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      PRO platform, a useful tool to improve monitoring and effective management of Covid-19 cancer patients

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          Abstract

          A central strategy for health care surge control would be to provide remote effective monitoring of Covid-19 patients and their follow-up. Telemedicine allows patients not only to be carefully screened, but also enabling a patient-centered system as well as being conducive to self-quarantine. Also patients, clinicians, and the community are protected from exposure (1). Patients with cancer during or after treatment, have an increased risk of complication and death related to Covid-19 contagion (2; 3). In this report, physicians in Gustave Roussy Center Institute (GR), France, a leading European tertiary cancer center, describe the use of telemedicine for monitoring and optimizing referral of Covid-19 cancer patients. The CAPRI telemedicine program has been set-up to monitor cancer patients undergoing oral therapy (4) (Figure 1 ). Faced with the Covid-19 crisis, we adapted the system accordingly in a period of two weeks, also drawing inspiration from another program (5). Figure 1 CAPRI Process for monitoring cancer patients. Figure 1 Capri-Covid19 consists of a web application for patients and a telephone platform with a dedicated call number, the entire procedure being managed by four GR’s nurse navigators (NN). It can allow NN and patients to communicate 24/7 (from 8:30 am to 6 pm; outside the center, the patient must contact the emergency service) through secure messaging (i.e. the platform complies with the French regulation on data protection). The web application allows patients to fill in questions specific to Covid-19 based on a Patient-Reported Outcome’s approach which has demonstrated its added value in an oncology context (6). Finally, the application provides NN with a complete panel to view individual electronic patient medical records. If Covid-19 is suspected, either when the patient comes to the hospital (emergency department or consultation; in which case, the patient is asked to return home while the test results are pending) or at home, the patient is tested. Covid-19 positive patients are included in the CAPRI program after having provided informed consent and follow a 4-phase remote monitoring strategy (see figure 2 ). Figure 2 Algorithm for remote monitoring of Covid-19 positive cancer patients. Figure 2 Initial assessment. NN calls each patient in order to assess their specific cancer concerns (e.g. medical prescriptions), comorbidities and social conditions (isolation and ability to acquire personal needs during the confinement period). In addition, information on the program is given when the individual account is created, following the guidelines provided by the French authorities (https://www.hcsp.fr/explore.cgi/avisrapportsdomaine?clefr=779). Lastly, the patient is offered to choose between two monitoring modes: either by phone, or by completing an application form (web or smartphone). Follow-up. This is based on six questions asked patients: (i) fever ≥ 38.3° (100.94° F); (ii) appearance or worsening of respiratory discomfort since the last assessment (LA); (iii) appearance or worsening of a cough since LA; (iv) drowsiness; (v) any new symptoms since LA (e.g. muscle aches, headaches); (vi) appearance or worsening of diarrhea since LA. The data are reported following the application twice a day whereas the call is daily in the case of a telephone follow-up. Patient orientation decision. The system generates alerts if one out of the six above questions is answered positively or if the patient has not responded for more than 24 h. The alert is automatically generated via the application, or during daily NN phone calls. In this case, the NN contacts the emergency department manager in order to organize the patient’s arrival to the emergency room or the Covid-19 ward directly. Evaluation. A longitudinal assessment is organized, based on five indicators: hospital admissions, emergency visits, access to Intensive Care Unit following a Covid-19 complication; deaths following a Covid-19 complication; recoveries. These indicators provide a real-time reading of the evolution of the epidemic and will then allow the impact of this intervention to be assessed. To date, more than hundred patients have been enrolled in the ongoing program. Our experience shows that Covid-19 crisis is a clinical, epidemiological and organizational issue to overcome. Although telemonitoring cannot solve every problems, it is well suited to the context of Covid-19, and organizations that have already invested in telemedicine are well positioned to expand them and ensure that patients with Covid-19 receive the appropriate care. This decision tree allows not only a collection of data, but also a secured organizational process for patient orientation and an optimal physician medical time. Our experience could help other cancer centers, or even healthcare organizations, to implement a rapid effective program with health care professionals monitoring patients at distance while being less exposed. Gustave Roussy Cancer Institute should provide for free the Capri-Covid app worldwide in order to help Covid-infected cancer patients. The authors are grateful to Richard Medeiros, Medical Editor from Medical Editing International. Declaration of interests The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. SCOTTE reports personal fees from helsinn, personal fees from MSD, personal fees from Roche, personal fees from AMGEN, personal fees from Pierre Fabre Oncology, personal fees from Pfizer, personal fees from Mundi Pharma, personal fees from Mylan, personal fees from Leo Pharma, outside the submitted work; Dr Minvielle has no disclosure to declare. Dr. MIR reports personal fees from Amgen, Astra-Zeneca, Bayer, Blueprint Medicines, Bristol Myers-Squibb, Eli-Lilly, Incyte, Ipsen, Lundbeck, MSD, Novartis, Pfizer, Roche, Servier, Vifor Pharma., other from Amplitude surgical, Ipsen, Transgene, outside the submitted work; Dr ANDRE has no disclosure to declare. Dr. Barlesi reports personal fees from Astra-Zeneca, Bayer, Bristol-Myers Squibb, Boehringer–Ingelheim, Eli Lilly Oncology, F. Hoffmann–La Roche Ltd, Novartis, Merck, MSD, Pierre Fabre, Pfizer and Takeda, outside the submitted work; Dr. Soria reports personal fees from In the last 3 years consultancy fees from: AstraZeneca, Astex, Clovis, GSK, GamaMabs. Lilly, MSD, Mission Therapeutics, Merus, Pfizer, PharmaMar. Pierre Fabre, Roche-Genentech, Sanofi, Servier, Symphogen, Takeda. Full time employee for AstraZeneca between September 2017-December 2019, other from Shareholder Gritstone, during the conduct of the study; personal fees from null, outside the submitted work; .

