. A particular concern for cross-
interference is treatment-related pneumonitis, which may mimic COVID-19 and increase the risk of
serious complications if the patient develops COVID-19. Furthermore, given that glucocorticoids are
cautioned against for mild to moderate COVID-19 but are used to manage ICI-related pneumonitis,
diagnostic uncertainty may delay proper management of a severe condition [64]. (See "Toxicities
associated with checkpoint inhibitor immunotherapy", section on 'Pneumonitis' and "Coronavirus
disease 2019 (COVID-19): Management in hospitalized adults", section on 'Dexamethasone and other
glucocorticoids' and 'Differentiating lymphangitic spread, pneumonitis, and COVID-19' below.)
For individuals with a known COVID-19 diagnosis or exposure, it is recommended to hold treatment
until it is clear that the patient will not develop COVID-19. (See "Coronavirus disease 2019 (COVID-19):
Risks for infection, clinical presentation, testing, and management in patients with cancer", section on
'Approach to SARS-CoV-2 positive patients'.)
Approach to use of immunotherapy — Updated guidelines from ASCO suggest that the potential
harm and benefit of therapy with these agents should be carefully considered for each patient. The role of
SARS-CoV-2 testing for patients initiating immunotherapy is discussed separately. (See "Coronavirus
with cancer", section on 'Testing issues specific to cancer patients'.)
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Less frequent drug administration is an option for patients who are already receiving the drug. One
modeling study suggested that pembrolizumab 400 mg every six weeks leads to similar exposures as
every-three-week administration of a single dose of either 200 mg or 2 mg/kg [65]. The safety and efficacy
of this extended dosing option has been shown in patients with advanced melanoma [66], and this is an
appropriate option for some patients receiving pembrolizumab monotherapy, particularly in areas where
the prevalence of SARS-CoV-2 is high. Both the US Food and Drug Administration and the European
Medicines Agency have approved a new dosing regimen of 400 mg every six weeks for pembrolizumab
across all currently approved adult indications, in addition to the current 200 mg every three week dosing
regimen [67,68]. (See "Immunotherapy of advanced melanoma with immune checkpoint inhibition",
section on 'Dosing considerations'.)
Decisions regarding whether it is appropriate to use combination versus single-agent immunotherapy will
need to be individualized. The risks of immune-related adverse effects associated with ipilimumab-
containing combination regimens (or other immunotherapy combinations), including the risks of
hospitalization and associated COVID-19 exposure, should be weighed against the diminished efficacy of
single-agent therapy in each particular setting. Other considerations are similar as to those receiving
chemotherapy. (See "Toxicities associated with checkpoint inhibitor immunotherapy".)
Anti-CD20 monoclonal antibodies and other immunomodulatory agents — Lymphopenia seems to

be a specific risk factor for adverse outcomes from COVID-19 and other coronaviruses [69-75]. This has led
some expert groups, including the European Society for Medical Oncology (ESMO), to recommend critical
re-evaluation of the need for drugs that inhibit B cells, such as anti-CD20 monoclonal antibodies, during
the pandemic, particularly optional treatments such as maintenance therapy for follicular lymphoma [76].
On the other hand, guidelines from the American Society of Hematology (ASH) state that rituximab
continues to be prescribed by some experts, but not others. Some have discontinued maintenance
rituximab, especially in older patients and in younger patients with low immunoglobulin levels.
By contrast, it has been suggested that ibrutinib, and other inhibitors of Bruton tyrosine kinase (BTK), may
reduce the incidence and severity of COVID-19 among patients receiving it for management of chronic
lymphocytic leukemia, but further data are necessary. (See "Coronavirus disease 2019 (COVID-19): Risks for
infection, clinical presentation, testing, and management in patients with cancer", section on
'Management of cancer therapy'.)
Specific guidance for treatment of hematologic malignancies on a disease-by-disease basis is available

from ASH and other societies. (See 'Guidance from expert groups' below.)
Allogeneic hematopoietic cell transplantation — Although there are limited data regarding the
impact of COVID-19 in transplant candidates and donors and cellular therapy recipients, there is sufficient
concern that COVID-19 could have a significant impact on post-transplant or post-therapy outcomes.
Decisions on whether hematopoietic cell transplantation should be delayed must be individualized.
ASH has published a list of frequently asked questions that pertain to treating hematologic malignancies
during the COVID-19 pandemic, many of which address the role of induction and consolidation therapies,
including hematopoietic cell transplantation in many malignancies. Guidance for stem cell transplantation
during the pandemic is available from the American Society of Transplantation and Cellular Therapy, the
European Society for Blood and Marrow Transplantation, and NICE. In addition, the Fred Hutchinson
Cancer Research Center and the Seattle Cancer Care Alliance have provided guidance on stem cell
transplantation and COVID-19 that may be of value.
Considerations from ASCO include the following:
● It may be prudent to test potential donors for COVID-19 even in an absence of evidence of
transmission by blood transfusion.
● As a general precaution, visitation post-transplant may need to be limited and visitors may need to be
screened for symptoms and potential exposure.
SUPPORTIVE CARE
The American Society of Clinical Oncology (ASCO) has set forth the following recommendations for
supportive care during cancer therapy:
● There is no known role for prophylactic antiviral therapy for COVID-19 in any patient, including
immune suppressed patients.
● Flushing of ports can occur at intervals as long as every 12 weeks, and patients who are capable of
flushing their own devices should be encouraged to do so. However, the process of training may itself
be a source of exposure, and access to sterile supplies at home may be limited.
● Transfusions should be given according to usual practice guidelines, if possible, with consideration of
erythropoietin-stimulating agents if severe or life-threatening anemia is anticipated or if blood
products become scarce due to lack of donations. If anemia is due to bleeding, tumor embolization,
volume expanders, and antifibrinolytic agents (eg, epsilon aminocaproic acid or tranexamic acid,
where available) can be offered as a temporizing measure; iron infusions are another option for those
in less immediate need. In the operating room, the use of cell saver may also be appropriate.
For patients in need of other blood products such as fresh frozen plasma or platelets, care should be
individualized based on the indications, severity, and alternatives. Donor-directed transfusions should
be encouraged from patient family members in order to help sustain blood product supply during the
pandemic.
● For patients who are febrile and likely to be neutropenic based on the timing of their cancer
treatments, it may be reasonable to prescribe empiric antibiotics if the patient seems stable by clinical
assessment (in person or via telemedicine evaluation). It is preferable that further evaluation be
pursued, if necessary, outside of the emergency department.
● Although myeloid growth factor support is typically administered for those at high risk for febrile
neutropenia (>20 percent), it may be reasonable for patients with a lower level of expected risk for
febrile neutropenia with treatment (eg, >10 percent) to be prescribed prophylaxis with growth factor
support during the pandemic.
National Comprehensive Cancer Center guidelines for cancer care during the pandemic have also lowered
the threshold for the use of myeloid growth factors to include those regimens with a febrile neutropenia
risk of >10 percent [77,78]. However, concerns have been raised about a possible link between the higher
neutrophil:lymphocyte ratios induced by use of myeloid growth factors, and worsened in hospital
mortality for patients who subsequently develop COVID-19 [79,80].
Glucocorticoids — Glucocorticoids are widely used in cancer patients, for example, for chemotherapy- or
radiation-induced nausea and vomiting; infusion-related reactions; management of edema in patients with
brain metastases or epidural spinal cord compression; and in conjunction with hormone therapies such as
abiraterone, to reduce the likelihood of treatment-related mineralocorticoid deficiency. Although data are
limited regarding the impact of glucocorticoids on host immunity to COVID-19 in patients with cancer [49],
we typically continue glucocorticoids, if they are indicated, in cancer patients who do not have suspected
or documented COVID-19. Select indications for glucocorticoids in cancer patients are discussed
elsewhere. (See "Prevention and treatment of chemotherapy-induced nausea and vomiting in adults" and
"Infusion-related reactions to therapeutic monoclonal antibodies used for cancer therapy" and
"Management of vasogenic edema in patients with primary and metastatic brain tumors" and "Treatment
and prognosis of neoplastic epidural spinal cord compression", section on 'Symptomatic and preventive
care'.)
Discussion on the approach to withholding immunosuppressive therapies in cancer patients who are
newly diagnosed with COVID-19 is found elsewhere. (See "Coronavirus disease 2019 (COVID-19): Risks for
infection, clinical presentation, testing, and management in patients with cancer", section on
'Management of cancer therapy'.)
Managing subcutaneous ports — The typical frequency for maintenance flushing of subcutaneous ports
is once every four to six weeks. However, at least some data suggest that extending the maintenance
flushing interval of implanted ports in adult oncology patients to once every 12 weeks is safe and effective
[81]. Patients who are capable of flushing their own devices may be encouraged to do so. However, the
process of training may itself be a source of exposure, and access to sterile supplies at home may be
limited.
Advance care planning — Proactive advance care planning is important for all cancer patients, but is
particularly critical given the additional risk of COVID-19. Aligning the care that is delivered with the
patient's values and goals of care in the setting of an acute life-threatening illness is important, especially
for patients with chronic, life-limiting disease. Individuals who are most likely to develop severe illness will
be older and have a greater burden of chronic illness; these are the very populations who may wish to
forego prolonged life support, should the need arise. If an oncology patient with late-stage disease or with
significant comorbid health conditions affecting the heart or lungs develops COVID-19 and requires
mechanical ventilation, the prognosis is likely to be dismal [53]. (See "Coronavirus disease 2019 (COVID-
19): Risks for infection, clinical presentation, testing, and management in patients with cancer", section on
'Advance care planning for patients with severe disease'.)
Because of these issues, it is imperative for clinicians to have proactive discussions with patients about
advance care planning, especially for those with advanced cancer [82]. This should include the use of
advance directives or other expressions of end-of-life preferences and clear documentation of these
conversations, especially if they take place during a telehealth visit. (See "Hospice: Philosophy of care and
appropriate utilization in the United States", section on 'Adaptations for COVID-19'.)
Helpful communication guides for clinicians on a wide range of pertinent topics related to COVID-19,
including preferencing and proactive planning, are available from VitalTalk and others [83]. In addition, a
helpful guide to navigating difficult conversations and serious illness communication remotely during the
pandemic using the Setting, Perception, Invitation, Knowledge, Empathy/Emotion, and
Strategy/Summarize (SPIKES) protocol is available ( table 1) [84]. (See "Discussing serious news", section
on 'Approaches to breaking serious news: existing models and key elements'.)
The following resources are also available from the Center to Advance Palliative Care (CAPC) and
Respecting Choices:
● CAPC COVID-19 Response Resources

● Respecting Choices COVID-19 Tools and Resources
Additional relevant UpToDate discussions are found elsewhere:
● (See "Palliative care: The last hours and days of life", section on 'COVID-19 communication resources'.)
● (See "Advance care planning and advance directives", section on 'COVID-19 resources'.)
For cancer patients with COVID-19, who are at increased risk of needing mechanical ventilation or ICU
care, a conversation about Physician Orders for Life Sustaining Treatment (POLST) is appropriate.
Additional information is available at National POLST.
Mental health issues — Globally, the COVID-19 pandemic is leading to mental health problems such as
stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear [85,86]. Cancer patients on and off
treatment may have additional feelings of anxiety, fear, and vulnerability for disruption of care, disease
recurrence, and/or progression [87]. As resources become constrained, cancer patients may feel loneliness
and isolation as they watch their system swamped with cases that literally freeze them out. (See 'Allocation
of limited health care resources' below.)
Specific resources are available for patients. (See "Society guideline links: Coronavirus disease 2019
(COVID-19) – Resources for patients".)
Clinicians are also at risk for increased anxiety and stress because of [88,89]:
● Physical isolation from friends and family

● Worry about their own health and health of family, peers, and colleagues
● Competing demands of typical daily workload and COVID-19 response, especially coupled with
changes in family care responsibilities
● Difficult choices and challenges in patient care, worry about patients, and the need to support
patients and families during reduced visitation
ASCO has recommended mental health resources with tips on enhancing coping. The suggestions include
avoiding information overload, and taking a break from news and social media regarding COVID-19. There
is also a set of tips for enhancing mental and physical health during the pandemic.
Resources for clinicians are also available from the National Alliance on Mental Illness and a wide variety of
other groups. (See 'Society guideline links' below and "Coronavirus disease 2019 (COVID-19): Psychiatric
illness".)
A communication guide to assist clinicians with oncology-specific language to respond to patient

questions about changes in delivery of cancer care during the pandemic is available from University of
Michigan clinicians [90]. In addition, helpful communication guides for clinicians on a range of potentially
stressful topics specific to COVID-19, including counseling when coping needs a boost or emotions are
running high, and for notifying a family member of a loved one's death by telephone, are available from
VitalTalk.
CANCER TYPE-SPECIFIC GUIDANCE
Conceptual framework for balancing competing risks — During the pandemic, individuals with cancer
are faced with competing risks of potentially more severe SARS-CoV-2 infection, and the possibility of
adverse consequences from delaying effective cancer treatment. There are no evidence-based
international guidelines to address the management of cancer patients in any infectious pandemic. An
algorithmic approach to managing solid tumors diagnosed during the pandemic has been proposed by an
international group ( algorithm 1) [91], but decision-making about whether specific treatments can be
safely postponed or not requires a conceptual framework for balancing the competing risks of the cancer
and infection.
Such a conceptual approach to decision-making regarding immediate cancer treatment during the COVID-
19 pandemic has been described, which attempts to balance the risk of progression with delay of cancer
care versus the risk for significant morbidity from COVID-19 ( figure 1) [92]. The list below presents
examples that are meant to provide general guidance. Specific patient comorbidities as well as values and
preferences must also be considered in each case when the risk:benefit ratio of delaying cancer treatment
is being assessed. Specific considerations for lung cancer patients are discussed below. (See 'Patients with
lung cancer' below.)
● Based on low risk of progression in certain cancers, it may be safe to delay for more than three
months certain treatments, regardless of age.
• Examples include surgery and radiation (where indicated) for the following:
- Nonmelanoma skin cancer.
- Hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative early

breast cancer in postmenopausal women. In such women, neoadjuvant endocrine therapy
can be administered, and a longer time to surgery does not appear to lower overall survival
[93].
• Similarly, medical oncology treatments may be delayed for chronic hematologic cancers such as
chronic lymphocytic leukemia. Specific guidance is available from the American Society of
Hematology.
● Based on intermediate risk of progression in other cancers, a delay of approximately three

