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      The experience on COVID-19 and cancer from an oncology hub institution in Milan, Lombardy Region

      a , a , b , a , b ,

      European Journal of Cancer

      Elsevier Ltd.

      cancer, COVID-19, SARS-CoV-2, coronavirus, hub

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          Abstract

          The rapid outbreak of the SARS-CoV-2 related disease (COVID-19) has spread rapidly to a pandemic proportion, increasing the demands on health systems for the containment and management of COVID-19. Cancer has been reported as a major risk factor for adverse outcomes of and death from COVID-19. We extracted data from the World Health Organization’s progress reports and from the Italian Council of Medicine. In addition, we retrieved clinical data on cancer patients with confirmed COVID-19 in our Institution. As of April 2nd, 2020, 110 574 COVID-19 cases and 13 157 deaths have been described in Italy, representing a global share of 5.1% and 28.9% for incidence and mortality, respectively. In Italy, we report the analysis of the Italian Medical Council on 909 patients who died from COVID-19, of whom 16.5% were cancer patients. The population was enriched with subjects with multiple co-morbid non-communicable diseases, with less than 1% of the population presenting no co-morbid conditions. At the patient level, we identified nine patients referred to our department in the last two months who were receiving standard of care or experimental medications in the curative and palliative settings. The median age was 68 years (range: 42–79 years), and patients carried a median of one co-morbid condition (0–2); two out of nine patients presented with severe COVID-19 presentation, and were receiving inpatient care. None of the patients receiving immunotherapy experienced severe adverse outcomes, and four patients were discharged with complete reversal of the clinical syndrome and SARS-CoV-2 clearance. Learning from the experience of countries with a high burden, efforts must be made to assure the access of cancer patients to treatments, prioritizing the cancer health interventions based on their intrinsic value, and limiting the exposure to an unacceptable risk of infection for both health providers and patients. Any significant work in the design and implementation of health system actions, including in clinical care, must be framed as an initiative under the Global Response Agenda and through a community approach, with the intention of pursuing common goals to tackle COVID-19 and cancer, as ‘One Community’ working for ‘One Health’s.

          Highlights

          • 1% of patients with COVID-19 in the series reported as cancer patients, 50% experienced a severe or fatal event.

          • in Italy, 16.5% of patients dying from COVID-19 are cancer patients.

          • In the first Italian series of cancer patients with COVID-19 receiving active treatment, 22% experienced severe presentation.

          • Research is emphasized to enhance knowledge on COVID-19 & cancer care, under a global response through community healthcare.

          • An intersectoral line must be pursued for this PH emergency, providing prevention & control measures to cancer patients.

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          Most cited references 6

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          The response of Milan's Emergency Medical System to the COVID-19 outbreak in Italy

          The number of people infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing coronavirus disease 2019 (COVID-19), is dramatically increasing worldwide. 1 The first person-to-person transmission in Italy was reported on Feb 21, 2020, and led to an infection chain that represents the largest COVID-19 outbreak outside Asia to date. Here we document the response of the Emergency Medical System (EMS) of the metropolitan area of Milan, Italy, to the COVID-19 outbreak. On Jan 30, 2020, WHO declared the COVID-19 outbreak a public health emergency of international concern. 2 Since then, the Italian Government has implemented extraordinary measures to restrict viral spread, including interruptions of air traffic from China, organised repatriation flights and quarantines for Italian travellers in China, and strict controls at international airports' arrival terminals. Local medical authorities adopted specific WHO recommendations to identify and isolate suspected cases of COVID-19.3, 4 Such recommendations were addressed to patients presenting with respiratory symptoms and who had travelled to an endemic area in the previous 14 days or who had worked in the health-care sector, having been in close contact with patients with severe respiratory disease with unknown aetiology. Suspected cases were transferred to preselected hospital facilities where the SARS-CoV-2 test was available and infectious disease units were ready for isolation of confirmed cases. Since the first case of SARS-CoV-2 local transmission was confirmed, the EMS in the Lombardy region (reached by dialling 112, the European emergency number) represented the first response to handling suspected symptomatic patients, to adopting containment measures, and to addressing population concerns. The EMS of the metropolitan area of Milan instituted a COVID-19 Response Team of dedicated and highly qualified personnel, with the ultimate goal of tackling the viral outbreak without burdening ordinary EMS activity (figure ). The team is active at all times and consists of ten health-care professionals supported by two technicians. Figure EMS organisation and procedural algorithm of the COVID-19 Response Team The activities of the EMS and the specifically instituted COVID-19 response team (A). On the basis of caller needs, the receiver operators of the primary PSAP dispatch calls to either the ordinary EMS for primary medical assistance or to the COVID-19 response team for the assessment of risk factors for SARS-CoV-2 infection. To address hospital needs and to receive medical directives, the COVID-19 response team maintains direct contacts with local hospitals and regional public health authorities. The COVID-19 response team algorithm to detect and manage suspected cases of COVID-19 (B). On the basis of risk factors for SARS-CoV-2 contagion and the clinical conditions of the screened individuals, the COVID-19 response team determines the need for hospital admission, home isolation, or SARS-Cov-2 testing. The COVID-19 response team also provides counselling (ie, hygiene recommendations and preventive actions to limit respiratory diseases spread) for non-suspected cases and for patients isolated at home, including their cohabitants. PSAP=public safety answering point. EMS=Emergency Medical System. COVID-19=coronavirus disease 2019. SARS-CoV-2=severe acute respiratory syndrome coronavirus 2. The COVID-19 Response Team collaborated with regional medical authorities to design a procedural algorithm for the detection of suspected cases of COVID-19 (figure). Patients were screened for: (1) domicile or prolonged stay in the hot zone (ie, where COVID-19 cases first appeared), or both; (2) close contact with suspected or confirmed cases of COVID-19; and (3) close contact with patients with respiratory symptoms from the hot zone or China. The COVID-19 Response Team assessed the clinical condition of screened individuals to determine the need for hospital admission or for home testing for SARS-CoV-2 and subsequent isolation. Finally, recommendations to limit viral spread were provided to the other family members, especially when isolation was indicated. 4 The COVID-19 Response Team handles patient flow to local hospitals and addresses specific issues about bed resources, emergency department overcrowding, and the need for patient transfer to other specialised facilities. The algorithm is constantly updated to meet regional directives about hot zone extension and modalities for SARS-CoV-2 testing. Recent literature suggests that viral spread is still expected to grow, and the preparedness of public health systems will be challenged worldwide. 5 In this context, the EMS is inevitably involved in facing the consequences of the SARS-CoV-2 outbreak. Specific algorithms, detailed protocols, and specialised teams must be fostered within each EMS department to allocate the right resources to the right individuals when cases of COVID-19 present. The Italian EMS, along with public health authorities, has just started to fight a battle that must be won.
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            A Rapid Fatal Evolution of Coronavirus Disease-19 in a Patient With Advanced Lung Cancer With a Long-Time Response to Nivolumab

