Opinion
Active and Effective Measures for the Care of Patients
VIEWPOINT
With Cancer During the COVID-19 Spread in China
Zhijie Wang, MD Recently, an outbreak of the highly infectious novel coro-
Department of Medical navirusdisease2019(COVID-19)hassweptWuhan,China,
Oncology, State Key with 80 303 confirmed diagnosed cases in China as of
Laboratory of
March 3, 2020.1 Considering its high risk of person-to-
Molecular Oncology,
National Cancer person transmission, hospitals, especially in China, are the
Center/National Clinical typical congregating places that will bear the brunt of this
Research Center for infectious disease. To reduce or avoid cross infection of
Cancer/Cancer
Hospital, Chinese
COVID-19, many hospitals have started taking actions to
Academy of Medical limit the number of outpatient visits and inpatient admis-
Sciences & Peking sions. For example, only emergency surgeries can be guar-
Union Medical College,
anteed, while most others are postponed. Maintenance
Beijing, China.
chemotherapy and/or immunotherapy treatments for pa-
Jie Wang, MD, PhD tients with advanced cancer are often suspended. How-
Department of Medical ever, forced delays or interruptions of routine treatment
Oncology, State Key might increase the risk of disease deterioration, especially
Laboratory of
for patients with cancer. In China, approximately 4.3 mil-
Molecular Oncology,
National Cancer lion cases of cancer are diagnosed each year.2 During the
Center/National Clinical epidemic of COVID-19, the treatment of patients with can-
Research Center for cer, which is often considered as nonemergent, is inevita-
Cancer/Cancer
Hospital, Chinese
bly affected across China, especially in Wuhan.
Academy of Medical As a result of powerful prevention and control mea-
Sciences & Peking sures, the spread of COVID-19 has been gradually con-
Union Medical College,
trolled. However, cases have been diagnosed in a number
Beijing, China.
ofcountriesoutsideofChina,especiallyinSouthKoreaand
Jie He, MD Iran, leading to a global outbreak. As of March 3, 2020,
Department of newly diagnosed cases and deaths owing to COVID-19 had
Thoracic Surgery, State occurred in nearly 70 countries or regions, including South
Key Laboratory of
Korea,Iran,Italy,Japan,Germany,Singapore,Spain,andthe
Molecular Oncology,
National Cancer US,withatotalof11 953confirmedcases.3 Theinsidiouson-
Center/National Clinical set(whichcanmanifestwithoutanyobviousclinicalsymp-
Research Center for toms, such as fever, in the early phase) and long incubation
Cancer/Cancer
Hospital, Chinese
period (up to 24 days4) indicate the strong transmissibility
Academy of Medical of COVID-19. The World Health Organization has declared
Sciences & Peking COVID-19tobea“publichealthemergencyofinternational
Union Medical College,
concern.”5 Therefore,itmayhaveaworldwideinfluenceon
Beijing, China.
the diagnosis and treatment of patients with cancer.
Patientswithcancerareusuallycharacterizedbyolder
ages, multiple complicated diseases, and lower immu-
nity, meaning a higher probability of severe illness and in-
creased mortality compared with the healthy population
once infected with COVID-19.6 To alleviate the difficulties
of patients with cancer in seeking medical aid and simul-
taneously avoid COVID-19–related nosocomial cross in-
fection between patients and medical staff, several man-
datory measures are being carried out in the National
Cancer Center/Cancer Hospital, Chinese Academy of Sci-
ences during this period.
First,multipleon-sitetemperaturetestsareperformed
at the entrances of the hospital, the outpatient clinic, and
Corresponding Authors: Jie Wang, MD, PhD, Surgery (hejie@cicams.ac.cn), State Key Laboratory
Department of Medical Oncology (zlhuxi@163. of Molecular Oncology, National Cancer Center/
com), and Jie He, MD, Department of Thoracic National Clinical Research Center for Cancer/Cancer
jamaoncology.com
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the wards. Also, the contact and travel histories regarding
the epidemic area of all individuals are recorded.
Second,anappointmentschedulingsystemisavailable
for outpatients, which allows both online appointment
scheduling and on-site registration. The appointment sys-
tem substantially reduced the flow of people in the hospi-
tal. For admitted patients, essential personal protective
measures are required (such as wearing a mask and bring-
ing their own disinfectant). Furthermore, online consulta-
tionchannelsforpatientswithcancerareopendaily,which
could help to instruct patients on medication taking and
cancer-related symptom management.
Third,forpatientspreparingtobeadmitted,symptoms
that are potentially associated with COVID-19, such as fe-
verandcough,arerequiredtoberoutinelyrecorded.Man-
datory routine blood tests and high-resolution computed
tomography scans of the lungs are performed. COVID-19
virus nucleic acid tests will be carried out for patients with
suspectedpneumoniaoncomputedtomographyimaging.
Fourth, some anticancer drugs conventionally ad-
ministered through infusion were changed to orally ad-
ministered drugs if available, for example, etoposide and
vinorelbine. For adjuvant chemotherapy or mainte-
nance chemotherapy, the infusion intervals were appro-
priately prolonged depending on patients’ conditions.
After the Chinese Spring Festival, the Cancer Hospital,
Chinese Academy of Medical Sciences initiated the level-1
response (the highest emergency response measures) to
COVID-19. From February 12, 2020, to March 2, 2020, the
Department of Medical Oncology received a total of 2944
patients for clinic consultation and treatment in the wards,
including 2795 outpatients and 149 inpatients. Under the
strict screening strategy, 27 patients showed radiologic
manifestations of inflammatory changes or multiple-site
exudative pneumonia in the lungs, 8 of whom were sus-
pectedofhavingCOVID-19infection.Fortunately,negative
resultsfromnucleicacidtestingultimatelyexcludedCOVID-
19infectioninallthesepatients.Importantly,2ofthesepa-
tientspresentedwithrecoveredpneumoniaaftersympto-
matictreatment.Underthestrictprotectivemeasures,not
a single patient or staff member had been diagnosed with
COVID-19 infection as of March 3, 2020.
UnderthefurtherattackofCOVID-19worldwide,more
attention should be paid to patients with cancer as a spe-
cial population. Both the effective prevention of cross in-
fection of COVID-19 and the rational arrangement of anti-
cancer treatment are extremely important. The measures
we are taking may be of great value to help guide patients
with cancer smoothly and safely through the epidemic.
Hospital, Chinese Academy of Medical Sciences &
Peking Union Medical College, 17 Pan-jia-yuan S Ln,
Chaoyang District, Beijing 100021, China.
(Reprinted) JAMA Oncology May 2020 Volume 6, Number 5 631
 Opinion Viewpoint