months may be acceptable in some settings, particularly for individuals 50 and older. Examples are
outlined below.
• Surgery for the following:
- Intermediate- or high-risk prostate cancer (androgen deprivation may be started in the

interim); the oncologic safety of delaying radical prostatectomy in this setting is supported by
at least two reports, one utilizing data from the National Cancer Database, and the other, a
large European cohort of men undergoing prostatectomy for intermediate- or high-risk
prostate cancer across Europe [94,95].
- Colon cancer with low risk for imminent obstruction.
- Low-risk melanoma.
• Radiation for postresection endometrial cancer and high-risk resected prostate cancer.
• In selected cases, chemotherapy for advanced metastatic breast, colorectal, lung, and other solid
tumors. However, these are difficult decisions, and must be individualized. For some patients with
rapidly progressive metastatic disease or a high tumor burden, a delay of three months could be
catastrophic. In such cases, shared decision-making is critically important. By contrast, active
surveillance may be an appropriate option for some patients with slow-growing advanced
disease, such as some patients with indolent or low-tumor-burden metastatic clear cell renal
cancer [96]. (See "Systemic therapy of advanced clear cell renal carcinoma", section on 'Active
surveillance'.)
● By contrast, given a high risk of progression in certain cancers, ideally there would be no delay in
treatments for the following individuals under age 70, although for older individuals, benefits of
immediate treatment must be balanced against the risks. Examples are as follows:
• Surgery for the following:
- ≥2 cm lung mass
- Colon cancer with imminent obstruction
- Type 2 endometrial cancer
- Pancreatic, ovarian, or liver mass(es) suspicious for malignancy
- High-risk non-muscle invasive or muscle invasive urothelial cancer of the bladder or upper
urinary tract who are not eligible for initial neoadjuvant chemotherapy; large and/or locally
advanced renal masses; localized testicular cancers; and invasive penile cancers [97]
• Radiation for the following:
- Lung cancer
- Locally advanced rectal cancer
- Initial management of most (but not all [98]) head and neck cancers
• Chemotherapy for the following:
- Acute leukemia, large cell lymphoma, Hodgkin lymphoma, symptomatic myeloma, and all
other non-low-grade hematologic cancers
- Metastatic testicular cancer
- Small cell lung cancer
- Most head and neck cancers, except thyroid
Other conceptual frameworks for prioritizing radiation and systemic treatment for cancer [99] and for
safely delivering surgical oncology care [100] during the pandemic are available.
In addition to potentially altering therapeutic protocols, other actions that have been suggested to
increase the safety of managing oncologic care during the COVID-19 pandemic include screening all
patients, caregivers, staff, and providers for COVID-19 symptoms; limiting exposure to sick contacts while
on anticancer therapy; minimizing nonessential follow-up visits; restricting visitors to both outpatient and
inpatient facilities; increasing engagement in telehealth and phone visits rather than in-person clinic visits;
and prescribing oral drugs that can be taken at home, rather than injectable agents requiring
administration in an infusion center, whenever possible.
Guidance from expert groups — Guidance is available from several expert groups on whether and how
care for certain cancer types should be affected by COVID-19, many of which have specific
recommendations for adaptation of treatment protocols. However, the extent and content of these
guidelines vary, and there is often disagreement on issues of prioritization, especially regarding the role
and timing of surgery for early stage disease [101-104]. The language of guidance delivery is a major
barrier to dissemination of recommendations in different countries. An international group has compiled a
summary of international recommendations in 23 languages for patients with cancer during the COVID-19
pandemic [105].
The following is not an exhaustive list, and additional society guideline links are provided elsewhere. (See
'Society guideline links' below.)
● Breast cancer
• In addition to guidance on breast cancer surgery from the American College of Surgeons, the
Society of Surgical Oncology, the American Society of Breast Surgeons, and the European Society
of Medical Oncology (ESMO) have published brief, high-level guidance on prioritization for
multidisciplinary care in breast cancer, and guidelines for radiation therapy for early breast cancer
are available from an international group [106].
• Guidelines for triage, prioritization, and treatment of breast cancer during the pandemic are also
available from several other consortiums of breast cancer experts [107-111], and from the
National Comprehensive Cancer Network (NCCN) [112].
A suggested approach for older patients with breast cancer has also been published [113].
● Gastrointestinal cancers
• In addition to guidance on colorectal surgery from the American College of Surgeons, and on
gastrointestinal tract cancer surgery from the Society of Surgical Oncology, an American group of
oncologists has developed recommendations for minimizing risks to patients with gastrointestinal
malignancies [114].
• Recommendations for management of colorectal cancer during the COVID-19 pandemic are
available from the US Colorectal Cancer Alliance, NCCN [112], ESMO, and from the City of Hope
National Medical Center [115].
• Specific guidance for managing pancreatic cancer during the pandemic are also available from
ESMO and from a multidisciplinary group from the United Kingdom [116].
• ESMO also has specific guidelines for management of gastroesophageal malignancies during the
pandemic.
● Genitourinary cancers
• Guidance from ESMO, Canadian guidelines, British guidelines [117], and German guidelines [118]
are available on prioritizing systemic therapy for patients with a range of genitourinary
malignancies.
• In addition, based on an analysis of published literature, an international multidisciplinary group

has published guidelines for management of genitourinary cancers based upon estimated risks of
deferring treatment during the COVID-19 pandemic [119].
• Recommendations for prioritization of urologic oncology surgeries and office-based procedures

during the COVID-19 pandemic are available from multiple sources, including the European
Association of Urology [120], a multi-institutional multidisciplinary group [121], the Cleveland
Clinic [122], and additional subspecialty experts [123].
• Guidelines specific to management of prostate cancer are available from a multidisciplinary

Canadian group [124] and the NCCN [112].
● Gynecologic cancers
• In addition to guidance from ESMO and the American College of Surgeons, guidance for
management of a range of gynecologic cancers is available from the Society of Gynecologic
Oncology [125,126], the National College of French Gynecologists and obstetricians [127], from
the editors of the International Journal of Gynecologic Cancer [128], from the International
Gynecologic Cancer Society, and from other multi-institutional expert groups [125,129,130].
• A collation of recommendations issued by multiple international government and professional

societies for the management of gynecologic cancers during the pandemic is also available [131].
• The American Society for Colposcopy and Cervical Pathology has published interim guidance for
timing of diagnostic and treatment procedures for women with abnormal cervical cytology where
patients cannot access medical care for nonurgent conditions. For example, women with low-
grade cervical cancer screening tests may have postponement of diagnostic evaluations up to 6 to
12 months, whereas those with high-grade screening tests should be evaluated within three
months, and for those with suspected invasive cancer, within four weeks. (See "Cervical
intraepithelial neoplasia: Management", section on 'Follow-up during COVID-19'.)
● Head and neck cancer
• A group from the United Kingdom has developed an evidence-based triage system for
assessment of patients with diagnosed or suspected head and neck cancer using outpatient
telemedicine consultations [132].
• Specific triage recommendations for head and neck cancer surgery are available from The
University of Texas MD Anderson Cancer Center [133]; from a joint consensus group of the French
Society of Otolaryngology, Head and Neck Surgery, the French Society of Head and Neck
Carcinology [134]; the Canadian Association of Head and Neck Surgical Oncology [135]; and
others [136-138]. However, these are all opinion- rather than evidence-based, and there is
disagreement as to surgical prioritization, particularly for those with early stage disease [104].
• In addition, joint guidance from ESTRO and ASTRO are available regarding risk-adapted head and
neck cancer radiotherapy during the pandemic [48].
• Investigators from Memorial Sloan Kettering Cancer Center have proposed subsite-specific
multimodality treatment recommendations during the pandemic [139].
● Hematologic malignancy
• In addition to guidelines from the American Society of Hematology, the American Society of
Transplantation and Cellular Therapy, the European Society for Blood and Marrow
Transplantation, and ESMO, the Seattle Cancer Care Alliance has published guidance on managing
patients with hematologic malignancies [140], and there are also recommendations from a
Brazilian task force [141] and a combined Australian/New Zealand consensus statement [142].
• The International Lymphoma Radiation Oncology Group has issued guidance on alternative
radiation treatment schemes in blood cancer during the COVID-19 pandemic.
• An international group has published recommendations on the care of older patients with
multiple myeloma [143]; separate recommendations are available from the European Myeloma
Network [144], and a group from the Mayo Clinic also has guidance on management of myeloma
[145].
• The United States Cutaneous Lymphoma consortium and the European Organisation for Research
and Treatment of Cancer Cutaneous Lymphoma Task Force have both published
recommendations on treatment of cutaneous lymphoma [146,147], and the NCCN also has short-
term recommendations for the management of T-cell and primary cutaneous lymphomas and
chronic myelogenous leukemia during the pandemic [112].
• One consortium group has summarized the challenges in managing systemic light chain
amyloidosis during the pandemic [148], and specific recommendations for management are
available from the International Society of Amyloidosis.
● Primary hepatic malignancies
• In addition to ESMO, the International Liver Cancer Association has issued guidance on
management of hepatocellular carcinoma (HCC) during the COVID-19 pandemic, as has the
American Association for the Study of Liver Diseases [149] and the French Association for the
Study of the Liver [150].
• A treatment pathway for treatment of HCC during the pandemic has been proposed by an
international multidisciplinary collaborative group, and this group also has proposed
recommendations for treatment of intrahepatic cholangiocarcinoma [151].
Information on issues relevant to solid organ transplantation is available elsewhere. (See "Coronavirus
disease 2019 (COVID-19): Issues related to solid organ transplantation".)
● Lung cancer – Guidelines for patients with lung cancer are addressed below. (See 'Patients with lung
cancer' below.)
● Neurooncology
• Joint guidance on care of patients with brain tumors and brain metastases is available from the
American Association of Neurological Surgeons/Congress of Neurological Surgeons Tumor
Section/Society for Neuro-Oncology [152], and specific guidance for management of primary
brain tumors is available from ESMO [153,154] and from two different international
multidisciplinary groups [155,156].
• Another group has established a quantitative framework for how COVID-19-associated risks affect
survival during different adjuvant therapy regimens for older adult patients with glioblastoma
using published results from randomized clinical trials to help guide clinical decision-making
during the pandemic [157].
● Neuroendocrine and endocrine tumors
• Guidance in managing neuroendocrine tumors during the COVID-19 pandemic is available from
the North American Neuroendocrine Tumor Society (NANETS), and from the UK and Ireland
Neuroendocrine Tumor Society.
• Guidelines for surgical triage for neuroendocrine and endocrine tumors are available from the
Society of Surgical Oncology.
● Skin cancer
• Recommendations for prioritization of treatment for melanoma are available from ESMO, the
Society of Surgical Oncology, and a multidisciplinary British group [158].
• Short-term recommendations for management of melanoma, as well as for non-melanoma skin

cancers, during the pandemic are available from NCCN [112].
• In addition, two multidisciplinary expert groups, one Italian and the other American, have
provided recommendations for prioritization and management of primary skin cancers during the
pandemic [159,160].
● Sarcoma – Recommendations for multidisciplinary management of sarcoma are available from the
Society of Surgical Oncology, ESMO, and the French Sarcoma Group [161].
Patients with lung cancer — Patients with lung cancer may be at higher risk for acquiring COVID-19 than
the general population; the disease may be more severe, and more often fatal, and COVID-19 may
interfere with effective diagnostic and therapeutic lung cancer management [162]. It has also been
postulated that smoking history and prior tobacco-related lung damage increase the incidence and
severity of SARS-CoV-2 infection [163,164]. Given all of these issues, such patients should be particularly
cautious about exposure to COVID-19, given that many have baseline respiratory comorbidity or
impairment due to the cancer itself, and should immediately report any new or changing symptoms to
their clinicians.
● Severity of COVID-19 – Evolving data indicate a high rate of severe disease and mortality from COVID-
19 in patents with lung cancer [165-168]:
• In the most recent results of a multi-institutional international registry study including 400
patients with thoracic cancer also diagnosed with SARS-CoV-2 infection through laboratory tests,
or with suspected SARS-CoV-2 infection based on exposure and symptoms, the majority of
patients were hospitalized (78 percent), and 36 percent of patients died [166]. Moreover, patients
who received chemotherapy within three months had a higher risk of dying from the virus versus
patients who did not (hazard ratio 1.7, 95% CI 1.1-2.6). In earlier reporting of this study (200
patients), despite the high rate of hospitalization, only 10 percent of those who met criteria for
intensive care unit (ICU) admission (13 of 134) were admitted to an ICU, which could have
influenced the high mortality rate [169]. (Predominantly, the reasons for patients not being
admitted to ICU included institutional policy against ICU admission for an underlying cancer
diagnosis, and severe infection with clinician recommendation not to escalate to ICU for futility in
advanced stage cancer.)
Regarding characteristics of included patients, approximately 50 percent of patients had