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          Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China

          China and the rest of the world are experiencing an outbreak of a novel betacoronavirus known as severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). 1 By Feb 12, 2020, the rapid spread of the virus had caused 42 747 cases and 1017 deaths in China and cases have been reported in 25 countries, including the USA, Japan, and Spain. WHO has declared 2019 novel coronavirus disease (COVID-19), caused by SARS-CoV-2, a public health emergency of international concern. In contrast to severe acute respiratory system coronavirus and Middle East respiratory syndrome coronavirus, more deaths from COVID-19 have been caused by multiple organ dysfunction syndrome rather than respiratory failure, 2 which might be attributable to the widespread distribution of angiotensin converting enzyme 2—the functional receptor for SARS-CoV-2—in multiple organs.3, 4 Patients with cancer are more susceptible to infection than individuals without cancer because of their systemic immunosuppressive state caused by the malignancy and anticancer treatments, such as chemotherapy or surgery.5, 6, 7, 8 Therefore, these patients might be at increased risk of COVID-19 and have a poorer prognosis. On behalf of the National Clinical Research Center for Respiratory Disease, we worked together with the National Health Commission of the People's Republic of China to establish a prospective cohort to monitor COVID-19 cases throughout China. As of the data cutoff on Jan 31, 2020, we have collected and analysed 2007 cases from 575 hospitals (appendix pp 4–9 for a full list) in 31 provincial administrative regions. All cases were diagnosed with laboratory-confirmed COVID-19 acute respiratory disease and were admitted to hospital. We excluded 417 cases because of insufficient records of previous disease history. 18 (1%; 95% CI 0·61–1·65) of 1590 COVID-19 cases had a history of cancer, which seems to be higher than the incidence of cancer in the overall Chinese population (285·83 [0·29%] per 100 000 people, according to 2015 cancer epidemiology statistics 9 ). Detailed information about the 18 patients with cancer with COVID-19 is summarised in the appendix (p 1). Lung cancer was the most frequent type (five [28%] of 18 patients). Four (25%) of 16 patients (two of the 18 patients had unknown treatment status) with cancer with COVID-19 had received chemotherapy or surgery within the past month, and the other 12 (25%) patients were cancer survivors in routine follow-up after primary resection. Compared with patients without cancer, patients with cancer were older (mean age 63·1 years [SD 12·1] vs 48·7 years [16·2]), more likely to have a history of smoking (four [22%] of 18 patients vs 107 [7%] of 1572 patients), had more polypnea (eight [47%] of 17 patients vs 323 [23%] of 1377 patients; some data were missing on polypnea), and more severe baseline CT manifestation (17 [94%] of 18 patients vs 1113 [71%] of 1572 patients), but had no significant differences in sex, other baseline symptoms, other comorbidities, or baseline severity of x-ray (appendix p 2). Most importantly, patients with cancer were observed to have a higher risk of severe events (a composite endpoint defined as the percentage of patients being admitted to the intensive care unit requiring invasive ventilation, or death) compared with patients without cancer (seven [39%] of 18 patients vs 124 [8%] of 1572 patients; Fisher's exact p=0·0003). We observed similar results when the severe events were defined both by the above objective events and physician evaluation (nine [50%] of 18 patients vs 245 [16%] of 1572 patients; Fisher's exact p=0·0008). Moreover, patients