Covid-19 and cancer patients: Choosing wisely is the key

Since December 2019, after the initial outbreak of the Covid-19 infectious disease in Wuhan in the Chinese province of Hubei, there has been an increasing spread of the severe adult respiratory syndrome coronavirus 2 (SARS-CoV-2) virus worldwide and on 11 March 2020, the World Health Organization (WHO) decreed a pandemic state.

The SARS-CoV-2 has been repeatedly defined as a hidden enemy but, remaining in the metaphor, it can also be defined as an unwelcome guest who enters without knocking. In particular, it enters without permission and, above all, it does it more easily where it finds accessible doors like those of fragile hosts. This is the case for cancer patients, among the most vulnerable targets of Covid-19 infection.

During the Covid-19 pandemic, in fact, patients with cancer are subject to multiple risks. First of all, they are more likely to get infected due to their immunosuppressed state related to the tumor disease or anticancer treatment they are receiving [1], [2], [3], [4]. Secondly, because of the usual hospital-centric management, they are often called to go to the hospital for treatment, diagnostic investigations and for follow-up. Thirdly, when they contract Covid-19 disease their clinical course is more likely to be severe.

Furthermore, an additional risk may be that related to the distraction effect [5]. Intensive care units in hospitals committed to managing patients with severe symptoms of Covid-19 may not be able to provide care for cancer patients. In addition, there may be a shortage of oncologists and nurses due to the spread of the disease among healthcare workers themselves or due to their need to remain in quarantine.

Covid-19 disease is an emergency and, as such, is unforeseen. In addition, the infection is new and therefore in many ways found us unprepared. The Chinese experience first, the Italian one then, but also what is happening in the various parts of the world, are the basis on which scientific knowledge is being generated. However, the differences in terms of context, health organization, measures taken to contain the viral spread, socio-cultural aspects, do not make it easy to transfer the best practices implemented by the countries initially affected to those most recently involved.

What is clear to the clinical community of oncologists, while recognizing the differences between the different contexts, is that cancer centers must limit the risks for patients and healthcare professionals. Consequently, specific guidelines have been issued by various scientific societies such as ASCO, ESMO, NCCN, AIOM, etc. The opportunity to keep cancer patients for whom there are no priority clinical needs away from hospitals is unanimously recognized. Outpatient visits are usually rescheduled or shifted to telemedicine. Triage of patients and health workers is critical to reduce exposure to other patients and staff with the aim of keeping the hospital virus free. The policy “stay at home when ill” together with a strategy that tests staff, tracking results for persons under investigation, tracing exposures, and defining return to work is fundamental to limit shortage in terms of workforce.

In this issue of Digestive and Liver Disease, Di Fiore et al report some management strategies proposed by the main French scientific societies of oncological gastroenterology to limit the risks for patients with digestive cancers [6].

Diagnostic and therapeutic adjustments are described by site of disease and are based on expert agreement/expert opinion.

Of note, from the diagnostic point of view, guidelines were also developed by other groups with indications about the management of endoscopy services aimed to creating a safe environment for patients and healthcare professionals [7,8].

Overall, the merit of the management proposals is the limitation of hospitalization to strictly necessary cases, forcing decisions on a careful evaluation of the risk / benefit ratio of treatments and based on studies that in pre-pandemic era had demonstrated the reliability and safety of certain clinical approaches.

In other words, it is based on the concept of "choosing wisely", the value of which is more clearly perceived under the stimuli induced by the Covid-19 emergency but which we are likely to bring with us even when the pandemic is over.

Conflict of interest

None declared.