metastatic disease. Approximately one-third of all patients were receiving chemotherapy alone,
one-quarter were receiving immunotherapy alone, and 19 percent were receiving a tyrosine
kinase inhibitor alone [166]. However, in univariate analysis, there were no factors that were
identified, including active cancer treatment, as being associated with mortality.
• In a report of 102 patients with lung cancer and confirmed COVID-19 treated at a single New York
cancer center over a seven-week period, disease was severe in 62 percent, and 25 percent were
hospitalized, although most recovered, including the 25 percent of patients initially requiring
intubation [168]. At a median follow-up of 25 days, 25 patients (25 percent) had died.
Determinants of severity were predominantly patient-specific (age, smoking status, chronic
obstructive pulmonary disease, need for supplemental oxygen at presentation), and cancer-
specific features (prior thoracic surgery or radiation, active or metastatic cancer, recent systemic
therapy [programmed cell death 1 (PD-1) blockade with or without chemotherapy]) did not impact
severity.
● SARS-CoV-2 testing – Some have advocated for SARS-CoV-2 testing in all lung cancer patients,
regardless of symptomatology, given that these patients often have baseline pulmonary deficits and
other comorbidities [162,163]. Our approach is to offer testing to lung cancer patients with new
symptoms or known exposures, as well as select asymptomatic patients (eg, prior to high-risk
procedures, including surgery, bronchoscopy, or pulmonary function testing), as discussed elsewhere.
(See "Coronavirus disease 2019 (COVID-19): Risks for infection, clinical presentation, testing, and
management in patients with cancer", section on 'Testing issues specific to cancer patients'.)
● Impact on diagnosis
• Distinguishing lung cancer evolution from a potential SARS-CoV-2 superinfection on the basis of
radiologic or clinical presentation can be difficult. The main computed tomography (CT) findings
of COVID-19 pneumonia can overlap with CT findings that are often found in patients with
progressive lung cancer. (See "Coronavirus disease 2019 (COVID-19): Clinical features", section on
'Imaging findings'.)
In addition, the worsening pulmonary symptoms during lung cancer progression can be similar to
that typical of COVID-19. (See "Coronavirus disease 2019 (COVID-19): Clinical features", section on
'Clinical manifestations'.)
• Adding further complexity, pneumonitis can also be induced by immune checkpoint inhibitor (ICI)
immunotherapy, an effective and widely used standard-of-care treatment for lung cancer in
various treatment lines and settings [170]. Although the risk of pneumonitis is approximately 2
percent in patients treated with ICIs for a variety of cancers, it may be higher in patients with lung
cancer [171]. The clinical symptoms and radiologic imaging findings associated with treatment-
related pneumonitis may overlap with those of COVID-19.
Pneumonitis may also complicate molecularly targeted therapies such as osimertinib and
standard cytotoxic chemotherapy. Furthermore, cytotoxic chemotherapy can have
immunosuppressive effects. (See "Pulmonary toxicity associated with antineoplastic therapy:
Molecularly targeted agents" and "Pulmonary toxicity associated with antineoplastic therapy:
Cytotoxic agents".)
● Treatment
• The clinical and biologic aggressiveness of many lung cancers often does not allow for anticancer
therapy to be withheld or postponed.
• Specific guidance for lung cancer treatment during the COVID-19 pandemic is available from
several expert groups:
- American College of Surgeons
- The Thoracic Surgery Outcomes Research Network [172], which includes guidance on triage
for thoracic surgery in patients with thoracic malignancy
- ESMO, which has laid out specific guidelines for the types of lung cancer care that should and
should not be delayed
- The International Association for the Study of Lung Cancer (IASLC), which includes a
Frequently Asked Questions page
- NCCN [112]
- ESTRO-ASTRO [173]
- And others, including an international group [174] and an American group from the
University of Pennsylvania [175]
An international consensus group has provided guidance on the management of lung nodules
and lung cancer screening during the pandemic [10]. (See "Screening for lung cancer", section on
'Counseling for screening'.)
• Observational evidence suggests certain treatments are reasonable to continue during the
COVID-19 pandemic. In a single-center observational study of 69 outpatients with lung cancer
with confirmed COVID-19, severity of COVID-19 was comparable among those who had received a
PD-1 inhibitor and those who had not [176]. Within the subset who had received anti-PD-1
therapy, there were no consistent trends regarding proximity of exposure to PD-1 blockade and
COVID-19 severity. Separate case reports have suggested safety with continuation of anaplastic
lymphoma kinase (ALK)- and c-ROS oncogene 1 (ROS1)-targeted therapies among those with the
relevant cancer genotypes and COVID-19 pneumonia [177]. (See "Personalized, genotype-directed
therapy for advanced non-small cell lung cancer", section on 'Genotypes with approved targeted
therapies'.)
SPECIAL CONSIDERATIONS
Older individuals with cancer — Older age is a predictor of adverse outcomes from COVID-19, with
mortality rates that sharply rise after age 70, both in patients with and without cancer [169,178].
Therefore, COVID-19 is an important competing risk to consider in treating older patients with cancer
during the pandemic, especially those with serious hematologic malignancies such as acute leukemia
[179]. (See "Coronavirus disease 2019 (COVID-19): Clinical features", section on 'Risk factors for severe
illness' and "Acute myeloid leukemia: Management of medically-unfit adults".)
Geriatric assessments allow clinicians to weigh the risks and benefits of a proposed treatment plan in
addition to predicting the risk of dying from the cancer versus other conditions, especially for frail older
patients. (See "Comprehensive geriatric assessment for patients with cancer" and "Pretreatment
evaluation and prognosis of acute myeloid leukemia in older adults", section on 'Pretreatment evaluation'.)
Various tools have been proposed to stratify frailty in the context of the COVID-19 pandemic, including the
Clinical Frailty Scale and the Frailty Index [180,181]. However, these tools have not been validated in this
population, and their use should not replace individualized discussions and care recommendations. Self-
administered screening tools such as the Vulnerable Elders Survey-13 (VES-13) ( table 2), as are used in
older cancer patients who are not infected with COVID-19, may identify those patients who are most
vulnerable. (See "Frailty", section on 'Instruments developed to identify frailty' and "Comprehensive
geriatric assessment for patients with cancer", section on 'Pre-CGA screening tools'.)
The International Society of Geriatric Oncology (SIOG) COVID-19 working group was established to provide
recommendations, guidelines, and action plans for the management of cancer in older adults during the
pandemic; specific recommendations for adapting cancer care from this group are available [182]. Specific
recommendations for managing vulnerable older patients with cancer during the pandemic are also
available from the Cancer and Aging Research Group (CARG) [183].
Children with cancer — Advice on managing children with cancer during the COVID-19 pandemic is
available from an international combined group with input from the International Society for Pediatric
Oncology, Children's Oncology Group, St Jude Global program, and Childhood Cancer International [184].
They include disease-specific guidance for managing acute lymphoblastic leukemia, Burkitt lymphoma,
Hodgkin lymphoma, retinoblastoma, Wilms tumor, and low-grade glioma, as well as guidance for
supportive care, and a summary of web links from expert groups that are relevant to the care of pediatric
oncology patients during the COVID-19 pandemic [185].
Guidance on management of young patients with acute lymphoblastic leukemia is also available from the
French Society for the Fight against Cancers and Leukemias in Children and Adolescents [186].
Specific topics about COVID-19 in children are available elsewhere in UpToDate. (See "Coronavirus disease
2019 (COVID-19): Clinical manifestations and diagnosis in children" and "Coronavirus disease 2019 (COVID-
19): Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis"
and "Coronavirus disease 2019 (COVID-19): Management in children".)
Head and neck, and upper aerodigestive tract procedures — Because of the spread of SARS-CoV-2
through respiratory droplets, health care workers who come in contact with the upper aerodigestive tract
during diagnostic or therapeutic procedures (eg, otolaryngologists, head and neck surgeons, upper
gastrointestinal tract endoscopists, ophthalmologists, dermatologists, and plastic surgeons working on
the head and neck) are particularly at risk [187]. Safety recommendations to guide evaluation and surgery
for head and neck cancers during the pandemic are available from two different international expert
groups [137,188]. Other expert guidance for multimodality management of head and neck cancer during
the pandemic, especially surgical prioritization, is discussed above. (See 'Guidance from expert groups'
above.)
At many institutions, testing for the SARS-CoV-2 virus is mandatory before any surgical procedures are
undertaken in patients. Given the significant risks of treating upper aerodigestive tract diseases in patients
with COVID-19 and the uncertain but considerably lower specificity of current tests, two negative tests
spaced ≥24 hours apart have been recommended for these patients. (See "Coronavirus disease 2019
(COVID-19): Diagnosis", section on 'Specific diagnostic techniques'.)
Other alternatives, such as computed tomography-guided biopsies, should be explored, if feasible.
Differentiating lymphangitic spread, pneumonitis, and COVID-19 — Some systemic cancer treatments

are associated with a risk of pneumonitis (eg, immune checkpoint inhibitors [ICIs], gemcitabine,
mechanistic [previously referred to as mammalian] target of rapamycin [mTOR] inhibitors). (See "Toxicities
associated with checkpoint inhibitor immunotherapy", section on 'Pneumonitis' and "Pulmonary toxicity
associated with antineoplastic therapy: Molecularly targeted agents" and "Pulmonary toxicity associated
with systemic antineoplastic therapy: Clinical presentation, diagnosis, and treatment" and "Pulmonary
toxicity associated with antineoplastic therapy: Molecularly targeted agents", section on 'Rapamycin and
analogs'.)
In other cases, new infiltrates on radiographic imaging may reflect disease progression (eg, lymphangitic
spread) or radiation pneumonitis [189]. Besides the fact that treatment-related pneumonitis might
increase the risk of serious complications if the patient develops COVID-19, it may be difficult to
distinguish therapy effect versus disease progression versus viral infection. In this setting, treatment
should be held until it is clear that the diagnosis is not COVID-19. Testing for COVID-19 is appropriate in
such circumstances, similar to the approach taken for patients with new respiratory symptoms. (See
"Coronavirus disease 2019 (COVID-19): Risks for infection, clinical presentation, testing, and management
in patients with cancer", section on 'Testing issues specific to cancer patients'.)
Cancer survivors — There is a growing population of cancer survivors worldwide [190]; in the United
States alone, there are more than 16.9 million cancer survivors [191]. (See "Overview of cancer
survivorship care for primary care and oncology providers", section on 'Epidemiology of cancer survivors'.)
Whether cancer survivors who have completed treatment are at increased risk for COVID-19 and its
complications is unclear; such risk may be influenced by the type of cancer, treatments received, timing of
prior treatments, and patient age and comorbid medical conditions. In addition to specific cancer history,
late and long-term effects of prior treatment (ie, pulmonary or cardiac toxicities, altered kidney function,
persistent immunosuppression) may also pose risks for survivors.
The following studies have addressed the risk of COVID-19 in cancer survivors:
● In at least one study, cancer patients in remission with no evidence of disease were at a lower risk of
poor outcomes from COVID-19 as compared with those receiving active treatment for their cancer
[178]. (See "Coronavirus disease 2019 (COVID-19): Risks for infection, clinical presentation, testing, and
management in patients with cancer", section on 'Is illness more severe in patients with malignancy?'.)
● Additional data on cancer survivors are available from a cohort study including records of 17 million
individuals derived from national primary care electronic health record data, which were linked to in-
hospital COVID-19 death data [192]. In multivariate analysis adjusted for age and sex, nonhematologic
or hematologic malignancies diagnosed within one year of infection were significant risk factors for
in-hospital death. (See "Coronavirus disease 2019 (COVID-19): Risks for infection, clinical presentation,
testing, and management in patients with cancer", section on 'Is illness more severe in patients with
malignancy?'.)
The risks of death were smaller, but still statistically significant for those diagnosed 1 to 4.9 years
before infection (for nonhematologic malignancy, hazard ratio [HR] for death 1.39, 95% CI 1.22-1.58;
for hematologic malignancy, HR for death 3.59, 95% CI 2.88-4.48). Thereafter, risks diverged, and the
risk of death was no longer elevated in patients diagnosed ≥5 years prior with a nonhematologic
malignancy (HR for death 1.03, 95% CI 0.94-1.12). By contrast, the risk of in-hospital death for patients
with a hematologic malignancy remained elevated even after five years (HR for death 2.13, 95% CI
1.76-2.59).
● On the other hand, in an analysis of 9275 individuals diagnosed with SARS-CoV-2 in the Veneto
regional of Italy, 723 with cancer and 8552 without, individuals diagnosed with cancer within the two
years before acquiring the infection had the highest rates of hospitalization and death compared with
those without cancer, but the risks were still elevated among those diagnosed with cancer five or
more years before infection was diagnosed [193]. Interestingly, the 2+ and 5+ year survivors were
more likely to be hospitalized and more likely to die, but less likely to be admitted to an intensive care
unit, possibly because of scarce resource allocation.
Survivorship care — As of August 2020, the American Society of Clinical Oncology (ASCO) position
statement does not recommend any different strategies for caring for cancer survivors who have
completed treatment. These patients should follow all of the general measures (eg, social isolation,
postponing clinic visits) advised by the United States Centers for Disease Control and Prevention (CDC) to
minimize their exposure to potential infection. Patients who receive intravenous immunoglobulin should
continue to receive it at the prescribed dose and schedule.
However, there are limited data regarding the impact of the COVID-19 pandemic on cancer survivors,
particularly those who have completed treatment. In addition to the implications of COVID-19 on the
physical well-being of survivors (many of whom are age 65 or older with comorbidities, or chronically
immunocompromised), the stress related to the pandemic may exacerbate other long-lasting treatment-
related effects in this population, including cognitive problems and anxiety [194].
In response to the pandemic, many face-to-face encounters which are deemed unessential have been
replaced with telehealth (telephone or video) visits. (See 'Telehealth versus in person visits' below.)
While there is limited evidence regarding the use of telehealth during COVID-19 for cancer survivorship
care, prior research suggested that this may be acceptable to most patients [195-198]. Furthermore, the
value of in-person follow-up, including the use of serial physical examination, surveillance blood work and
imaging in the absence of symptoms, has not been established for long-term survivors. Therefore, at this
time, it is reasonable to provide survivorship care by telehealth visits, with thorough assessment of
symptoms, and use of validated patient-reported instruments and using these to guide in-person care
accordingly. However, if the pandemic is long-lasting, the postponement of routine face-to-face
surveillance visits, may become problematic, particularly among those with limited availability of
telehealth services.
Cancer survivors, particularly adolescents and young adults, may have a high level of psychological
distress and anxiety as a result of the pandemic and the uncertainty as to their overall risk [199].
Telehealth visits may serve to assess psychological distress in order to refer patients to appropriate
counseling services [200,201]. Common questions about COVID-19 and answers for patients and cancer
survivors are available from ASCO and the National Coalition for Cancer Survivorship [202]. In addition, a
compilation of selected COVID-19 resources for cancer survivors and health care providers in the United
States is available [194].
Clinical trials — Clinical research has transformed cancer management and is often seamlessly integrated
into routine oncologic care, offering eligible patients additional treatment options. The COVID-19
pandemic presents a major barrier to enrollment and ongoing participation in clinical trials, and as a
result, many programs have halted or prioritized screening and/or enrollment for certain cancer clinical
trials, and ceased research-only visits [203-205].
However, centers have successfully adapted research practices in order to maintain safe and compliant
clinical research protocols for cancer patients during the pandemic [206]. The US Food and Drug
Administration (FDA), the European Medicines Agency, and others have published guidance for sponsors
and study sites to ensure the safety of trial participation, while maintaining regulatory compliance and
minimizing risks to study integrity [207,208]. The FDA has also issued statistical guidance for clinical trials
impacted by the pandemic.
MINIMIZING THE COMPROMISE OF PHYSICAL DISTANCING DURING CANCER CARE

