Introduction
On December 8, 2019, a few cases of previously unidentified viral pneumonia were reported
in Wuhan, China, which was later designated as coronavirus disease 2019 (COVID-19)
caused by severe acute respiratory syndrome coronavirus-2 (SARS CoV-2)
1
. Since its initial outbreak in Hubei region of China, the disease spread worldwide
and the World Health Organization (WHO) declared as a global pandemic by March 11,
2020. This highly contagious disease has significantly affected management of cancer
patients in Asia, as well as other regions of the world. Cancer centers in each country
have endeavored to provide the appropriate management for patients in different manners.
Discussion
In China, the number of COVID-19 cases increased steeply since the first report in
December 2019, doubling almost every day during the early phase of the outbreak
1
. Currently, a total of 83,057 confirmed patients with 4,634 mortality cases have
been reported as of June 12, 2020. The spread of the disease within healthcare facilities
was a major issue, with a report from a hospital in Wuhan showing that 41% of confirmed
cases were nosocomial
2
. Compared with other types of patients, cancer patients are more likely to be immuno-compromised
and more frequently visit the clinic and/or get admitted. Hence, infection control
by reducing unnecessary hospital visits is absolutely crucial for the optimal management
of cancer patients in China where the nosocomial spread of COVID-19 has been noted.
The Chinese National Cancer Center recommended weighing the risk of COVID-19 infection
and the benefit of continuing treatment for cancer patients
3
. They also recommended simplifying the dosing schedules of chemotherapy and treating
on an outpatient basis if allowed. Outpatients should be thoroughly screened with
history and chest radiography. Screening with COVID-19 testing should be performed
if patients present with fever, chills, shortness of breath, and cough and/or if patient
express exposure to infected patients.
In response to this pandemic, cancer centers in China made several important changes
in colorectal cancer management
4
. Patients with early cancer requiring endoscopic resection had their invasive procedures
delayed
1
. For patients requiring surgical resection, non-emergency cases were delayed even
for those unlikely to have COVID-19, especially if personal protective equipment (PPE)
and negative pressure rooms were in short supply. The decision was also made to reduce
the intensity and duration for adjuvant chemotherapy following surgical resection
5
. Neoadjuvant chemotherapy for locally advanced disease was administered as normal,
but regimens with long intervals (3 to 4 weeks) were recommended to reduce clinic
visits. Long-term radiotherapy schedules were provided to bridge the gap of delayed
surgical resection. Treatment for metastatic colorectal cancer was continued, although
a switch to oral chemotherapy regimens and treatments with longer interval regimens
were favored. In some centers, capecitabine and oxaliplatin (CAPOX) or capecitabine
and irinotecan (CAPIRI) regimens were preferred due to shorter hospitalization duration
and similar efficacy, as shown in the AXEPT study
1
. They also referred patients to nearby local centers to avoid unnecessary travel.
Immediate surgery was only offered to patients who presented with acute symptoms such
as hemorrhage or obstruction, which could not be managed by endoscopic procedures,
and fully protective measures were necessary during surgery. Delaying imaging follow-up
was also considered reasonable, especially if the disease and patients’ clinical status
were stable.
In South Korea, COVID-19 spread quickly since the confirmation of the first case on
January 20, 2020 and currently, a total of 12,003 COVID-19 cases have been confirmed,
with 277 mortality cases as of June 12, 2020. In the early phase of the outbreak,
dissemination peaked in the Daegu city and the surrounding Gyeongbuk province during
February 2020, with more than 100 new daily confirmed cases. A surge in COVID-19 during
that time hindered standard management of cancer patients, but the propagation of
this infection has subsided. The unique characteristic of cancer management in South
Korea is that most patients have been diagnosed and treated in centers located in
metropolitan areas (e.g., Seoul, Daegu, and Busan). At present, most cancer centers
have policies on maintaining the usual standard of care in patients with all types
of cancer including GI cancer, even under strict protocols for preventing the spread
of COVID-19. Continuation of cancer management without major compromises in South
Korea is largely due to the well-established infection control protocols in each hospital,
which stemmed from their experience with the Middle East respiratory syndrome (MERS)
outbreak in 2015. Importantly, the Korean government provides complete and systematic
epidemiologic data of confirmed COVID-19 cases—this allows effective preemptive isolation
for those with close contacts, which minimizes the spread of the disease through healthcare
facilities. In addition, the testing capacity for SARS-CoV-2 PCR was rapidly established
throughout the nation, which supported extensive screening for suspicious cases. The
nationwide cooperation of South Korean citizens to the government policies against
COVID-19 (e.g., social distancing, personal hygiene) was also an encouraging phenomenon
that likely also played a critical in controlling the outbreak.
According to the guidelines published by the Korean Cancer Association and National
Cancer Center, changes and delays in the management of cancer patients (including
clinical trials) are not necessary in the absence of direct suspicion or confirmation
of COVID-19 6. If a patient is suspected or confirmed with COVID-19, cancer treatment
should be stopped and appropriate evaluation and management must be given to the patient.
The timing of resuming cancer treatment should be determined by a shared decision-making
process among treating physicians including expert oncologists. In the South Korean
cancer centers, strict infection control was applied since the early phase of the
outbreak
7
. This approach included the screening of all patients before their outpatient clinic
visits
7
. Patients with COVID-19 associated symptoms or epidemiologic links to confirmed COVID-19
cases are categorized as high-risk patients—for these patients, clinic visits are
delayed for 14 days or COVID-19 screening tests are carried out according to the specific
groups as defined in the protocols of each center. Patients being admitted to general
inpatient services undergo screening with PCR testing irrespective of their symptoms.
High-risk patients being admitted to the hospital are isolated in single-bed rooms
until they are allowed to move to multi-bed rooms according to the hospital protocol
of each center. With these efforts, the standard of care was given to patients without
compromise, except for some protocol deviations in clinical trials due to the delay
of monitoring visits.
In Japan, COVID-19 spread vastly througout the country, and the government announced
a state of emergency on April 7, 2020. As of June 12, 2020, a total of 17,292 confirmed
patients and 920 mortality cases due to COVID-19 have been reported. The outbreak
affected the daily practice of cancer patient management in Japan. In a survey on
1,101 breast cancer and gynecologic cancer patients from April 19-25, 2020, 272 (24.7%)
patients responded that they had their scheduled treatment or follow-up visits postponed
during the pandemic. A similar approach was taken for colorectal cancer patients.
Psychologic aspect of the patients was also influenced by the outbreak. Cancer patients
are feeling anxious as they find themselves more vulnerable to the disease than others.
Conclusion
In summary, among the various Asian nations, differences exist between the measures
applied to provide optimal management to cancer patients during the COVID-19 pandemic.
We believe that everyday practice provided to cancer patients in each local center
will improve towards less compromise in standard care while minimizing the risk of
COVID-19 infection.
Uncited reference
6..