ARTICLE INFORMATION
Published Online: April 1, 2020.
doi:10.1001/jamaoncol.2020.1198
Conflict of Interest Disclosures: None reported.
Additional Contributions: The authors would like
to thank Shangli Cai, PhD, Burning Rock Biotech, for
the data collection. He received no compensation
for his assistance.
REFERENCES
1. Huang C, Wang Y, Li X, et al. Clinical features of
patients infected with 2019 novel coronavirus in
Wuhan, China. Lancet. 2020;395(10223):497-506.
doi:10.1016/S0140-6736(20)30183-5
2. Chen W, Zheng R, Baade PD, et al. Cancer
statistics in China, 2015. CA Cancer J Clin. 2016;66
(2):115-132. doi:10.3322/caac.21338
3. Tencent. Epidemic situation tracker. Accessed
March 23, 2020. https://news.qq.com/zt2020/
page/feiyan.htm#/global
4. Guan WJ, Ni ZY, Hu Y, et al; China Medical
Treatment Expert Group for Covid-19. Clinical
characteristics of coronavirus disease 2019 in China
[published online February 28, 2020]. N Engl J Med.
doi:10.1056/NEJMoa2002032
5. World Health Organization. Coronavirus disease
(COVID-19) pandemic. Accessed March 23, 2020.
https://www.who.int/emergencies/diseases/novel-
coronavirus-2019
6. Liang W, Guan W, Chen R, et al. Cancer patients
in SARS-CoV-2 infection: a nationwide analysis in
China. Lancet Oncol. 2020;21(3):335-337. doi:10.
1016/S1470-2045(20)30096-6