DELIVERY
In the absence of effective pharmacologic therapy for COVID-19, nonpharmacologic interventions are
being relied upon to reduce disease transmission and the burden of COVID-19. In addition to personal
preventive measures (eg, hand hygiene, respiratory etiquette and face covers, environmental disinfection),
transmission reduction strategies also include social/physical distancing, stay-at-home mandates, and
recommendations to limit unnecessary excursions, including clinic visits. (See "Coronavirus disease 2019
(COVID-19): Epidemiology, virology, and prevention", section on 'Other public health measures'.)
Telehealth versus in person visits — Patients undergoing cancer care including diagnosis, counseling,
active treatment, surveillance, and long-term survivorship follow-up are highly exposed to medical centers,
providers, staff, and other patients. This results in a massive number of personal contact points and a
large number of potential opportunities for viral transmission for both patients and caregivers. American
Society of Clinical Oncology (ASCO) guidelines recommend adoption of telemedicine visits for patients not
requiring a physical exam, treatment, or in-office diagnostics [8].
Prior to the COVID-19 pandemic, telehealth and virtual visits were available but were little used. Early
studies exploring the possibilities for telehealth focused on reducing cost and increasing convenience of
care, mainly through the use of interventions such as vital sign monitors that were linked to home hubs
and transmitted electronically; they were variably effective [209,210]. A later Australian study exploring the
benefits of both vital sign monitors and technologies that included participant videoconferencing
capabilities and messaging features in approximately 300 individuals found reduced hospital admissions,
and a significant improvement in participants' health literacy and health behaviors, with improved anxiety,
depression, and quality of life [211]. Other smaller studies focused mainly on improving the convenience
of care for rural patients, including those with cancer, by using telehealth, mobile applications, and
wearable devices [212-214]. However, multiple barriers, including cost-effectiveness, security of
communication links for personal (including health) data, limitations/unreliability of internet connections,
concerns regarding the impact of telehealth on patient rapport, liability and legal issues, time constraints,
and financial (ie, incentives, billing) barriers slowed progress in telehealth [215,216].
The COVID-19 pandemic cast telehealth into a new light because it is accessed by people directly from
home and may reduce the likelihood of viral transmission by limiting person-to-person contact, thus
safeguarding both the patients and health/social care workers. Furthermore, at least in the United States,
the current payment parity between telehealth and clinic-based care from the Centers for Medicare and
Medicaid Services (CMS) transformed outpatient oncology practically overnight [58]. Over the course of
less than one year, many centers now report two-thirds or more of follow-up cancer care is conducted
virtually, a dramatic transformation in the way care is delivered [217,218]. As patients and providers shift
to utilizing telephone and video platforms to communicate and deliver care, both must accept the benefits
as well as the risks. While there are many advantages, including less exposure to SARS-CoV-2, decreased
travel time, and potential cost savings, there are also many challenges, including data privacy, data
security, medical liability, access to devices and the internet, understanding how to use telehealth
equipment, lack of physical exam, decreased ability to participate in clinical trials, hampered fellow and
resident training, and difficulties in coordinating care, including services such as financial assistance,
patient education, symptom management, and supportive care [58,219]. Guidance on how oncologists can
implement telemedicine while addressing concerns for data privacy, data security, and medical liability are
available in an ASCO statement of telemedicine in cancer care.
Operationalizing telehealth workflows to mimic those that providers and patients are accustomed to in
person may be helpful to maintain familiarity and avoid missed opportunities to improve care and
communication. Specific strategies to address barriers during telephone and video visits have been
proposed [220]. It is reassuring that at least one randomized trial of remote video visits in men
undergoing prostatectomy for prostate cancer prior to the pandemic suggests that patient perception of
visit confidentiality, efficiency, education quality, and overall satisfaction is acceptable during telehealth
visits, urologist satisfaction was also high, and the clinician time dedicated to each visit was similar for
virtual and face-to-face visits [221].
At the same time, personal contact often provides confidence, reassurance, and comfort that the patient is
receiving optimal care. Furthermore, some aspects of follow-up cancer care, such as physical
examinations, cannot be provided through telehealth technology, and this may particularly impact toxicity
assessment during treatments such as RT [222].
An important point is that while telemedicine is an important paradigm for patient-provider

communication, in an effort to maximize physical distancing, it has the potential to interrupt important
aspects of the patient's relationships with the care team. This can lead to miscommunication and
misunderstandings as well as avoidable delays and even adverse events related to improper care. As an
example, one unintended consequence of telehealth visits for patients receiving chemotherapy is the
inability to document an accurate weight, which may lead to incorrect dosing for weight-based drugs
[223].
Therefore, for patients who are already coming into the cancer center for imaging, procedures, surgeries,
radiation therapy, or infusions, a face-to-face visit remains an important option, with the usual precautions
(masks, strict attention to hand hygiene). In general, minimizing time in waiting rooms, rearranging
patient contact areas to maximize physical distancing, augmenting early discharge planning efforts,
executing prompt and safe discharge events, minimizing visitors, instituting pharmacy deliveries, and
anticipating/avoiding the possibility of urgent care/emergency department visits (eg, consider more
delayed removal of drains/catheters based on risk benefit profile) are all necessary steps in creating a safe
experience [224]. Both ASCO and the National Comprehensive Cancer Network (NCCN) [9] have issued
recommendations for oncology practices to keep patients with cancer, as well as their caregivers and
health care staff, as safe as possible during the COVID-19 pandemic.
ALLOCATION OF LIMITED HEALTH CARE RESOURCES
The COVID-19 pandemic is challenging health care systems worldwide and raising important ethical
issues, especially regarding the potential need for rationing health care in the context of scarce resources
and crisis capacity.
Limited availability of personal protective equipment (PPE) has complicated medical care of patients with
suspected or documented COVID-19 (and other transmissible conditions) worldwide. In general, physical
distancing and barrier protective measures are the most potent forms of COVID-19 avoidance. We suggest
following the United States Centers for Disease Control and Prevention (CDC) recommendations on face
mask wearing. Further measures to prevent viral spread are discussed elsewhere. (See "Coronavirus
disease 2019 (COVID-19): Infection control in health care and home settings", section on 'Infection control
in the health care setting'.)
Local and regional considerations and policies should be informed on prevailing conditions. Special
attention should be paid to augmenting PPE for care providers in close contact with known COVID-19-
positive patients and those who manage the airway and respiratory tracts. Rapidly emerging data suggest
that PPE such as N95 masks can safely be sterilized for reuse. In the United States, the CDC offers
guidance on optimizing the supply of PPE when sudden increases in patient volume threaten a facility's
PPE capacity. Strategies include canceling nonurgent procedures or visits that would warrant use of PPE,
prioritizing the use of certain PPE for the highest-risk situations, and cautious extended or limited reuse of
PPE. This subject is discussed in detail elsewhere. (See "Coronavirus disease 2019 (COVID-19): Infection
control in health care and home settings".)
Beyond the care of individual patients, oncology clinicians may face the reality of rationing care due to
limited resources, particularly hospital and intensive care unit capacity. In the face of limited resources,
clinicians must consider carefully what cancer treatments are most likely to be successful, symptom-
relieving, or life-saving, and identify those patients who are likely to get the greatest benefit from
treatment [53,225]. If treatments are withheld, from a medico-legal standpoint, national and local
guideline standards should be followed [226,227].
The American Society of Clinical Oncology has released guidance on allocation of limited resources during
the COVID-19 pandemic [228]. They emphasize that decisions regarding allocation of scarce resources
should be separated from bedside decision-making. In addition, interim guidelines for use during the
COVID-19 pandemic are available from the Oncology Nursing Society for use of PPE during clinical
oncology care and for safe handling and administration of hazardous cancer drugs. (See "Coronavirus
disease 2019 (COVID-19): Critical care and airway management issues", section on 'Surge capacity and
scarce resource allocation'.)
While high quality of and accessibility to care remains the greatest concern of providers, as resources
become constrained, cancer patients may feel that their disease progression may become collateral
damage to health care shortages and deferrals. Neither patients nor clinicians have any significant
experience with rationing of care. Addressing fears such as these is critical to an open dialogue and may
lead to opportunities to improve communication and prioritize care goals and shared decision-making.
(See 'Mental health issues' above.)
Helpful communication guides for clinicians on a range of topics specific to COVID-19, including limitations
in resources, are available from VitalTalk, and others [83], and a communication guide to assist clinicians
with oncology-specific language to communicate about changes in delivery of cancer care during the
pandemic is available from University of Michigan clinicians [90].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored disease-specific guidelines (including those for hematology
and oncology patients) from selected countries and regions around the world are provided separately.
(See "Society guideline links: Coronavirus disease 2019 (COVID-19) – International public health and
government guidelines" and "Society guideline links: Coronavirus disease 2019 (COVID-19) – Guidelines for
specialty care" and "Society guideline links: Coronavirus disease 2019 (COVID-19) – Resources for
patients".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they
answer the four or five key questions a patient might have about a given condition. These articles are best
for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These articles are written at
the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Coronavirus disease 2019 (COVID-19) overview (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Delivering cancer care during the COVID-19 pandemic is challenging given the competing risks of
death from cancer versus death from infection, and the higher lethality of infection with the severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in immunocompromised hosts, among
other reasons. Clinicians must balance the risks of delaying cancer treatments versus the risks for
SARS CoV-2 exposure and the potential increased vulnerability to adverse outcomes from COVID-19,
while navigating the disruption in care associated with physical distancing and limited health care
resources. (See 'General considerations' above.)
● Recommendations about cancer screening are evolving and should be based on the state of COVID-19
in an individual community as well as the availability of resources. In areas where infection is still an
ongoing issue, in general, any clinic visits that can be postponed without risk to the patient should be
postponed, according to the United states Centers for Disease Control and Prevention (CDC). (See
'Providing safe care for outpatients' above.)
There is no evidence that SARS-CoV-2 infection interferes with or has an effect on the diagnosis or
staging of cancer. In a patient newly diagnosed with cancer, it is reasonable to limit staging
procedures and pretreatment evaluation only to those that are most necessary to inform development
of the initial care plan. (See 'Cancer diagnosis and staging' above.)
● The rationale for delaying elective surgeries during the pandemic is conservation of resources,
limitation of viral spread, and minimizing risks, particularly of postoperative infection. (See 'Cancer
surgery' above.)
● Some patients receiving radiation therapy (RT) with curative intent or for rapidly progressive tumors
may reasonably proceed with therapy, as the risks of delaying treatment may outweigh the risks of
SARS-CoV-2 exposure and infection. Where available, alternative RT regimens should be offered. (See
'Radiation therapy' above.)
● There is no direct evidence to support changing or withholding chemotherapy or immunotherapy in

