By Veronica Hackethal
Individuals with cancer are at heightened risk for serious illness and worse outcomes from COVID-19 infection, especially if they have received bone marrow transplants, or have hematological malignancies and/or advanced cancer. Guidance on providing safe cancer care during this unprecedented time has been issued by professional societies and public health authorities, including state public health authorities, the Centers for Disease Control and Prevention (CDC), World Health Organization, American Society of Clinical Oncology, American College of Surgeons, and National Comprehensive Cancer Network. Cancer centers around the country have responded by integrating this advice into safety protocols.
While these protocols may change to reflect the rapidly changing COVID-19 situation, for now they fall into the following six broad categories.
1. Restricting visitors
Across the board, top cancer centers are restricting visitors, with limited exceptions. In general, centers are not allowing visitors for adult inpatients, except for patients with neurocognitive or physical frailties who require accompaniment. Other inpatient exceptions include pediatric patients, certain surgical patients, patients at the end of life, and unique circumstances as assessed by the care team.
Children are not allowed as visitors, though the age cutoff varies. Most centers are not allowing children under age 18, though Seattle Cancer Care Alliance (SCCA) has decreased the cutoff to age 12.
The number of visitors also varies by institution. The Sidney Kimmel Cancer Center at Johns Hopkins University is allowing patients at the end of life to have two visitors while other family members will need to stay outside the facility. Family members are allowed to rotate in for visitation under special circumstances. On the other hand, Moffitt Cancer Center is allowing only one visitor for patients near the end of life.
Most top cancer centers are not allowing visitors at adult outpatient appointments. As with inpatient care, exceptions generally include pediatric patients and those with disabilities or frail patients who require assistance.
2. Screening for COVID-19
All top cancer centers are screening patients, visitors, employees, and vendors for symptoms of COVID-19. Patients are being asked to phone their providers and report any symptoms before outpatient appointments or before coming to the hospital. Many institutions such as Robert H. Lurie Comprehensive Cancer Center at Northwestern University, City of Hope, and SCCA have set up COVID-19 hotlines. In general, those who arrive with symptoms are taken to a separate isolation room for evaluation and testing when indicated. Some centers, such as Hopkins and SCCA, have set up drive through testing for individuals who qualify.
Cancer centers have also closed entrances to decrease the flow of people within their building and allow for more effective screening. While some centers now have a single entrance for patients, others have kept several entrances open. MD Anderson Cancer Center is screening patients and authorized visitors at five entrances to their Texas Medical Center Campus, while employees are being screened at separate entrances. At City of Hope, patients and employees are being screened through the same checkpoints. Patients are being told to allow extra time for screening and entry, and many institutions are issuing badges to individuals who pass screening. At UPMC Shadyside, screened individuals are also given an optional face mask.
3. Social Distancing
Cancer centers are following federal and local recommendations regarding social distancing, including delaying screening for new cancers and postponing or canceling outpatient appointments and elective surgeries when medically appropriate. Institutions have also canceled patient support and education groups, fundraising events, community relations events, conferences, and similar functions. They have also suspended volunteer activities.
Nonessential employees are being asked to work remotely from home, and those required for direct patient care are being asked to maintain social distancing. For example, MD Anderson is limiting work meetings to no more than five people, and asking workers to stand at least six feet apart with no more than five people allowed in an area. Occupancy in elevators is also being limited.
Hospital gift shops, relaxation areas, and barber shops have closed, and dining facilities have been either closed or reconfigured. For example, Dana-Farber has reconfigured their dining pavilion to allow the recommended amount of room for social distancing. They have closed the salad bar and deli, and most food on offer is now pre-packaged.
While many institutions have suspended valet parking, Moffitt Cancer Center still provides this service.
Research institutions have decreased lab staff to those required for essential functions of the lab, and clinical research is being curtailed. Most on-site lab and clinical research is being conducted remotely. For example, Hopkins is not launching new trials and has halted new accruals into clinical trials unless medically necessary.
4. Going Online: Virtual Cancer Centers
Most top cancer centers are using MyChart for telemedicine and conducting virtual outpatient visits when medically appropriate. For example, Cleveland Clinic is scheduling virtual visits even for some patients with active disease, such as those on oral therapies.
Patient support and education groups are also going online, and institutions are encouraging patients to use smart devices and other virtual methods to remain connected to their support network. Some institutions have set up designated areas to encourage smart phone use. For example, Dana-Farber now has a free cellphone waiting lot where the support person can communicate with a patient during her cancer care appointment.
At most cancer centers, decisions about whether patients should travel to their facilities for treatment are being left to the patient's care team. However, most have canceled domestic and foreign business travel for staff, though some are allowing intra-state travel. For example, Moffitt Cancer Center is allowing business travel within Florida but only if it is essential for ongoing Moffitt operations.
5. Cleaning Hospitals & Clinics
Top cancer centers are following CDC guidelines for daily deep cleaning of their facilities, and increased frequency of disinfection of high-touch surfaces such as elevator buttons, restrooms, and doorknobs using disinfectant that is effective against COVID-19. Some, such as City of Hope, have hired additional staff solely for the purpose of disinfecting high-traffic and high-touch areas. Cancer centers are also requiring care teams to wear protective face masks, though concern about limited availability of PPE is growing.
At Moffitt Cancer Center, which still offers valet service, staff are disinfecting steering wheels, keys, and wheelchairs after each use, and using hand sanitizer before and after parking each car.
6. COVID-19 Hotspots: MSK & SCCA
Memorial Sloan Kettering Cancer Center (MSK) and SCCA, located in the COVID-19 hotspots of New York City and Seattle, are following very similar policies as other centers to keep patients safe. Both are restricting visitors, though their policies differ slightly. MSK is not allowing visitors for inpatients or outpatients, with the exception of imminent end-of-life patients (two caregivers allowed simultaneously with the option to swap visitors throughout the day), pediatric patients (one caregiver), and extreme extenuating circumstances (one caregiver). SCCA is allowing only one visitor over age 12 to appointments, though visitors are not allowed in chemotherapy infusion rooms. Both institutions are screening patients by phone before appointments. Patients, employees, and authorized visitors are screened upon arrival, and both centers have severely restricted access to their facilities to a single entrance. MSK and SCCA are also following similar social distancing, travel, and cleaning policies as other centers.
"SCCA already had a robust and strict infection prevention protocol to safeguard the health and safety of our patients and staff. In response to the COVID-19 pandemic, we have implemented additional policies and procedures to help protect and support our community and to mitigate risks of COVID-19 exposure for all of our patients," Catherine Liu, MD, Associate Director of Infection Control at SCCA, shared with Oncology Times. "We know this is a difficult time, especially for individuals with cancer, but we are doing our best to ensure safe, high-quality, compassionate cancer care."
Veronica Hackethal is a contributing writer.