. 2020 May 28;22(6):60. doi: 10.1007/s11912-020-00945-4

Table 2.

Proposed special considerations of the cardio-oncology patient during the COVID-19 pandemic

Cardio-oncology aspect of care	Theoretical areas of concern	Proposed Strategies to Mitigate COVID-19 Exposure
Initiating/ongoing cancer treatments (i.e., chemotherapy, targeted therapies, immunotherapy, BMT, CAR-T), and timing of oncologic-related surgery	• Compromised immune systems induced by cancer treatments may make patient more susceptible to COVID-19 • Cancer treatments may require healthcare facility/inpatient stay exposing patient to asymptomatic carriers (i.e., HCW) • Delaying of potential critical, life-prolonging surgery as it may be deemed as “elective” • Ensuring COVID-19 testing adequacy by healthcare providers	• Implementation of universal PPE and social distancing during cancer treatments in outpatient/inpatient settings, and with family members/caretakers • Weighing risk-benefit of postponing/delaying timing of cancer treatments/surgery to minimize exposure to inpatient healthcare setting • Preoperative/procedural screening and testing for COVID-19 • Telemedicine for routine follow-up cardio-oncology/oncology visits unless clinically symptomatic • Research efforts investigating earlier utilization of immune system restorative measures post anti-tumor therapy • Consideration of delaying myeloablative therapies and immunotherapies for patients in clinical remission if possible • Consideration of minimizing surveillance/staging imaging during and after treatments
Cardiotoxicity experienced during cancer treatments (i.e., cardiomyopathy, arrhythmias, and ischemic events)	• Further delay of cancer treatments and cardio-oncology evaluation because of COVID-19 may increase cardiac and cancer-related comorbidity and mortality • Cardiac imaging and testing may cause further exposure to asymptomatic carriers	• Inpatient admission and evaluation as clinically indicated for severe symptoms • Telemedicine for patients who are asymptomatic or minimally symptomatic, or CVD risk factor modification (i.e., visits for HTN and/or dyslipidemia) • Preemptive aggressive treatment for suspected symptoms related to CAD, arrhythmias, or CHF and deferring of imaging unless clinically necessary • Mail ambulatory rhythm monitors to home to evaluate suspected/known arrhythmias
Cardiotoxicity surveillance in cancer patients during and after treatment	• Some cancer treatments (i.e., anti-HER2, BRAF-MEK treatments, clinical trials) require frequent surveillance of cardiac function (i.e., every 3 months) • Patients with known cardiotoxicity, or with known treatments that can cause long-term cardiotoxicity (i.e., anthracyclines, radiation) may not get timely surveillance imaging	• Minimize cardiac imaging to patients who are symptomatic • Multidisciplinary discussion with hematologist/oncologist about reducing frequency of cardiotoxicity screening, especially if prior serial testing unremarkable • Limited imaging protocols to evaluate LVEF to minimize acquisition time • Defer primary prevention assessment (i.e., dyslipidemia management) unless critical to care of patient • Telemedicine visits for patients who do not require face-to-face assessment for medical issues (i.e., blood pressure/lipid management/stable CHF) • Defer asymptomatic long-term cancer survivor surveillance (i.e., assessment of ventricular and valvular function) if no symptoms

Cardio-oncology aspect of care

Theoretical areas of concern

Proposed Strategies to Mitigate COVID-19 Exposure

Initiating/ongoing cancer treatments (i.e., chemotherapy, targeted therapies, immunotherapy, BMT, CAR-T), and timing of oncologic-related surgery

• Compromised immune systems induced by cancer treatments may make patient more susceptible to COVID-19

• Cancer treatments may require healthcare facility/inpatient stay exposing patient to asymptomatic carriers (i.e., HCW)

• Delaying of potential critical, life-prolonging surgery as it may be deemed as “elective”

• Ensuring COVID-19 testing adequacy by healthcare providers

• Implementation of universal PPE and social distancing during cancer treatments in outpatient/inpatient settings, and with family members/caretakers

• Weighing risk-benefit of postponing/delaying timing of cancer treatments/surgery to minimize exposure to inpatient healthcare setting

• Preoperative/procedural screening and testing for COVID-19

• Telemedicine for routine follow-up cardio-oncology/oncology visits unless clinically symptomatic

• Research efforts investigating earlier utilization of immune system restorative measures post anti-tumor therapy

• Consideration of delaying myeloablative therapies and immunotherapies for patients in clinical remission if possible

• Consideration of minimizing surveillance/staging imaging during and after treatments

Cardiotoxicity experienced during cancer treatments (i.e., cardiomyopathy, arrhythmias, and ischemic events)

• Further delay of cancer treatments and cardio-oncology evaluation because of COVID-19 may increase cardiac and cancer-related comorbidity and mortality

• Cardiac imaging and testing may cause further exposure to asymptomatic carriers

• Inpatient admission and evaluation as clinically indicated for severe symptoms

• Telemedicine for patients who are asymptomatic or minimally symptomatic, or CVD risk factor modification (i.e., visits for HTN and/or dyslipidemia)

• Preemptive aggressive treatment for suspected symptoms related to CAD, arrhythmias, or CHF and deferring of imaging unless clinically necessary

• Mail ambulatory rhythm monitors to home to evaluate suspected/known arrhythmias

Cardiotoxicity surveillance in cancer patients during and after treatment

• Some cancer treatments (i.e., anti-HER2, BRAF-MEK treatments, clinical trials) require frequent surveillance of cardiac function (i.e., every 3 months)

• Patients with known cardiotoxicity, or with known treatments that can cause long-term cardiotoxicity (i.e., anthracyclines, radiation) may not get timely surveillance imaging

• Minimize cardiac imaging to patients who are symptomatic

• Multidisciplinary discussion with hematologist/oncologist about reducing frequency of cardiotoxicity screening, especially if prior serial testing unremarkable

• Limited imaging protocols to evaluate LVEF to minimize acquisition time

• Defer primary prevention assessment (i.e., dyslipidemia management) unless critical to care of patient

• Telemedicine visits for patients who do not require face-to-face assessment for medical issues (i.e., blood pressure/lipid management/stable CHF)

• Defer asymptomatic long-term cancer survivor surveillance (i.e., assessment of ventricular and valvular function) if no symptoms

BMT bone marrow transplantation, CAR-T chimeric antigen receptor therapy, HCW healthcare workers, PPE personal protective equipment, CVD cardiovascular disease, CAD coronary artery disease, CHF congestive heart failure, LVEF left ventricular ejection fraction