patients with cancer, and routinely withholding critical anticancer or potentially immunosuppressive
therapy is not recommended for those who do not have COVID-19. For most patients, home infusion
of chemotherapy, therapeutic monoclonal antibodies, or other anticancer therapies is not a safe
alternative to conventional outpatient treatment and cannot be endorsed without evidence of safety
protocols or direct oncologist oversight. (See 'Systemic anticancer treatments' above.)
The approach to resuming cancer therapy among those with COVID-19 is discussed in detail
elsewhere. (See "Coronavirus disease 2019 (COVID-19): Risks for infection, clinical presentation,
testing, and management in patients with cancer", section on 'When can cancer treatment be safely
restarted?'.)
● Extending the maintenance flushing interval of implanted ports in adult oncology patients to once
every 12 weeks is safe and effective. Guidelines for cancer care during the pandemic have lowered the
threshold for the use of myeloid growth factors to include those chemotherapy regimens with a
febrile neutropenia risk of >10 percent. (See 'Supportive care' above.)
● A decision-making approach regarding immediate versus delayed cancer treatment during the COVID-
19 pandemic is presented above, which balances the estimated risk of progression with delay of
cancer care versus the risk for significant morbidity from COVID-19 ( figure 1). Additionally, several
groups have laid out cancer type-specific guidance during the COVID-19 pandemic. However,
individual patient morbidities and values and preferences must also be weighed in these decisions.
(See 'Cancer type-specific guidance' above.)
● Clinicians should proactively discuss goals of care and advance care planning, including advance
directives, especially for those with advanced cancer who are at elevated risk for COVID-19. (See
'Advance care planning' above.)
● Given the number of opportunities for viral transmission for both patients and caregivers during
cancer care, the use of video and/or telephone visits is encouraged, but both clinicians and patients
must accept the benefits as well as the risks. When patients must receive in-person care, specific
strategies can be used to accomplish physical distancing (eg, minimizing time in waiting rooms,
minimizing/restricting visitors, instituting pharmacy deliveries, and avoiding emergency department
visits, when possible). (See 'Minimizing the compromise of physical distancing during cancer care
delivery' above.)
● Limited availability of personal protective equipment (PPE) has complicated medical care of patients
with suspected or documented SARS-CoV-2 infection (and other transmissible conditions) worldwide.
In general, physical distancing and barrier protective measures are the most potent forms of COVID-
19 avoidance. We suggest following the CDC recommendations on face mask wearing and optimizing
the supply of PPE when sudden increases in patient volume threaten a facility's PPE. (See 'Allocation of
limited health care resources' above.)
● Clinicians are at high risk for stress during the COVID-19 pandemic for a number of reasons. American
Society of Clinical Oncology guidelines contain mental health resources with tips on enhancing coping
and enhancing mental and physical health during the pandemic. (See 'Mental health issues' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. World Health Organization. Director-General's remarks at the media briefing on 2019-nCoV on 11 Feb
ruary 2020. http://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at-the-media-bri
efing-on-2019-ncov-on-11-february-2020 (Accessed on February 12, 2020).
2. Yu J, Ouyang W, Chua MLK, Xie C. SARS-CoV-2 Transmission in Patients With Cancer at a Tertiary Care
Hospital in Wuhan, China. JAMA Oncol 2020; 6:1108.
3. Lewis MA. Between Scylla and Charybdis - Oncologic Decision Making in the Time of Covid-19. N Engl
J Med 2020; 382:2285.
4. Cannistra SA, Haffty BG, Ballman K. Challenges Faced by Medical Journals During the COVID-19
Pandemic. J Clin Oncol 2020; 38:2206.
5. Dinmohamed AG, Visser O, Verhoeven RHA, et al. Fewer cancer diagnoses during the COVID-19
epidemic in the Netherlands. Lancet Oncol 2020; 21:750.
6. Kaufman HW, Chen Z, Niles J, Fesko Y. Changes in the Number of US Patients With Newly Identified
Cancer Before and During the Coronavirus Disease 2019 (COVID-19) Pandemic. JAMA Netw Open
2020; 3:e2017267.
7. London JW, Fazio-Eynullayeva E, Palchuk MB, et al. Effects of the COVID-19 Pandemic on Cancer-
Related Patient Encounters. JCO Clin Cancer Inform 2020; 4:657.
8. ASCO Special report: Guide to cancer care delivery during the COVID-19 pandemic. May 19, 2020. htt
p://www.asco.org/sites/new-www.asco.org/files/content-files/2020-ASCO-Guide-Cancer-COVID19.pdf
(Accessed on May 20, 2020).
9. Cinar P, Kubal T, Freifeld A, et al. Safety at the Time of the COVID-19 Pandemic: How to Keep our
Oncology Patients and Healthcare Workers Safe. J Natl Compr Canc Netw 2020; :1.
10. Mazzone PJ, Gould MK, Arenberg DA, et al. Management of Lung Nodules and Lung Cancer Screening
During the COVID-19 Pandemic: CHEST Expert Panel Report. Chest 2020; 158:406.
11. Ciavattini A, Delli Carpini G, Giannella L, et al. Expert consensus from the Italian Society for
Colposcopy and Cervico-Vaginal Pathology (SICPCV) for colposcopy and outpatient surgery of the
lower genital tract during the COVID-19 pandemic. Int J Gynaecol Obstet 2020; 149:269.
12. Villani A, Fabbrocini G, Costa C, Scalvenzi M. Melanoma Screening Days During the Coronavirus
Disease 2019 (COVID-19) Pandemic: Strategies to Adopt. Dermatol Ther (Heidelb) 2020; 10:525.
13. Ceugnart L, Delaloge S, Balleyguier C, et al. [Breast cancer screening and diagnosis at the end of the
COVID-19 confinement period, practical aspects and prioritization rules: recommendations of 6
French health professionals societies]. Bull Cancer 2020; 107:623.
14. NCCN guidance for early diagnosis and screening for prostate cancer. Available at: https://www.nccn.
org/covid-19/default.aspx (Accessed on June 10, 2020).
15. ASCCP interim guidance for timing of diagnostic and treatment procedures for patients with abnorm
al cervical screening tests. http://www.asccp.org/covid-19 (Accessed on July 31, 2020).
16. https://www.nccn.org/covid-19/pdf/Prostate_Early_Detection.pdf (Accessed on September 23, 2020).
17. Jones D, Neal RD, Duffy SRG, et al. Impact of the COVID-19 pandemic on the symptomatic diagnosis
of cancer: the view from primary care. Lancet Oncol 2020; 21:748.
18. Tan KK, Lau J. Cessation of cancer screening: An unseen cost of the COVID-19 pandemic? Eur J Surg
Oncol 2020; 46:2154.
19. Gralnek IM, Hassan C, Dinis-Ribeiro M. COVID-19 and endoscopy: implications for healthcare and
digestive cancer screening. Nat Rev Gastroenterol Hepatol 2020; 17:444.
20. Amit M, Tam S, Bader T, et al. Pausing cancer screening during the severe acute respiratory syndrome
coronavirus 2pandemic: Should we revisit the recommendations? Eur J Cancer 2020; 134:86.
21. Sharpless NE. COVID-19 and cancer. Science 2020; 368:1290.
22. Wise J. Covid-19: Cancer mortality could rise at least 20% because of pandemic, study finds. BMJ 2020;
369:m1735.
23. Maringe C, Spicer J, Morris M, et al. The impact of the COVID-19 pandemic on cancer deaths due to
delays in diagnosis in England, UK: a national, population-based, modelling study. Lancet Oncol 2020;
21:1023.
24. Ricciardiello L, Ferrari C, Cameletti M, et al. Impact of SARS-CoV-2 pandemic on colorectal cancer
screening delay: effect on stage shift and increased mortality. Clin Gastroenterol Hepatol 2020.
25. Neal RD, Nekhlyudov L, Wheatstone P, Koczwara B. Cancer care during and after the pandemic. BMJ
2020; 370:m2622.
26. Maida M. Screening of gastrointestinal cancers during COVID-19: a new emergency. Lancet Oncol
2020; 21:e338.
27. Helsper CW, Campbell C, Emery J, et al. Cancer has not gone away: A primary care perspective to
support a balanced approach for timely cancer diagnosis during COVID-19. Eur J Cancer Care (Engl)
2020; 29:e13290.
28. COVID19 Subcommittee of the O.R. Executive Committee at Memorial Sloan Kettering. Cancer
Surgery and COVID19. Ann Surg Oncol 2020; 27:1713.
29. Thompson CK, Lee MK, Baker JL, et al. Taking a Second Look at Neoadjuvant Endocrine Therapy for
the Treatment of Early Stage Estrogen Receptor Positive Breast Cancer During the COVID-19
Outbreak. Ann Surg 2020; 272:e96.
30. Sud A, Jones ME, Broggio J, et al. Collateral damage: the impact on outcomes from cancer surgery of
the COVID-19 pandemic. Ann Oncol 2020; 31:1065.
31. Fligor SC, Wang S, Allar BG, et al. Gastrointestinal Malignancies and the COVID-19 Pandemic:
Evidence-Based Triage to Surgery. J Gastrointest Surg 2020; 24:2357.
32. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery
with perioperative SARS-CoV-2 infection: an international cohort study. Lancet 2020; 396:27.
33. Myles PS, Maswime S. Mitigating the risks of surgery during the COVID-19 pandemic. Lancet 2020;
396:2.
34. Local Resumption of Elective Surgery Guidance. American College of Surgeons, April 17, 2020. Availab
le at: https://www-facs-org.ezproxy.javeriana.edu.co/covid-19/clinical-guidance/resuming-elective-sur
gery (Accessed on April 18, 2020).
35. Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic. American College
of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses,
American Hospital Association. April 17, 2020. Available at: https://www-facs-org.ezproxy.javeriana.ed
u.co/covid-19/clinical-guidance/roadmap-elective-surgery (Accessed on April 18, 2020).
36. Centers for Medicare and Medicaid Services (CMS). CMS recommendations: Reopening facilities to pr
ovide nonemergent non-COVID-19 health care: Phase I. http://www.cms.gov/files/document/covid-fle
xibility-reopen-essential-non-covid-services.pdf (Accessed on April 28, 2020).
37. Centers for Medicare and Medicaid Services. Nonemergent, elective medical services, and treatment
recommendations. http://www.cms.gov/files/document/cms-non-emergent-elective-medical-recomm
endations.pdf (Accessed on April 28, 2020).
38. Cancer Research UK. Priorities for the UK governments and health services to recover cancer services
through and beyond the COVID-19 pandemic. http://www.cancerresearchuk.org/sites/default/files/cr
uk_priorities_for_recovery_of_cancer_services.pdf (Accessed on July 21, 2020).
39. Coleman NL, Argenziano M, Fischkoff KN. Developing an Algorithm to Guide Resumption of
Operative Activity in the COVID-19 Pandemic and Beyond. Ann Surg 2020.
40. Nagar H, Formenti SC. Cancer and COVID-19 - potentially deleterious effects of delaying radiotherapy.
Nat Rev Clin Oncol 2020; 17:332.
41. Marijnen CAM, Peters FP, Rödel C, et al. International expert consensus statement regarding
radiotherapy treatment options for rectal cancer during the COVID 19 pandemic. Radiother Oncol
2020; 148:213.
42. Muralidhar V, Dee EC, D'Amico AV. Sequencing Treatments for Cancer During the COVID-19
Pandemic. Am J Clin Oncol 2020; 43:457.
43. Dee EC, Mahal BA, Arega MA, et al. Relative Timing of Radiotherapy and Androgen Deprivation for
Prostate Cancer and Implications for Treatment During the COVID-19 Pandemic. JAMA Oncol 2020;
6:1630.
44. Huang SH, O'Sullivan B, Su J, et al. Hypofractionated radiotherapy alone with 2.4 Gy per fraction for
head and neck cancer during the COVID-19 pandemic: The Princess Margaret experience and
proposal. Cancer 2020; 126:3426.
45. Mendez LC, Raziee H, Davidson M, et al. Should we embrace hypofractionated radiotherapy for
cervical cancer? A technical note on management during the COVID-19 pandemic. Radiother Oncol
2020; 148:270.
46. Thomson DJ, Yom SS, Saeed H, et al. Radiation Fractionation Schedules Published During the COVID-
19 Pandemic: A Systematic Review of the Quality of Evidence and Recommendations for Future
Development. Int J Radiat Oncol Biol Phys 2020; 108:379.
47. Tchelebi LT, Haustermans K, Scorsetti M, et al. Recommendations for the use of radiation therapy in
managing patients with gastrointestinal malignancies in the era of COVID-19. Radiother Oncol 2020;
148:194.
48. Thomson DJ, Palma D, Guckenberger M, et al. Practice Recommendations for Risk-Adapted Head and
Neck Cancer Radiation Therapy During the COVID-19 Pandemic: An ASTRO-ESTRO Consensus
Statement. Int J Radiat Oncol Biol Phys 2020; 107:618.
49. Russell B, Moss C, George G, et al. Associations between immune-suppressive and stimulating drugs
and novel COVID-19-a systematic review of current evidence. Ecancermedicalscience 2020; 14:1022.
50. Elkrief A, Kazandjian S, Bouganim N. Changes in Lung Cancer Treatment as a Result of the
Coronavirus Disease 2019 Pandemic. JAMA Oncol 2020.
51. Papautsky EL, Hamlish T. Patient-reported treatment delays in breast cancer care during the COVID-
19 pandemic. Breast Cancer Res Treat 2020; 184:249.
52. Segelov E, Underhill C, Prenen H, et al. Practical Considerations for Treating Patients With Cancer in
the COVID-19 Pandemic. JCO Oncol Pract 2020; 16:467.
53. Ueda M, Martins R, Hendrie PC, et al. Managing Cancer Care During the COVID-19 Pandemic: Agility
and Collaboration Toward a Common Goal. J Natl Compr Canc Netw 2020; :1.
54. Murthy V, Wilson J, Suhr J, et al. Moving cancer care closer to home: a single-centre experience of
home chemotherapy administration for patients with myelodysplastic syndrome. ESMO Open 2019;
4:e000434.
55. Depledge J. Chemotherapy in the community for adult patients with cancer. Br J Community Nurs
2012; 17:214.
56. https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/20
20_Home-Infusion-Position-Statement.pdf?cid=DM5714&bid=53107298 (Accessed on August 21, 202
0).
57. Neuss MN, Gilmore TR, Belderson KM, et al. 2016 Updated American Society of Clinical
Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including
Standards for Pediatric Oncology. Oncol Nurs Forum 2017; 44:31.
58. Mulvey TM, Jacobson JO. COVID-19 and Cancer Care: Ensuring Safety While Transforming Care
Delivery. J Clin Oncol 2020; 38:3248.
59. National Comprehensive Cancer Network (NCCN). NCCN Best Practices Committee Infusion Efficiency
Workgroup. Toolkit: Providing oncology treatments in the outpatient setting. http://www.nccn.org/co
vid-19/pdf/NCCN_Toolkit_Updated_for_COVID-19.pdf (Accessed on May 13, 2020).
60. Rolfo C, Russo A, de Miguel-Pérez D. Speeding tumor genotyping during the SARS-CoV-2 outbreak
through liquid biopsy. Cancer 2020.
61. Di Giacomo AM, Gambale E, Monterisi S, et al. SARS-COV-2 infection in patients with cancer
undergoing checkpoint blockade: Clinical course and outcome. Eur J Cancer 2020; 133:1.
62. Maio M, Hamid O, Larkin J, et al. Immune Checkpoint Inhibitors for Cancer Therapy in the COVID-19
Era. Clin Cancer Res 2020; 26:4201.
63. Pickles OJ, Lee LYW, Starkey T, et al. Immune checkpoint blockade: releasing the breaks or a
protective barrier to COVID-19 severe acute respiratory syndrome? Br J Cancer 2020; 123:691.
64. Souza IL, Fernandes Í, Taranto P, et al. Immune-related pneumonitis with nivolumab and ipilimumab
during the coronavirus disease 2019 (COVID-19) pandemic. Eur J Cancer 2020; 135:147.
65. Lala M, Li TR, de Alwis DP, et al. A six-weekly dosing schedule for pembrolizumab in patients with
cancer based on evaluation using modelling and simulation. Eur J Cancer 2020; 131:68.
66. Lala M, et al "Pembrolizumab 400 mg Q6W dosing: First clinical outcomes data from Keynote-555 coh
ort B in metastatic melanoma patients" AACR 2020; Abstract CT042. https://www.aacr.org/profession
als/blog/aacr-virtual-annual-meeting-i-results-presented-provide-basis-for-fda-decision-to-approve-al
ternative-pembrolizumab-dosing-schedule/ (Accessed on May 01, 2020).
67. US Food and Drug Administration (FDA). FDA approves new dosing regimen for pembrolizumab. htt
p://www.fda.gov/drugs/drug-approvals-and-databases/fda-approves-new-dosing-regimen-pembroliz
umab (Accessed on April 30, 2020).
68. European Medicines Agency. Pembrolizumab summary of product characteristics. http://www.ema.e

uropa.eu/en/documents/product-information/keytruda-epar-product-information_en.pdf (Accessed o
n April 30, 2020).
69. Shah V, Ko Ko T, Zuckerman M, et al. Poor outcome and prolonged persistence of SARS-CoV-2 RNA in
COVID-19 patients with haematological malignancies; King's College Hospital experience. Br J
Haematol 2020; 190:e279.
70. Hirsch HH, Martino R, Ward KN, et al. Fourth European Conference on Infections in Leukaemia (ECIL-
4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainfluenza virus,
metapneumovirus, rhinovirus, and coronavirus. Clin Infect Dis 2013; 56:258.
71. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-
19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054.
72. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med
2020; 382:1708.
73. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in
Wuhan, China. Lancet 2020; 395:497.
74. Terpos E, Ntanasis-Stathopoulos I, Elalamy I, et al. Hematological findings and complications of