who underwent chemotherapy or surgery in the past month had a numerically higher risk (three [75%] of four patients) of clinically severe events than did those not receiving chemotherapy or surgery (six [43%] of 14 patients; figure ). These odds were further confirmed by logistic regression (odds ratio [OR] 5·34, 95% CI 1·80–16·18; p=0·0026) after adjusting for other risk factors, including age, smoking history, and other comorbidities. Cancer history represented the highest risk for severe events (appendix p 3). Among patients with cancer, older age was the only risk factor for severe events (OR 1·43, 95% CI 0·97–2·12; p=0·072). Patients with lung cancer did not have a higher probability of severe events compared with patients with other cancer types (one [20%] of five patients with lung cancer vs eight [62%] of 13 patients with other types of cancer; p=0·294). Additionally, we used a Cox regression model to evaluate the time-dependent hazards of developing severe events, and found that patients with cancer deteriorated more rapidly than those without cancer (median time to severe events 13 days [IQR 6–15] vs 43 days [20–not reached]; p<0·0001; hazard ratio 3·56, 95% CI 1·65–7·69, after adjusting for age; figure). Figure Severe events in patients without cancer, cancer survivors, and patients with cancer (A) and risks of developing severe events for patients with cancer and patients without cancer (B) ICU=intensive care unit. In this study, we analysed the risk for severe COVID-19 in patients with cancer for the first time, to our knowledge; only by nationwide analysis can we follow up patients with rare but important comorbidities, such as cancer. We found that patients with cancer might have a higher risk of COVID-19 than individuals without cancer. Additionally, we showed that patients with cancer had poorer outcomes from COVID-19, providing a timely reminder to physicians that more intensive attention should be paid to patients with cancer, in case of rapid deterioration. Therefore, we propose three major strategies for patients with cancer in this COVID-19 crisis, and in future attacks of severe infectious diseases. First, an intentional postponing of adjuvant chemotherapy or elective surgery for stable cancer should be considered in endemic areas. Second, stronger personal protection provisions should be made for patients with cancer or cancer survivors. Third, more intensive surveillance or treatment should be considered when patients with cancer are infected with SARS-CoV-2, especially in older patients or those with other comorbidities.
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            Virtually Perfect? Telemedicine for Covid-19

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              Clinical characteristicsof coronavirus disease2019 in China.

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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
                7 April 2020
                7 April 2020
                Affiliations
                [1]Gustave Roussy Cancer Institute, 114 rue Edouard Vaillant, 94800 Villejuif, France
                Author notes
                [] Corresponding author. flscotte@ 123456gmail.com
                Article
                S0959-8049(20)30161-1
                10.1016/j.ejca.2020.03.020
                7141484
                32192809
                9bec2107-6754-4ba1-8e6c-6d809c68b9d7
                © 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.

                History
                : 27 March 2020
                : 28 March 2020
                Categories
                Article

                Oncology & Radiotherapy
                Oncology & Radiotherapy

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