At the time of writing, the COVID-19 pandemic has infected 146 million people, and 3.09 million have lost their lives worldwide. COVID-19 went straight leg in the yet warped, tricky journey of cancer patients by hampering their access to hospitals, raising concern about continuing systemic therapy or solely representing an umpteenth worry in dark times.
Soft tissue sarcomas (STS) represent a broad spectrum of mesenchymal tumours, with more than 70 histotypes wherein extremely aggressive entities with dismal prognosis lurk. STS are exceedingly rare with an incidence of 4–5 cases/100 000 people, accounting for 8700 new cases/year in the USA and 2100 in Italy (Trama et al. 2019). A major effort in orchestrating the winding path of sarcoma patients has been paid in recent years to reduce the incidence of initial misdiagnosis, nearly 30%, and optimise their management (Ray-Coquard et al. 2012). A timely and accurate diagnosis is of critical importance to rapidly address STS patients to dedicated multidisciplinary STS teams available at a few referral sarcoma centres scattered over the territory (Soomers et al 2020). Italy was the epicentre of the European COVID-19 outbreak (Del Buono et al 2020), and some cancer centres – mainly those provided with an emergency department – have been asked to actively care for COVID-19 patients while maintaining their primary commitment. Such war on two fronts necessarily undermined the oncologic services, resulting in a soul-crushing selection of whom should deserve priority attention according to the clinical urgency (Kutikov et al 2020). As a referral cancer centre treating around 6500 patients every year, we aim to provide a continuum of care during the pandemic. This represented a unique challenge for STS patients, being among the most demanding to treat due to their complex multidisciplinary management. The COVID-19 outbreak represented a dark shade for STS patients in several aspects. First, referral centres suddenly became difficult to reach due to the massive lockdown and the understandable fear of defying it. In addition, hospitals witnessed a dramatic reduction in the number of surgeries as a reflection of the increasing of the number of intensive care beds dedicated to COVID-19 patients and the reallocation of healthcare professionals in the most critical areas. Indeed, despite our institution being appointed as a regional hub for surgical oncology, major surgeries for high-grade sarcoma decreased by 25% during March–April 2020 compared to the same period in 2019. Since the beginning of the emergency, multidisciplinary tumour boards went virtual and, despite an overall decrease of 23% of new cases, continued to play a prominent role in the optimisation of the therapeutic strategy (Gennaro et al. 2021). This was particularly true for those patients who could not benefit from surgery in the short term. Favouring neoadjuvant therapy was one of the options considered by our multidisciplinary team in specific histologies (i.e. myxoid liposarcoma or undifferentiated pleomorphic sarcoma). Medical oncologists had to balance the risk of nosocomial infection COVID-19 considering the chemotherapy-induced immunosuppression, especially related to the intensive myelotoxic regimens indicated as neoadjuvant treatment in STS, requiring in hospital admission and determining severe neutropenia. In this regard, we recall that the worrisome assumptions on possible interference between systemic therapy and risk of COVID-19 are still merely speculative without sound evidence (Bertuzzi et al. 2020; Xia et al 2020). In addition, peripheric facilities discontinued their activity during the current emergency, possibly delaying their first diagnosis and contributing to the general slowdown of the cancer patient’s journey.
The scientific community has not turned a blind eye to the thorny issue of ensuring cancer care in such an alarming background. European Society for Medical Oncology (ESMO) virtuously delivered practical point-to-point recommendations with regard to the management of sarcoma, and so did the French Sarcoma Group (ESMO-EURACAN 2020;Penel et al. 2020). As for other cancers, a valid strategy to pursue the appropriate clinical decisions is to give priority to patients with specific histology and critical clinical presentation. Based on recommendations coming from referral STS centres, ESMO labelled suspicious/newly diagnosed high-intermediate-grade sarcoma or relapse of disease at follow-up as urgent (ESMO-EURACAN 2020). For systemic medical treatment, ESMO and American Society of Clinical Oncology warranted extreme caution in prescribing chemotherapy, as data robust about COVID-19 infection in cancer patients are still lacking. Clinical research is significantly embedded in rare cancer care, providing considerable advantages and high-value alternative therapeutic strategies to eligible patients. Indeed, in a complex scenario where personalised and targeted medicine headed the clinical decision, the enrolment in a dedicated clinical trial represents the best option for patients and physicians. Unfortunately, the pandemic has overshadowed this opportunity for many STS patients due to restrictive measures imposed by the local Government or study sponsors and to safety concerns for trial participants. A similar dropout was observed in the authorisation process to obtain off-label medications, a valid system to gain access to cutting-edge treatments.
It was hard enough to deal with rare cancer before COVID-19. The pandemic is seriously testing physicians’ commitment to care by creating new obstacles in the management of already exceedingly complex disease (Rossi et al. 2020). In the hope of seeing the pandemic contained soon, cancer centres should be aware of the imperative needs that rare cancers claim. A forward-thinking vision is necessary to promptly rearrange the health system, to restart the clinical activity once the epidemic peak has passed and to be prepared for the next pandemic with a detailed blueprint that goes beyond drafting general emergency plans to preserve cancer care. In this regard, efficient hub-spoke networking between regional institutions and widespread use of telemedicine should represent the key elements to ease a physician-patient interaction and to build a solid oncologic groundwork for future emergencies (Bertuzzi et al 2020). A coordinated effort by all stakeholders involved in cancer care is crucial to punctually safeguard patients and physicians in their fierce battles, as sarcoma might not forgive delays.
N.G., A.F.B., A.M. and F.C. drafted the manuscript. N.G., A.M., A.F.B., A.S., U.C., V.L.Q. and F.D.O. critically revised the article.
Conflicts of interest
There are no conflicts of interest.
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