            To the Editor: Coronavirus disease-19 (COVID-19) is now a pandemic disease. In Italy, the first set of cases were documented at the end of January 2020 reporting a dramatic spread. Liang et al. 1 reported an increased risk of COVID-19 for patients with cancer, having poorer prognosis than those without cancer. We present a case of a rapid fatal evolution of COVID-19 in a patient with metastatic lung cancer in partial remission with immunotherapy since 2013. On March 4, 2020, a 65-year-old male patient presented in the emergency department for shortness of breath, fever, and mental confusion. The hemogasanalysis revealed hypoxia; laboratory tests revealed normal leukocytes with lymphopenia, and elevation of C-reactive protein, transaminases, and lactate dehydrogenase. Chest radiograph showed reticular interstitial addensative findings (Fig. 1). Nasal swab was positive for COVID-19. Figure 1 March 4 2020 Chest X-ray. His medical history was positive for emphysema and lung adenocarcinoma diagnosed in August 2012. At that time, the patient underwent cerebral metastasectomy, panencephalic radiotherapy, and chemotherapy (carboplatin and pemetrexed) until July 2013. After six cycles of chemotherapy, brain magnetic resonance imaging and computed tomography scan revealed progression of the disease. He was then enrolled in CA209-057 clinical trial and treated from August 2013 to February 14, 2020 with nivolumab, a programmed cell death protein-1 checkpoint inhibitor, in which there was partial response without adverse events reported. The last computed tomography scan was performed on February 2, 2020, which described stable disease (Fig. 2). Figure 2 February 4 2020 CT scan. On March 5, 2020, he was admitted to the infectious disease unit and started empiric antibiotic treatment and oxygen therapy with a reservoir mask at 15 L/minute. He was sedated because of agitation; because of this, he never received prescribed lopinavir plus ritonavir and hydroxychloroquine. The patient had a rapid worsening of the condition and died on March 9, 2020. There are no specific therapeutic agents for coronavirus infections. As per WHO’s guidelines in the management of severe COVID-19, our patient was treated with an empiric antimicrobial, oxygen therapy, and other symptomatic treatment. 2 Emerging evidence suggests that the same patient with a severe course may respond to the infection with a “cytokine storm.” 3 Histologic examination of the biopsy samples at autopsy from a patient who died from severe COVID-19 revealed the presence of bilateral diffuse alveolar damage with cellular fibromyxoid exudates and mononuclear inflammatory lymphocytes in both lungs. 4 Our patient had a history of long exposure to immunotherapy; and although a kind of paradoxical immunologic response to influenza infection or vaccination during the use of immune checkpoint inhibitors has been previously described, 5 we have no data regarding immune checkpoint inhibitors and the risk of COVID-19. Our patient presented a rapid evolution of respiratory failure and was not treated with more invasive procedures, probably owing to his cancer and emphysema history. We do not know whether treatment with steroids, not routinely recommended in COVID-19 (but very useful against side effects of immunotherapy), could help to control pneumonitis in these patients. This case emphasized the importance of a multidisciplinary approach, even in the presence of a severe outbreak like the pandemic COVID-19, because the knowledge of underlying disease and concomitant treatments is important to take the best individual therapeutic decision.
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              A segregated-team model to maintain cancer care during the COVID-19 outbreak at an academic center in Singapore

               N. Ngoi,  J Lim,  S. Ow (2020)
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                Author and article information

                Contributors
                Journal
                Eur J Cancer
                Eur. J. Cancer
                European Journal of Cancer
                Elsevier Ltd.
                0959-8049
                1879-0852
                29 April 2020
                29 April 2020
                Affiliations
                [a ]Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
                [b ]Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
                Author notes
                [] Corresponding author. Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, University of Milan, Department of Oncology and Haemato-Oncology, Via Giuseppe Ripamonti n. 435, 20141, Milan, Italy. giuseppe.curigliano@ 123456ieo.it
                Article
                S0959-8049(20)30220-3
                10.1016/j.ejca.2020.04.017
                7188643
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                Categories
                Article

                Oncology & Radiotherapy

                hub, coronavirus, sars-cov-2, covid-19, cancer

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