COVID-19. Am J Hematol 2020; 95:834.
75. Yarza R, Bover M, Paredes D, et al. SARS-CoV-2 infection in cancer patients undergoing active
treatment: analysis of clinical features and predictive factors for severe respiratory failure and death.
Eur J Cancer 2020; 135:242.
76. von Lilienfeld-Toal M, Vehreschild JJ, Cornely O, et al. Frequently asked questions regarding SARS-CoV-
2 in cancer patients-recommendations for clinicians caring for patients with malignant diseases.
Leukemia 2020; 34:1487.
77. Short-term recommendations from the NCCN specific to issues with COVID-19. Available at: https://w
ww.nccn.org/covid-19/pdf/HGF_COVID-19.pdf (Accessed on May 15, 2020).
78. Griffiths EA, Alwan LM, Bachiashvili K, et al. Considerations for Use of Hematopoietic Growth Factors
in Patients With Cancer Related to the COVID-19 Pandemic. J Natl Compr Canc Netw 2020; :1.
79. Lasagna A, Zuccaro V, Ferraris E, et al. How to Use Prophylactic G-CSF in the Time of COVID-19. JCO
Oncol Pract 2020; 16:771.
80. Nawar T, Morjaria S, Kaltsas A, et al. Granulocyte-colony stimulating factor in COVID-19: Is it

stimulating more than just the bone marrow? Am J Hematol 2020; 95:E210.
81. Diaz JA, Rai SN, Wu X, et al. Phase II Trial on Extending the Maintenance Flushing Interval of
Implanted Ports. J Oncol Pract 2017; 13:e22.
82. Curtis JR, Kross EK, Stapleton RD. The Importance of Addressing Advance Care Planning and
Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19). JAMA 2020;
323:1771.
83. ARIADNE labs. Serious illness care program COVID-19 response toolkit. Accesed at https://covid19.ari
adnelabs.org/2020/04/15/serious-illness-care-program-covid-19-response-toolkit (Accessed on Septe
mber 17, 2020).
84. Holstead RG, Robinson AG. Discussing Serious News Remotely: Navigating Difficult Conversations
During a Pandemic. JCO Oncol Pract 2020; 16:363.
85. Torales J, O'Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its
impact on global mental health. Int J Soc Psychiatry 2020; 66:317.
86. Young AM, Ashbury FD, Schapira L, et al. Uncertainty upon uncertainty: supportive Care for Cancer
and COVID-19. Support Care Cancer 2020; 28:4001.
87. Chen-See S. Disruption of cancer care in Canada during COVID-19. Lancet Oncol 2020; 21:e374.
88. National Center for PTSD. Managing health care workers' stress associated with the COVID-19 virus o
utbreak. http://www.ptsd.va.gov/covid/COVID19ManagingStressHCW032020.pdf (Accessed on April 0
3, 2020).
89. Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety Among Health Care
Professionals During the COVID-19 Pandemic. JAMA 2020; 323:2133.
90. Gharzai LA, Resnicow K, An LC, Jagsi R. Perspectives on Oncology-Specific Language During the
Coronavirus Disease 2019 Pandemic: A Qualitative Study. JAMA Oncol 2020; 6:1424.
91. Al-Shamsi HO, Alhazzani W, Alhuraiji A, et al. A Practical Approach to the Management of Cancer
Patients During the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: An International
Collaborative Group. Oncologist 2020; 25:e936.
92. Kutikov A, Weinberg DS, Edelman MJ, et al. A War on Two Fronts: Cancer Care in the Time of COVID-
19. Ann Intern Med 2020; 172:756.
93. Minami CA, Kantor O, Weiss A, et al. Association Between Time to Operation and Pathologic Stage in
Ductal Carcinoma in Situ and Early-Stage Hormone Receptor-Positive Breast Cancer. J Am Coll Surg
2020; 231:434.
94. Ginsburg KB, Curtis GL, Timar RE, et al. Delayed Radical Prostatectomy is Not Associated with Adverse
Oncologic Outcomes: Implications for Men Experiencing Surgical Delay Due to the COVID-19
Pandemic. J Urol 2020; 204:720.
95. Diamand R, Ploussard G, Roumiguié M, et al. Timing and delay of radical prostatectomy do not lead
to adverse oncologic outcomes: results from a large European cohort at the times of COVID-19
pandemic. World J Urol 2020.
96. Rini BI, Dorff TB, Elson P, et al. Active surveillance in metastatic renal-cell carcinoma: a prospective,
phase 2 trial. Lancet Oncol 2016; 17:1317.
97. Katims AB, Razdan S, Eilender BM, et al. Urologic oncology practice during COVID-19 pandemic: A
systematic review on what can be deferrable vs. nondeferrable. Urol Oncol 2020; 38:783.
98. Forner D, Noel CW, Wu V, et al. Nonsurgical management of resectable oral cavity cancer in the wake
of COVID-19: A rapid review and meta-analysis. Oral Oncol 2020; 109:104849.
99. Hanna TP, Evans GA, Booth CM. Cancer, COVID-19 and the precautionary principle: prioritizing
treatment during a global pandemic. Nat Rev Clin Oncol 2020; 17:268.
100. Hwang ES, Balch CM, Balch GC, et al. Surgical Oncologists and the COVID-19 Pandemic: Guiding
Cancer Patients Effectively through Turbulence and Change. Ann Surg Oncol 2020; 27:2600.
101. Amparore D, Campi R, Checcucci E, et al. Forecasting the Future of Urology Practice: A
Comprehensive Review of the Recommendations by International and European Associations on
Priority Procedures During the COVID-19 Pandemic. Eur Urol Focus 2020; 6:1032.
102. Shinder BM, Patel HV, Sterling J, et al. Urologic oncology surgery during COVID-19: a rapid review of
current triage guidance documents. Urol Oncol 2020; 38:609.
103. Garg PK, Kaul P, Choudhary D, et al. Discordance of COVID-19 guidelines for patients with cancer: A
systematic review. J Surg Oncol 2020.
104. Galloway TJ, Kowalski LP, Matos LL, et al. Head and neck surgery recommendations during the COVID-
19 pandemic. Lancet Oncol 2020; 21:e416.
105. Mauri D, Kamposioras K, Tolia M, et al. Summary of international recommendations in 23 languages

