Table 1.

Executive summary of SOPA practical strategies to manage cancer patients during the COVID-19 pandemic.

Recommendation	Examples
1. Delaying adjuvant chemotherapy within the recommended range of treatment initiation	• Delaying adjuvant chemotherapy for a maximum of 12 weeks in early stages breast cancer (excluding TNBC & HER2-positive breast cancer) • Delaying adjuvant chemotherapy for a maximum of 8 weeks in colorectal and gastric cancer
2. Use of extended dosing schedule of cancer therapy	• Extended dosing schedule of ICPIs • Use of every 3 weeks schedule of taxanes in patients with advanced breast cancer • Use of every 12 weeks BMAs for bone metastases • Use of every 12 and 24 weeks GnRHa for advance breast and prostate cancer, respectively • Use of every 12 weeks VCR/DEX pulses for pediatric with SR B-ALL according to NCI without CNS or testicular leukemia, unfavorable genetic characteristics • Use of pegaspargase for pediatric and adult ALL without previous history of E. coli L-asparaginase allergy
3. Switching from intravenous chemotherapy to oral or subcutaneous route of administration	• Shifting patients to from IV to PO chemotherapy (e.g. etoposide, cyclophosphamide, topotecan and vinorelbine) • Replacing IV 5-FU with PO capecitabine • Use oral chemotherapy for maintenance therapy in multiple myeloma; lenalidomide in standard-risk patients and ixazomib in high-risk patients (If PO ixazomib is not available and bortezomib SQ cannot be provided, lenalidomide PO can be considered, with close monitoring). • Using the SQ route for rituximab, trastuzumab, and daratumumab.
4. Home administration of chemotherapy and supportive care therapy	• Ideal chemotherapy medications that can be administered at home can include the following: ○ Medications administered SQ: azacitidine, bortezomib, cladribine, cytarabine (palliative setting), SQ rituximab, SQ trastuzumab, SQ daratumumab ○ Medications administered intravenously through IV push or short infusions (e.g. vinca alkaloids) ○ Medications administered intravenously through IV pump (e.g. 5-FU and blinatumomab) • Supportive care medications can be given orally instead of intravenously as: ○ IV hydration can be given orally with proper patient education or intravenously at home through elastomeric infusion pumps when needed. ○ Oral antiemetics. ○ Growth factors and oral antibiotics can be used for patients receiving high-risk chemotherapy as primary prophylaxis for FN and empiric oral antibiotics in clinically stable patients with FN. ○ Oral sodium bicarbonate with or without acetazolamide if needed, and oral leucovorin with HDMTX with proper monitoring. ○ Oral mesna at home can be given with ifosfamide or high-dose cyclophosphamide administration. ○ In non-acute cases, electrolytes should be replaced orally when feasible.
5. Delay stem cell transplants if medically feasible	• If the patient disease risk allows, postpone all procedures related to HSCT (mobilization, collection, and conditioning) ○ Examples of autologous transplants: multiple myeloma and low-grade lymphomas. ○ Examples of allogeneic transplant: MRD negative ALL, intermediate-risk AML tolerating consolidation, MDS patients tolerant to transfusion and without excessive blasts, MF patients tolerating transfusions, and benign hematology indications (e.g. SCD, thalassemia) • If patient with high risk/aggressive disease, and the transplant cannot be postponed ○ Patient need to be tested for COVID-19 ○ Patient who doesn’t have respiratory symptoms and no exposure to COVID-19, proceed to transplant after self-isolating for 14 days. ○ Patient who has had close contact with a COVID-19 patient, BMT procedures should be deferred for 14–21 days from the date of last contact. The patient needs to have two negative PCR results one week apart before proceeding with any procedures. ○ Patients who are diagnosed with COVID-19, transplant procedures should be deferred until the patient becomes asymptomatic and has two negative PCR results at least one week apart, with a minimum of a 14-day deferral. ○ The use of lowest possible intensity regiment is used for such patient.
6. Consider intermittent chemotherapy or treatment discontinuation for eligible patients	• Chemotherapy holidays in metastatic diseases setting after multidisciplinary tumor board discussion and according to patient preference • Discontinuation of TKIs therapy in adult CML patients who achieve and maintain MMR with careful monitoring
7. Activating telemedicine for managing stable cancer patients on oral chemotherapy	Activating virtual oncology clinics for managing stable patients including the ones on oral chemotherapy (e.g. CML, CLL, lung cancer, breast cancer, renal cancer, prostate cancer, and HCC)
8. Applying innovative ideas to minimize patients visits to the pharmacy	• Sending medications by postal carriers to patients’ homes and use of a drive-through medications collection area • Providing more medications supply to chronic and stable cancer patients while maintaining pharmacy stock • Collaboration between pharmacy departments at oncology centers to continue providing treatments of patients who are affected by the travel restriction • Activation of 24 h hotline/on-call service run by oncology pharmacist for consultation and inquires related to cancer therapies.

TNBC: triple-negative breast cancer; ICPIs: immune checkpoint inhibitors; BMAs: bone modifying agents; LHRH: luteinizing hormone-releasing hormone; GnRHa: gonadotropin-releasing hormone agonist; SR B-ALL: standard-risk B cell acute lymphoblastic leukemia; NCI: National Cancer Institute; VCR/DEX: vincristine/dexamethasone; TKI: tyrosine kinase inhibitors; CML: chronic myeloid leukemia; MMR: major molecular response; CLL: chronic lymphocytic leukemia; HCC: hepatocellular cancer; SQ: subcutaneous; HDMTX: high-dose methotrexate; FN: febrile neutropenia; MRD: minimal residual disease; AML: acute myeloid leukemia; MDS: myelodysplastic syndromes; MF: myelofibrosis; SCD: sickle cell disease.