Cancer Survivorship—A Call to Action

VIEWPOINT

Laurence H. Baker, DO
Department of Internal
Medicine, University of
Michigan Medical
School, Ann Arbor.
Corresponding
Author: Laurence H.
Baker, DO, Department
of Internal Medicine,
University of Michigan
Medical School,
300 N Ingalls St,
3A17 North Ingalls
Building, Ann Arbor, MI
48109 (bakerl@med.
umich.edu).
As of July 1, 2019, I marked the beginning of my 50th year
in the field of medical oncology. This transition has led me
to take stock of the changes I have witnessed, including
some remarkable accomplishments in the 1970s: MOPP
(mechlorethamine hydrochloride, vincristine sulfate
[Oncovin], procarbazine, and prednisone) therapy for
Hodgkin lymphoma, adjuvant and neoadjuvant chemo-
therapyandlimbsalvagesurgeryinpatientswithbonesar-
coma, and combination chemotherapy and new hor-
monal therapies for metastatic breast cancer.
Recently, I received a message from a colleague con-
gratulating me on my transition to active emeritus status
(M. Varterasian, written e-mail communication, June
2019). Brief and heartfelt, her message underscored the
challenges practicing oncologists face when she com-
mented that her husband, also a medical oncologist at an
academic medical institution, shared in her congratula-
tions and that he would not come home until 9:00 PM that
Friday night because he was finishing clinic. Knowing both
of them well, I understood this subtle but shared signal of
how the autonomy of physicians and the care of patients
have been overshadowed by the corporatization of medi-
cine in public and private practice.
Although this institutionalization is endemic in the
field of medicine, for the last 5 years, I have turned my at-
tention to sarcoma survivorship—a phase of cancer care
thatcrystallizestheinfluenceofcorporatecultureonmedi-
cine today. I chose to focus on survivorship, recognizing
that my patients are far from well years after surviving ag-
gressive treatment of their soft-tissue and bone sarco-
mas. I thought that tenure enabled me to make the bold
choice of attending to this population and often ignored
theschedulingtemplateappliedacrossthedivision.Ishare
the lessons learned from this experience as both a com-
mentary and a call to action.
Survivorshipcareexistsinnameonlyinmostacademic
medical centers seeking to maintain accreditation. Most
comprehensivecancercentersarefarfromcomprehensive
in caring for cancer survivors. For the most part, these clin-
ics focus on more common types of cancer, such as breast
and prostate cancers (survivorship care for the latter is
seemingly devoted only to recovery of sexual function).
A few cancer centers provide holistic care to survivors, but
too often survivorship care exists to fulfill accreditation
requirements from the Commission on Cancer and the
Center for Medicare and Medicaid Services, which require
psychosocial services and survivorship care planning.
My Sarcoma Survivorship Clinic1 and corresponding
prospective cohort studies2,3 sought to both provide care
and document the chronic long-term effects, as reported
by Oeffinger et al,4 who identified survivors of sarcomas
(especially bone sarcomas) as experiencing the highest
rates of severe, chronic, life-threatening, and even fatal
illnesses compared with all childhood cancer survivors. Af-
ter 5 years, we at the Sarcoma Survivorship Clinic can con-
fidently say that the 2 most common conditions experi-
encedbysurvivorsofsarcomawhoreceivedanthracycline
chemotherapy are premature coronary artery disease
(CAD) and psychosocial distress. The breakdown of the
mentalhealthcaresystemmakesmeaninglessthemandate
for psychosocial care and is beyond the scope of this essay.
However,CADiswellwithinthescopeofcareofphysicians
trained in internal medicine, medical oncologists included.
Cardiotoxicityisawell-knownconsequenceofanthra-
cycline chemotherapy. Despite mounting evidence that
the most threatening chronic toxicity is CAD, a disease for
whichcardiologistshaveextensivelycharacterizedtherisk
factors(eg,hypertension,obesity,dyslipidemia)anddevel-
oped management strategies, cardiomyopathy continues
todominatediscussionswithinthefieldsofcardiologyand
oncology. The confusion between both cardiomyopathy
andCADstemmingfromdoxorubicin-basedchemotherapy
failstorecognizethedistinctpatternsofcardiotoxicity.The
first form of cardiomyopathy is trastuzumab-induced car-
diomyopathy, which is prominent in patients undergoing
breastcancertreatmentandisalmostalwaysreversible.The
secondformofcardiomyopathyiscumulativedose-related
cardiomyopathy, often irreversible, resulting in dose-
limitingtreatmentregimensand/ortheuseofdexrazoxane.
Lack of understanding of the differences in cardiotoxicity
too often permeates medical oncology and cardiology.
Themostpromisingresearchinthisareahasemerged
from Ridker and colleagues,5,6 who describe a common
pathwayofinflammationinbothcancerandCADviaaltera-

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