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Daily Practice

Summary

General Clinic Guidelines

Follow WHO, CDC and state/local infection control and public health guidelines, and work with your institution/clinic to develop local specific guidelines. As per WHO guidelines, handwashing and social distancing are recommended. Frequent handwashing for at least 20 seconds is important or using a 60% alcohol hand sanitizer -- gloves are not a substitute. Do not shake hands and avoid touching your face. Multiple facilities are recommending a limit of one adult accompanying a patient. Small capacity waiting rooms and machine waiting areas may need to be limited to patients only, aiming for social distancing when possible (three to ten feet). At this time, no specific evidence or guidance on mask use in cancer patietnts has been published. There is currently no guidance or evidence to suggest that N95 masks are required for these patients. Patients and clinicians are urged to follow the U.S. CDC's general recommendations on mask wear. However, for staff interfacing with direct high-volume patient care such as radiation therapists, the work group consensus recommends the following.

  • Encourage routine non-95, surgical masking of radiation therapists for all patients, if your health system can support this from the standpoint or PPE supply.
  • Encourage minimum of droplet precautions for any COVID-19 positive or COIVD-19 suspected patient.

The overarching goal is to reduce the risk of transmission of COVID-19 and to allow cancer care to continue for those most likely to benefit. Given expected reduced resources and staff, considerations for all patients include whether it is possible to avoid radiation therapy, delay radiation therapy and if not, hypofractionation is preferred when appropriate. Following ASTRO’s Choosing Wisely recommendations is a good starting point.

Screening

Since cancer patients are particularly vulnerable, a process should be in place to screen all patients and accompanying family entering the clinic, either at the hospital entrance, the department front desk or a kiosk. Typical screening questions include: “Have you had a fever, cough or difficulty breathing in the past 48 hours?” and “Have you tested positive for COVID-19 or have you been in contact with a COVID-19 positive person in the past 14 days?” New patients should be screened for recent travel, both domestic and international, or a recent cruise or airplane flight. If staff capacity permits, new patients, simulations, new starts and follow-up patients should be screened by phone the day prior to their appointment, and if appropriate, their appointment may be deferred or changed to a remote assessment (telemedicine). Patients under treatment should be screened prior to each fraction. Ideally, patients who are “screen-positive” should self-isolate and monitor their conditions, and follow up as per local recommendations (e.g., nasal swab if appropriate with personal protective equipment (PPE) precautions if in clinic, separate waiting room, follow up with their PCP if at home). Symptomatic visitors should not accompany patients to the clinic.

Scheduling of Follow Up Patients

All patients in follow-up should be screened prior to their appointments, with consideration to delay the appointment or use remote (telemedicine) follow-up, if appropriate. Follow-up visits for COVID-19 positive patients should be delayed until they are cleared from COVID-19.  Patients with breast and prostate cancer who have just completed their course of radiation and have none/mild post-treatment symptoms should not be scheduled for follow-up visits < 3-months, and remote (tele) follow-up is encouraged. All other patients should be scheduled on a case-by-case basis in consultation with their physician. For asymptomatic patients, follow-up appointments every three to six months may be appropriate. Shared follow-up with other members of the oncology team should be considered. Post treatment symptomatic patients, regardless of the interval since completing treatment, or those with concerns, should receive follow-up as scheduled.

In departments with significant reduction in staff capabilities, all asymptomatic patients may be rescheduled for a later follow-up visit.

Scheduling of New Consults

New patient consults may be triaged on a case-by-case basis according to the urgency of the situation following discussion with the referring physician (e.g., with pre-screening before the patient is seen). Examples of non-urgent cases that may be delayed for two or more months include prostate cancer patients, breast cancer patients on adjuvant chemotherapy and benign CNS patients, such as meningiomas or schwannomas. Care must be taken to avoid delays in consultation and treatment which may adversely affect potentially curable patients. Staff reductions may force delays in scheduling.

Palliative care patients should also be screened for whether radiation therapy may be omitted (e.g., if thought to be futile, if patients prognosis is very poor (e.g., ECOG 3 PS), or if other palliative treatments may be used instead) or delayed if appropriate (e.g., painful bone metastases), with the exception of function- or life-threatening situations (e.g., spinal cord compression, cauda equina compression, cranial nerve compression, superior vena cava syndrome, airway obstruction, hemoptysis or other bleeding from the tumor).

Radiation Treatment Schedules

Recognizing the potential for staff reductions, radiation oncologists should follow appropriate evidence-based guidelines (e.g., NCCN) while striving for the shortest possible course of radiotherapy (e.g., single-fraction treatment for bone pain, hypofractionation where appropriate, e.g., breast, prostate).

Read more about the impact of COVID-19 on cancer patients in the article Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China.

Listen to an ASTRO webcast from the University of Washington.