for patients with cancer during the COVID-19 pandemic. Lancet Oncol 2020; 21:759.
106. Coles CE, Aristei C, Bliss J, et al. International Guidelines on Radiation Therapy for Breast Cancer
During the COVID-19 Pandemic. Clin Oncol (R Coll Radiol) 2020; 32:279.
107. Dietz JR, Moran MS, Isakoff SJ, et al. Recommendations for prioritization, treatment, and triage of
breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer
consortium. Breast Cancer Res Treat 2020; 181:487.
108. Curigliano G, Cardoso MJ, Poortmans P, et al. Recommendations for triage, prioritization and
treatment of breast cancer patients during the COVID-19 pandemic. Breast 2020; 52:8.
109. Dowsett M, Ellis MJ, Dixon JM, et al. Evidence-based guidelines for managing patients with primary
ER+ HER2- breast cancer deferred from surgery due to the COVID-19 pandemic. NPJ Breast Cancer
2020; 6:21.
110. Sheng JY, Santa-Maria CA, Mangini N, et al. Management of Breast Cancer During the COVID-19
Pandemic: A Stage- and Subtype-Specific Approach. JCO Oncol Pract 2020; 16:665.
111. Martin M, Guerrero-Zotano A, Montero Á, et al. GEICAM Guidelines for the Management of Patients
with Breast Cancer During the COVID-19 Pandemic in Spain. Oncologist 2020.
112. National Comprehensive Cancer Network (NCCN). NCCN coronavirus disease 2019 (COVID-19) resour
ces for the cancer care community. http://www.nccn.org/covid-19/default.aspx (Accessed on June 10,
2020).
113. Freedman RA, Sedrak MS, Bellon JR, et al. Weathering the Storm: Managing Older Adults with Breast
Cancer Amid COVID-19 and Beyond. J Natl Cancer Inst 2020.
114. Lou E, Beg S, Bergsland E, et al. Modifying Practices in GI Oncology in the Face of COVID-19:
Recommendations From Expert Oncologists on Minimizing Patient Risk. JCO Oncol Pract 2020;
16:383.
115. O'Leary MP, Choong KC, Thornblade LW, et al. Management Considerations for the Surgical
Treatment of Colorectal Cancer During the Global Covid-19 Pandemic. Ann Surg 2020; 272:e98.
116. Jones CM, Radhakrishna G, Aitken K, et al. Considerations for the treatment of pancreatic cancer
during the COVID-19 pandemic: the UK consensus position. Br J Cancer 2020; 123:709.
117. Gillessen S, Powles T. Advice Regarding Systemic Therapy in Patients with Urological Cancers During
the COVID-19 Pandemic. Eur Urol 2020; 77:667.
118. Ivanyi P, Grüllich C, Kroeger N, et al. Systemic treatment of advanced/metastatic renal cell carcinoma
in the context of SARS-CoV-2 pandemic: recommendations from the interdisciplinary working group
for renal tumors (IAG-N). J Cancer Res Clin Oncol 2020; 146:3075.
119. Wallis CJD, Novara G, Marandino L, et al. Risks from Deferring Treatment for Genitourinary Cancers: A
Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic. Eur Urol 2020;
78:29.
120. Ribal MJ, Cornford P, Briganti A, et al. European Association of Urology Guidelines Office Rapid
Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of
Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era. Eur Urol 2020; 78:21.
121. Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the Triage of Urologic Surgeries
During the COVID-19 Pandemic. Eur Urol 2020; 77:663.
122. Goldman HB, Haber GP. Recommendations for Tiered Stratification of Urological Surgery Urgency in
the COVID-19 Era. J Urol 2020; 204:11.
123. Katz EG, Stensland KD, Mandeville JA, et al. Triaging Office Based Urology Procedures during the
COVID-19 Pandemic. J Urol 2020; 204:9.
124. Kokorovic A, So AI, Hotte SJ, et al. A Canadian framework for managing prostate cancer during the
COVID-19 pandemic: Recommendations from the Canadian Urologic Oncology Group and the
Canadian Urological Association. Can Urol Assoc J 2020; 14:163.
125. Pothuri B, Alvarez Secord A, Armstrong DK, et al. Anti-cancer therapy and clinical trial considerations
for gynecologic oncology patients during the COVID-19 pandemic crisis. Gynecol Oncol 2020; 158:16.
126. Fader AN, Huh WK, Kesterson J, et al. When to Operate, Hesitate and Reintegrate: Society of
Gynecologic Oncology Surgical Considerations during the COVID-19 Pandemic. Gynecol Oncol 2020;
158:236.
127. Akladios C, Azais H, Ballester M, et al. Recommendations for the surgical management of
gynecological cancers during the COVID-19 pandemic - FRANCOGYN group for the CNGOF. J Gynecol
Obstet Hum Reprod 2020; 49:101729.
128. Ramirez PT, Chiva L, Eriksson AGZ, et al. COVID-19 Global Pandemic: Options for Management of
Gynecologic Cancers. Int J Gynecol Cancer 2020; 30:561.
129. Elledge CR, Beriwal S, Chargari C, et al. Radiation therapy for gynecologic malignancies during the
COVID-19 pandemic: International expert consensus recommendations. Gynecol Oncol 2020;
158:244.
130. Garganese G, Tagliaferri L, Fragomeni SM, et al. Personalizing vulvar cancer workflow in COVID-19
era: a proposal from Vul.Can MDT. J Cancer Res Clin Oncol 2020; 146:2535.
131. Uwins C, Bhandoria GP, Shylasree TS, et al. COVID-19 and gynecological cancer: a review of the
published guidelines. Int J Gynecol Cancer 2020; 30:1424.
132. Paleri V, Hardman J, Tikka T, et al. Rapid implementation of an evidence-based remote triaging
system for assessment of suspected referrals and patients with head and neck cancer on follow-up
after treatment during the COVID-19 pandemic: Model for international collaboration. Head Neck
2020; 42:1674.
133. MD Anderson Head and Neck Surgery Treatment Guidelines Consortium, Consortium members,
Maniakas A, et al. Head and neck surgical oncology in the time of a pandemic: Subsite-specific triage
guidelines during the COVID-19 pandemic. Head Neck 2020; 42:1194.
134. Fakhry N, Schultz P, Morinière S, et al. French consensus on management of head and neck cancer
surgery during COVID-19 pandemic. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 137:159.
135. O'Connell DA, Seikaly H, Isaac A, et al. Recommendations from the Canadian Association of Head and
Neck Surgical Oncology for the Management of Head and Neck Cancers during the COVID-19
pandemic. J Otolaryngol Head Neck Surg 2020; 49:53.
136. Topf MC, Shenson JA, Holsinger FC, et al. Framework for prioritizing head and neck surgery during
the COVID-19 pandemic. Head Neck 2020; 42:1159.
137. Mehanna H, Hardman JC, Shenson JA, et al. Recommendations for head and neck surgical oncology
practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an
international consensus. Lancet Oncol 2020; 21:e350.
138. de Almeida JR, Noel CW, Forner D, et al. Development and validation of a Surgical Prioritization and
Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN) in a scarce resource
setting: Response to the COVID-19 pandemic. Cancer 2020; 126:4895.
139. Kang JJ, Wong RJ, Sherman EJ, et al. The 3 B's of cancer care amid the COVID-19 pandemic crisis: "Be
safe, be smart, be kind"-A multidisciplinary approach increasing the use of radiation and embracing
telemedicine for head and neck cancer. Cancer 2020.
140. Percival MM, Lynch RC, Halpern AB, et al. Considerations for Managing Patients With Hematologic
Malignancy During the COVID-19 Pandemic: The Seattle Strategy. JCO Oncol Pract 2020; 16:571.
141. Perini GF, Fischer T, Gaiolla RD, et al. How to manage lymphoid malignancies during novel 2019
coronavirus (CoVid-19) outbreak: a Brazilian task force recommendation. Hematol Transfus Cell Ther
2020; 42:103.
142. Di Ciaccio P, McCaughan G, Trotman J, et al. Australian and New Zealand consensus statement on the
management of lymphoma, chronic lymphocytic leukaemia and myeloma during the COVID-19
pandemic. Intern Med J 2020; 50:667.
143. Mian H, Grant SJ, Engelhardt M, et al. Caring for older adults with multiple myeloma during the
COVID-19 Pandemic: Perspective from the International Forum for Optimizing Care of Older Adults
with Myeloma. J Geriatr Oncol 2020; 11:764.
144. Terpos E, Engelhardt M, Cook G, et al. Management of patients with multiple myeloma in the era of
COVID-19 pandemic: a consensus paper from the European Myeloma Network (EMN). Leukemia
2020; 34:2000.
145. Al Saleh AS, Sher T, Gertz MA. Multiple Myeloma in the Time of COVID-19. Acta Haematol 2020;
143:410.
146. Zic JA, Ai W, Akilov OE, et al. United States Cutaneous Lymphoma Consortium recommendations for
treatment of cutaneous lymphomas during the COVID-19 pandemic. J Am Acad Dermatol 2020;
83:703.
147. Papadavid E, Scarisbrick J, Ortiz Romero P, et al. Management of primary cutaneous lymphoma
patients during COVID-19 pandemic: EORTC CLTF guidelines. J Eur Acad Dermatol Venereol 2020;
34:1633.
148. Kastritis E, Wechalekar A, Schönland S, et al. Challenges in the management of patients with systemic
light chain (AL) amyloidosis during the COVID-19 pandemic. Br J Haematol 2020; 190:346.
149. Fix OK, Hameed B, Fontana RJ, et al. Clinical Best Practice Advice for Hepatology and Liver Transplant
Providers During the COVID-19 Pandemic: AASLD Expert Panel Consensus Statement. Hepatology
2020; 72:287.
150. Ganne-Carrié N, Fontaine H, Dumortier J, et al. Suggestions for the care of patients with liver disease
during the Coronavirus 2019 pandemic. Clin Res Hepatol Gastroenterol 2020; 44:275.
151. Barry A, Apisarnthanarax S, O'Kane GM, et al. Management of primary hepatic malignancies during
the COVID-19 pandemic: recommendations for risk mitigation from a multidisciplinary perspective.
Lancet Gastroenterol Hepatol 2020; 5:765.
152. Ramakrishna R, Zadeh G, Sheehan JP, Aghi MK. Inpatient and outpatient case prioritization for
patients with neuro-oncologic disease amid the COVID-19 pandemic: general guidance for neuro-
oncology practitioners from the AANS/CNS Tumor Section and Society for Neuro-Oncology. J
Neurooncol 2020; 147:525.
153. Weller M, Preusser M. How we treat patients with brain tumour during the COVID-19 pandemic.
ESMO Open 2020; 4.
154. European Society for Medical Oncology (ESMO). ESMO management and treatment adapted recomm
endations in the COVID-19 era: Primary brain tumors. Priorities for primary brain tumor patients. htt
p://www.esmo.org/guidelines/cancer-patient-management-during-the-covid-19-pandemic/primary-b
rain-tumours-in-the-covid-19-era (Accessed on July 22, 2020).
155. Mohile NA, Blakeley JO, Gatson NTN, et al. Urgent Considerations for the Neuro-oncologic Treatment
of Patients with Gliomas During the COVID-19 Pandemic. Neuro Oncol 2020.
156. Bernhardt D, Wick W, Weiss SE, et al. Neuro-oncology Management During the COVID-19 Pandemic
With a Focus on WHO Grade III and IV Gliomas. Neuro Oncol 2020.
157. Tabrizi S, Trippa L, Cagney D, et al. A Quantitative Framework for Modeling COVID-19 Risk During
Adjuvant Therapy Using Published Randomized Trials of Glioblastoma in the Elderly. Neuro Oncol
2020.
158. Nahm SH, Rembielak A, Peach H, et al. Consensus Guidelines for the Management of Melanoma
during the COVID-19 Pandemic: Surgery, Systemic Anti-cancer Therapy, Radiotherapy and Follow-up.
Clin Oncol (R Coll Radiol) 2020.
159. Tagliaferri L, Di Stefani A, Schinzari G, et al. Skin cancer triage and management during COVID-19
pandemic. J Eur Acad Dermatol Venereol 2020; 34:1136.
160. Baumann BC, MacArthur KM, Brewer JD, et al. Management of primary skin cancer during a
pandemic: Multidisciplinary recommendations. Cancer 2020; 126:3900.
161. Penel N, Bonvalot S, Minard V, et al. French Sarcoma Group proposals for management of sarcoma
patients during the COVID-19 outbreak. Ann Oncol 2020; 31:965.
162. Calabrò L, Peters S, Soria JC, et al. Challenges in lung cancer therapy during the COVID-19 pandemic.
Lancet Respir Med 2020; 8:542.
163. Passaro A, Peters S, Mok TSK, et al. Testing for COVID-19 in lung cancer patients. Ann Oncol 2020;
31:832.
164. Cai H. Sex difference and smoking predisposition in patients with COVID-19. Lancet Respir Med 2020;
8:e20.
165. Mehta V, Goel S, Kabarriti R, et al. Case Fatality Rate of Cancer Patients with COVID-19 in a New York
Hospital System. Cancer Discov 2020; 10:935.
166. Horn L, Whisenant JG, Torri V, et al. Thoracic Cancers International COVID-19 Collaboration (TERAVOL
T): Impact of type of cancer therapy and COVID therapy on survival (abstract). J Clin Oncol 38:2020 (su
ppl; abstr LBA111). Abstract available at: https://meetinglibrary.asco.org/record/191969/abstract (Acc
essed on June 01, 2020).
167. Cai Y, Hao Z, Gao Y, et al. Coronavirus Disease 2019 in the Perioperative Period of Lung Resection: A
Brief Report From a Single Thoracic Surgery Department in Wuhan, People's Republic of China. J
Thorac Oncol 2020; 15:1065.
168. Luo J, Rizvi H, Preeshagul IR, et al. COVID-19 in patients with lung cancer. Ann Oncol 2020; 31:1386.
169. Garassino MC, Whisenant JG, Huang LC, et al. COVID-19 in patients with thoracic malignancies
(TERAVOLT): first results of an international, registry-based, cohort study. Lancet Oncol 2020; 21:914.
170. Remon J, Passiglia F, Ahn MJ, et al. Immune Checkpoint Inhibitors in Thoracic Malignancies: Review of
the Existing Evidence by an IASLC Expert Panel and Recommendations. J Thorac Oncol 2020; 15:914.
171. Delaunay M, Prévot G, Collot S, et al. Management of pulmonary toxicity associated with immune
checkpoint inhibitors. Eur Respir Rev 2019; 28.
172. Thoracic Surgery Outcomes Research Network, Inc, Antonoff M, Backhus L, et al. COVID-19 Guidance
for Triage of Operations for Thoracic Malignancies: A Consensus Statement From Thoracic Surgery
Outcomes Research Network. Ann Thorac Surg 2020; 110:692.
173. Guckenberger M, Belka C, Bezjak A, et al. Practice recommendations for lung cancer radiotherapy
during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radiother Oncol 2020;
146:223.
174. Dingemans AC, Soo RA, Jazieh AR, et al. Treatment Guidance for Patients With Lung Cancer During
the Coronavirus 2019 Pandemic. J Thorac Oncol 2020; 15:1119.
175. Singh AP, Berman AT, Marmarelis ME, et al. Management of Lung Cancer During the COVID-19
Pandemic. JCO Oncol Pract 2020; 16:579.
176. Luo J, Rizvi H, Egger JV, et al. Impact of PD-1 Blockade on Severity of COVID-19 in Patients with Lung
Cancers. Cancer Discov 2020; 10:1121.
177. Leonetti A, Facchinetti F, Zielli T, et al. COVID-19 in lung cancer patients receiving ALK/ROS1 inhibitors.
Eur J Cancer 2020; 132:122.
178. Kuderer NM, Choueiri TK, Shah DP, et al. Clinical impact of COVID-19 on patients with cancer (CCC19):
a cohort study. Lancet 2020; 395:1907.
179. Falandry C, Filteau C, Ravot C, Le Saux O. Challenges with the management of older patients with
cancer during the COVID-19 pandemic. J Geriatr Oncol 2020; 11:747.
180. Bellelli G, Rebora P, Valsecchi MG, et al. Frailty index predicts poor outcome in COVID-19 patients.
Intensive Care Med 2020; 46:1634.
181. National Institute for Health and Care Excellence: COVID-19 rapid guideline: Critical Care in Adults. M
arch 20, 2020. Available at https://www.nice.org.uk/guidance/ng159/resources/covid19-rapid-guidelin
e-critical-care-in-adults-pdf.66141848681413. (Accessed on September 09, 2020).
182. Battisti NML, Mislang AR, Cooper L, et al. Adapting care for older cancer patients during the COVID-
19 pandemic: Recommendations from the International Society of Geriatric Oncology (SIOG) COVID-
19 Working Group. J Geriatr Oncol 2020; 11:1190.
183. Mohile S, Dumontier C, Mian H, et al. Perspectives from the Cancer and Aging Research Group:
Caring for the vulnerable older patient with cancer and their caregivers during the COVID-19 crisis in
the United States. J Geriatr Oncol 2020; 11:753.
184. Sullivan M, Bouffet E, Rodriguez-Galindo C, et al. The COVID-19 pandemic: A rapid global response for
children with cancer from SIOP, COG, SIOP-E, SIOP-PODC, IPSO, PROS, CCI, and St Jude Global.
Pediatr Blood Cancer 2020; 67:e28409.
185. Bouffet E, Challinor J, Sullivan M, et al. Early advice on managing children with cancer during the
COVID-19 pandemic and a call for sharing experiences. Pediatr Blood Cancer 2020; 67:e28327.
186. Baruchel A, Bertrand Y, Boissel N, et al. COVID-19 and acute lymphoblastic leukemias of children and
adolescents: First recommendations of the Leukemia committee of the French Society for the fight
against Cancers and Leukemias in children and adolescents (SFCE). Bull Cancer 2020; 107:629.
187. Garcia-Doval I. Head and neck surgery is a high-risk procedure for COVID-19 transmission, and there
is a need for a preventive strategy to protect professionals. J Am Acad Dermatol 2020; 83:705.
188. Givi B, Schiff BA, Chinn SB, et al. Safety Recommendations for Evaluation and Surgery of the Head
and Neck During the COVID-19 Pandemic. JAMA Otolaryngol Head Neck Surg 2020; 146:579.
189. Ippolito E, Fiore M, Greco C, et al. COVID-19 and radiation induced pneumonitis: Overlapping clinical
features of different diseases. Radiother Oncol 2020; 148:201.
190. https://canceratlas.cancer.org/the-burden/cancer-survivorship/ (Accessed on September 29, 2020).
191. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatme
nt-and-survivorship-facts-and-figures/cancer-treatment-and-survivorship-facts-and-figures-2019-202
1.pdf (Accessed on October 07, 2020).
192. Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using
OpenSAFELY. Nature 2020; 584:430.
193. van Doesum J, Chinea A, Pagliaro M, et al. Clinical characteristics and outcome of SARS-CoV-2-infected
patients with haematological diseases: a retrospective case study in four hospitals in Italy, Spain and
the Netherlands. Leukemia 2020; 34:2536.
194. Nekhlyudov L, Duijts S, Hudson SV, et al. Addressing the needs of cancer survivors during the COVID-
19 pandemic. J Cancer Surviv 2020; 14:601.
195. Cox A, Lucas G, Marcu A, et al. Cancer Survivors' Experience With Telehealth: A Systematic Review and
Thematic Synthesis. J Med Internet Res 2017; 19:e11.
196. Signorelli C, Wakefield CE, Johnston KA, et al. 'Re-engage' pilot study protocol: a nurse-led eHealth
intervention to re-engage, educate and empower childhood cancer survivors. BMJ Open 2018;
8:e022269.
197. Signorelli C, Wakefield CE, Johnston KA, et al. Re-Engage: A Novel Nurse-Led Program for Survivors of
Childhood Cancer Who Are Disengaged From Cancer-Related Care. J Natl Compr Canc Netw 2020;
18:1067.
198. Jansen F, van Uden-Kraan CF, van Zwieten V, et al. Cancer survivors' perceived need for supportive
care and their attitude towards self-management and eHealth. Support Care Cancer 2015; 23:1679.
199. Košir U, Loades M, Wild J, et al. The impact of COVID-19 on the cancer care of adolescents and young
adults and their well-being: Results from an online survey conducted in the early stages of the
pandemic. Cancer 2020.
200. Langarizadeh M, Tabatabaei MS, Tavakol K, et al. Telemental Health Care, an Effective Alternative to
Conventional Mental Care: a Systematic Review. Acta Inform Med 2017; 25:240.
201. Chen JA, Chung WJ, Young SK, et al. COVID-19 and telepsychiatry: Early outpatient experiences and
implications for the future. Gen Hosp Psychiatry 2020; 66:89.
202. Cancer.Net. Common questions about COVID-19 and cancer: Answers for patients and survivors. htt
p://www.cancer.net/blog/2020-04/common-questions-about-covid-19-and-cancer-answers-patients-a
nd-survivors?cmpid=ks_net_blog_dcnews_-_all_04-10-20_blog (Accessed on July 31, 2020).
203. Waterhouse DM, Harvey RD, Hurley P, et al. Early Impact of COVID-19 on the Conduct of Oncology
Clinical Trials and Long-Term Opportunities for Transformation: Findings From an American Society
of Clinical Oncology Survey. JCO Oncol Pract 2020; 16:417.
204. Tan AC, Ashley DM, Khasraw M. Adapting to a Pandemic - Conducting Oncology Trials during the
SARS-CoV-2 Pandemic. Clin Cancer Res 2020; 26:3100.
205. Unger JM, Blanke CD, LeBlanc M, Hershman DL. Association of the Coronavirus Disease 2019 (COVID-
19) Outbreak With Enrollment in Cancer Clinical Trials. JAMA Netw Open 2020; 3:e2010651.
206. Tolaney SM, Lydon CA, Li T, et al. The Impact of COVID-19 on Clinical Trial Execution at the Dana-
Farber Cancer Institute. J Natl Cancer Inst 2020.
207. de Paula BHR, Araújo I, Bandeira L, et al. Recommendations from national regulatory agencies for
ongoing cancer trials during the COVID-19 pandemic. Lancet Oncol 2020; 21:624.
208. Fleming TR, Labriola D, Wittes J. Conducting Clinical Research During the COVID-19 Pandemic:
Protecting Scientific Integrity. JAMA 2020; 324:33.
209. https://www.nuffieldtrust.org.uk/files/2017-01/impact-telehealth-on-hospital-care-mortality-web-fina
l.pdf (Accessed on September 08, 2020).
210. https://pure.qub.ac.uk/en/publications/evaluation-of-past-and-present-implementation-of-telemonit
oring-n (Accessed on September 08, 2020).
211. https://www.csiro.au/~/media/BF/Files/Telehealth-Trial-Final-Report-May-2016_3-Final.pdf (Accessed o

n September 08, 2020).
212. https://openjournals.library.sydney.edu.au/index.php/HEP/article/view/13100/11927.
213. Sabesan S. Specialist cancer care through telehealth models. Aust J Rural Health 2015; 23:19.
214. Cannon C. Telehealth, Mobile Applications, and Wearable Devices are Expanding Cancer Care Beyond
Walls. Semin Oncol Nurs 2018; 34:118.
215. Dinesen B, Nonnecke B, Lindeman D, et al. Personalized Telehealth in the Future: A Global Research
Agenda. J Med Internet Res 2016; 18:e53.
216. Fisk M, Livingstone A, Pit SW. Telehealth in the Context of COVID-19: Changing Perspectives in
Australia, the United Kingdom, and the United States. J Med Internet Res 2020; 22:e19264.
217. Lonergan PE, Washington Iii SL, Branagan L, et al. Rapid Utilization of Telehealth in a Comprehensive
Cancer Center as a Response to COVID-19: Cross-Sectional Analysis. J Med Internet Res 2020;
22:e19322.
218. Gill S, Hao D, Hirte H, et al. Impact of COVID-19 on Canadian medical oncologists and cancer care:
Canadian Association of Medical Oncologists survey report. Curr Oncol 2020; 27:71.
219. Jiang CY, El-Kouri NT, Elliot D, et al. Telehealth for Cancer Care in Veterans: Opportunities and
Challenges Revealed by COVID. JCO Oncol Pract 2020; :OP2000520.
220. Flint L, Kotwal A. The New Normal: Key Considerations for Effective Serious Illness Communication
Over Video or Telephone During the Coronavirus Disease 2019 (COVID-19) Pandemic. Ann Intern Med
2020; 173:486.
221. Viers BR, Lightner DJ, Rivera ME, et al. Efficiency, satisfaction, and costs for remote video visits
following radical prostatectomy: a randomized controlled trial. Eur Urol 2015; 68:729.
222. Finazzi T, Papachristofilou A, Zimmermann F. "Connection Failed": A Word of Caution on Telemedicine

in Radiation Oncology. Int J Radiat Oncol Biol Phys 2020; 108:435.
223. Institute for Safe Medication Practices (ISMP) Medication Safety Alert (5/14/2020). Hospital pharmacy
medication safety newsletter. Available at: https://www.ismp.org/newsletters/acute-care (Accessed o
n June 29, 2020).
224. Schmidt JM. Seeking evidence-based COVID-19 preparedness: A FEMA framework for clinic managem
ent. NEJM Catalyst, March 25, 2020. Available at: https://catalyst-nejm-org.ezproxy.javeriana.edu.co/d
oi/full/10.1056/CAT.20.0079 (Accessed on April 02, 2020).
225. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of
Covid-19. N Engl J Med 2020; 382:2049.
226. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19
Pandemic. JAMA 2020; 323:1773.
227. Cohen IG, Crespo AM, White DB. Potential Legal Liability for Withdrawing or Withholding Ventilators
During COVID-19: Assessing the Risks and Identifying Needed Reforms. JAMA 2020; 323:1901.
228. Marron JM, Joffe S, Jagsi R, et al. Ethics and Resource Scarcity: ASCO Recommendations for the
Oncology Community During the COVID-19 Pandemic. J Clin Oncol 2020; 38:2201.
Topic 127556 Version 37.0
GRAPHICS
Selected considerations for approaching serious discussions remotely during the COVID-19 pandemic, with
example phrases
SPIKES protocol Telehealth considerations Examples
Setup
Before meeting At the time of ordering a diagnostic test, request "We expect to have the results of your biopsy in 2
permission to discuss the results with a patient, weeks. Is it okay if we call you by
regardless of the test result. telephone/videoconference to discuss the results at
that time?"
At the meeting Similar to silencing pagers and cell phones, "Hello, I am Dr X. I am calling from my office to
mute/defer notifications on your computer and discuss the results of your biopsy. I see that you are
arrange so that you are not intruded upon during the in your living room and sitting down. Can you
appointment. see/hear me clearly? Do you have time to discuss
During the introduction, describe your setting and your test results now? Who is there with you? Is there
members present. If on video, describe what you see anybody else present and able to hear our
and inquire about whom may be present or listening discussion?"
to the discussion.
Privacy is important to patients. Explicitly state that "I am sitting down, my office door is closed, and I
information shared is confidential. Inquire regarding have the volume set so that our conversation will not
whether the discussion is being recorded. be overheard. We are using a secure connection that
is not being recorded on our end. Please let me know
if you are recording anything."
Perception, invitation, Disciplined use of communication skills, such as "I am going to tell you the results of your biopsy/the
knowledge signposting or teach-back, can help to overcome the treatment options for your cancer. I will be asking
shortcomings of remote conversations. you questions often to ensure that you can hear me
Anticipate delayed audio transmission by using short clearly and understand what I am saying. Please let
sentences and allowing longer-than-usual pauses me know if you have any questions at any time."
after statements to give time for patients to ask
questions.
If videoconferencing, have the camera at eye level or
slightly above. Have a simple backdrop behind you to
minimize distractions.
Empathy With telemedicine, displaying empathy can be "I understand that this is difficult news to hear,
difficult, but not impossible. Sometimes a prolonged especially over the phone/by video."
silence can take the place of offering a tissue or an "I can hear that you are upset. Please share your
understanding touch that would be used in real life. thoughts with me."
Summary Plan for follow-up by addressing the setting where "Do you have any further questions? I will schedule a
the next meeting would be. Deliver handouts follow-up telephone/videoconference/in-person
through mail or electronic transfer. meeting in 2 weeks. I would like to share some
handouts with you. Do you have any objections with
us sending this to your e-mail address?"
SPIKES: Setting, Perception, Invitation, Knowledge, Empathy/Emotion, and Strategy/Summarize.
From: Holstead RG, Robinson AG. Discussing Serious News Remotely: Navigating Diﬃcult Conversations During a Pandemic. JCO Oncol Pract 2020; 16(7):363-368.
Reprinted with permission. Copyright © 2020 American Society of Clinical Oncology. All rights reserved.
Graphic 129045 Version 1.0
Proposed algorithmic approach to treatment of a solid tumor diagnosed during

the coronavirus disease 2019 (COVID-19) pandemic
From: Al-Shamsi HO, Alhazzani W, Alhuraiji A, et al. A practical approach to the management of cancer patients during the
novel Coronavirus disease 2019 (COVID-19) pandemic: An international collaborative group. Oncologist 2020.
https://theoncologist.onlinelibrary.wiley.com/doi/full/10.1634/theoncologist.2020-0213. Copyright © 2020 The Authors. The
Oncologist published by Wiley Periodicals, Inc. on behalf of AlphaMed Press. Reproduced with permission of John Wiley &
Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded
to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department either via email:
permissions@wiley.com or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article
on Wiley Online Library (https://onlinelibrary.wiley.com/).
Decision-making about immediate cancer treatment during the coronavirus disease 2019 (COVID-19)
pandemic
HR+: hormone receptor positive; HER2–: human epidermal growth factor receptor 2 negative.
From Annals of Internal Medicine, Kutikov A, Weinberg DS, Edelman MJ, et al. A war on two fronts: Cancer care in the time of COVID-19. Ann Intern Med 2020. Copyright
© 2020 American College of Physicians. All Rights Reserved. Reprinted with the permission of American College of Physicians, Inc.
The Vulnerable Elders Survey (VES) 13 scale
Domain Score
Age
75-85 1
>85 3
Self-rated health
Good, very good, and excellent 0
Fair and poor 1
Activities of daily living (ADLs)/instrumental ADLs (IADLs)

Needs assistance with
Bathing or showering 1
Shopping 1
Money management 1
Transfer 1
Light housework 1
Difficulty in special activities
Kneeling, bending, and stooping 1
Performance of housework (example: scrubbing the floor) 1
Reaching out and lifting upper extremities above the shoulder 1
Lifting and carrying 10 pounds 1
Walking 0.25 miles 1
Writing or handling and grasping small objects 1
Score ≥3: Vulnerable elderly
Adapted from: Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr
Soc 2001; 49:1691.
Contributor Disclosures
Robert G Uzzo, MD, MBA, FACS Grant/Research/Clinical Trial Support: Novartis [Sporadic angiomyolipomas].
Speaker's Bureau: Janssen Pharmaceuticals [Prostate cancer]. Consultant/Advisory Boards: Pfizer [Adjuvant therapy in
kidney cancer]; Urogen [Upper tract urothelial cancers]. Alexander Kutikov, MD, FACS Consultant/Advisory Boards:
Merck & Co, Inc [Bladder cancer]; Oncosec, Inc [Bladder immunotherapy delivery device]; UroToday, Inc
[Education]. Daniel M Geynisman, MD Grant/Research/Clinical Trial Support: Merck; Genentech; Calithera Bioscience
[Bladder and kidney cancer research grants to institution]. Consultant/Advisory Boards: AstraZeneca [Bladder cancer];
Pfizer [Kidney cancer]; Exelixis [Kidney cancer]; Seattle Genetics/Astellas [Bladder cancer]. Michael B Atkins,
MD Equity Ownership/Stock Options: Werewolf Therapeutics; Pyxis [Immunotherapy]. Grant/Research/Clinical Trial
Support: Bristol Myers Squibb [Melanoma and RCC]; Novartis [Melanoma]; Genentech [RCC]; Pfizer [RCC]; Merck [RCC
and melanoma]. Consultant/Advisory Boards: Array; BMS; Merck; Novartis; Pfizer; Roche; Exelixis; Eisai [Melanoma;
RCC; Immunotherapy]; Agenus; Aveo; Ideera; ImmunoCore; Iovance; Surface; Pneuma; Leads; Arrowhead; Fathom;
Symphogen; PACT; Neoleukin [Melanoma; RCC; Immunotherapy]; COTA [Melanoma]. Larissa Nekhlyudov, MD,
MPH Nothing to disclose Richard A Larson, MD Grant/Research/Clinical Trial Support: Astellas [Leukemia]; Novartis
[Leukemia]; Daiichi Sankyo [Leukemia]; Celgene [Leukemia]; Raphael Pharmaceuticals [Leukemia]; Cellectis
[Leukemia]; Forty Seven [Leukemia]. Grant/Research/Clinical Trial Support (Spouse): Merck [Lymphoma].
Consultant/Advisory Boards: Novartis [Leukemia]; Ariad/Takeda Data Safety Monitoring Board [Leukemia];
CVS/Caremark [Leukemia]; Celgene Data Safety Monitoring Board [Leukemia]; Amgen [Leukemia]; Astellas [Leukemia];
Epizyme Data Safety Monitoring Board [Lymphoma]; Delta Fly Pharmaceuticals [Leukemia]; AstraZeneca
[Leukemia]. David I Soybel, MD Nothing to disclose Diane MF Savarese, MD Nothing to disclose Sadhna R Vora,
MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed
by vetting through a multi-level review process, and through requirements for references to be provided to support
the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of
evidence.
Conflict of interest policy

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29/11/2020 Coronavirus disease 2019 (COVID-19): Cancer screening, diagnosis, treatment, and posttreatment surveillance in uninfected patients during

ts during the pande…

Official reprint from UpToDate®

Coronavirus disease 2019 (COVID-19): Cancer screening,

● General health care facility and health care professional guidance

ISSUES RELATED TO ANTICANCER TREATMENTS

● Testing of patients and employees must be strongly considered.

Other resources for resuming cases are available [36-39].

Systemic anticancer treatments — There is no direct evidence to support changing or withholding

Chemotherapy — Administration of chemotherapy is determined on a case-by-case basis. In general,

Issues related to tumor genotyping — Tumor genotyping is becoming an essential step in cancer

Anti-CD20 monoclonal antibodies and other immunomodulatory agents — Lymphopenia seems to

Specific guidance for treatment of hematologic malignancies on a disease-by-disease basis is available

Considerations from ASCO include the following:

● CAPC COVID-19 Response Resources

Additional relevant UpToDate discussions are found elsewhere:

● Physical isolation from friends and family

A communication guide to assist clinicians with oncology-specific language to respond to patient

CANCER TYPE-SPECIFIC GUIDANCE

- Nonmelanoma skin cancer.

- Hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative early

● Based on intermediate risk of progression in other cancers, a delay of approximately three

• Surgery for the following:

- Intermediate- or high-risk prostate cancer (androgen deprivation may be started in the

- Colon cancer with low risk for imminent obstruction.

• Surgery for the following:

- Colon cancer with imminent obstruction

- Type 2 endometrial cancer

- Pancreatic, ovarian, or liver mass(es) suspicious for malignancy

• Radiation for the following:

- Locally advanced rectal cancer

• Chemotherapy for the following:

- Metastatic testicular cancer

- Small cell lung cancer

- Most head and neck cancers, except thyroid

• In addition, based on an analysis of published literature, an international multidisciplinary group

• Recommendations for prioritization of urologic oncology surgeries and office-based procedures

• Guidelines specific to management of prostate cancer are available from a multidisciplinary

• A collation of recommendations issued by multiple international government and professional

● Head and neck cancer

● Primary hepatic malignancies

● Neuroendocrine and endocrine tumors

• Short-term recommendations for management of melanoma, as well as for non-melanoma skin

Regarding characteristics of included patients, approximately 50 percent of patients had

- American College of Surgeons

Other alternatives, such as computed tomography-guided biopsies, should be explored, if feasible.

Differentiating lymphangitic spread, pneumonitis, and COVID-19 — Some systemic cancer treatments

MINIMIZING THE COMPROMISE OF PHYSICAL DISTANCING DURING CANCER CARE

An important point is that while telemedicine is an important paradigm for patient-provider

ALLOCATION OF LIMITED HEALTH CARE RESOURCES

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● There is no direct evidence to support changing or withholding chemotherapy or immunotherapy in

Use of UpToDate is subject to the Subscription and License Agreement.

16. https://www.nccn.org/covid-19/pdf/Prostate_Early_Detection.pdf (Accessed on September 23, 2020).

21. Sharpless NE. COVID-19 and cancer. Science 2020; 368:1290.

68. European Medicines Agency. Pembrolizumab summary of product characteristics. http://www.ema.e

74. Terpos E, Ntanasis-Stathopoulos I, Elalamy I, et al. Hematological findings and complications of

80. Nawar T, Morjaria S, Kaltsas A, et al. Granulocyte-colony stimulating factor in COVID-19: Is it

105. Mauri D, Kamposioras K, Tolia M, et al. Summary of international recommendations in 23 languages

pandemic. Intern Med J 2020; 50:667.

190. https://canceratlas.cancer.org/the-burden/cancer-survivorship/ (Accessed on September 29, 2020).