Comment on “The experience on coronavirus disease 2019 and cancer from an oncology hub institution in Milan, Lombardy Region” and reflections from the Italian Association of Oncology Nurses

Abstract

To the editor: We thank Trapani et al. [1] for their contribution aimed at sharing the experience of the reorganization of cancer care to respond to COVID-19 in the Lombardy Region (Italy). Trapani et al. [1] described the Italian cancer mortality and an interim analysis of nine cancer patients with COVID-19, mainly managed using home-based management. We agree with the authors in identifying the continuum of care as the key to success in COVID-19 and cancer management, as well as the strong need of keeping the connection between health needs and cancer management. Forasmuch, in accordance with what highlighted by Trapani et al. [1], the Italian Association of Oncology Nurses (AIIAO) is mapping the situation of the cancer patients self-isolated at home in the context of the COVID-19. On the 9th March 2020, the Italian authority locked down the country to contain the spread of COVID-19. Specific recommendations were provided to people living with cancer, who were encouraged to stay at home in self-isolation, especially elderly and immunocompromised patients, since they were considered at increased risk of COVID-19 infection and severe events [2]. Moreover, non-urgent visits were postponed, and several specialist cancer wards were converted into isolation units for patients with COVID-19 infection or closed because of staff shortage [3]. Furthermore, cancer patients are in urgent need of blood monitoring, chemotherapy, scans, transplants, and surgery, which, if delayed indefinitely, could mean loss of the window to treat. In this context, we started an online survey to describe the situation of the cancer patients self-isolated at home in the context of the COVID-19. Thus far, we have performed an interim analysis for data collected between 29th March and 3rd May 2020. Accordingly, 195 patients completed the survey. They were mainly female (n = 148, 75.9%), with a mean age of 50.3 (SD = 11.2, range = 25-78) years and a high level of education (university or postgraduate = 66, 34%). The majority of patients had haematological malignancies (n = 100, 51.3%), followed by patients with breast cancer (n = 51, 26.2%), and other solid tumours (n = 44, 22.6%). The majority were from the north of Italy (38.9%), 34.7% from the south, and 26.4% from central regions. Table 1 shows patients’ beliefs, behaviour, and access to care. Table 1 Participants’ beliefs, behaviour, and access to care (n = 195). Table 1 n % Leaving the house  Never 41 21.1  Rarely 115 59.3  Sometimes (2-3 times per week) 23 11.9  Every day 15 7.7 Reason for leaving the housea  Health 96 49.7  Job 16 8.3  Supermarket 97 50.3  Walking 25 13.0  Never going out 28 14.5 COVID-19 risk infection  I believe I am at higher risk 105 53.8  I believe I am not at higher risk 90 46.2 I believe I will suffer from severe consequences in case of infection due to my cancer  Very much/Completely 99 50.8  Quite a bit 46 23.6  A little/Not at all 50 25.6 Behaviours to lower infection riska  Hand washing 180 95.2  Social distance 154 81.5  Face mask without valve 136 72.0  Face mask with valve 46 24.3  Gloves 105 55.6  Disinfecting surfaces/cloths/groceries 56 29.6 Changes in relating with family membersa  Nothing changed 107 56.0  No kisses and hugs 61 31.9  Social distance 23 12.0  Separate rooms 13 6.8  Other 13 6.8 Using remedies to prevent COVID-19 infection  Yes 57 29.2  No 138 70.8 Health status under control  Yes 137 71.0  No 56 29.0 Fear of going to the hospital  Very much/Completely 72 37.3  Quite a bit 40 20.7  A little 65 33.7  Not at all 16 8.3 Frequency of going to the hospital  Not going at all 73 37.8  Diminished frequency 46 23.8  Same frequency as usual 68 35.2  Other 5 2.6 a multi response variable. Overall, an important number of patients reported that their cancer disease was not under control (29%). This is especially alarming given that one patient out of four experienced difficult access to safe cancer care (24%), especially regarding follow-up visits, which were often postponed. Cancer patients not only were considered at higher risk for COVID-19 infection, but they also paid the price for an emergent imperative to reduce cancer care activity associated with several factors [4]. These included the need to respect imperative social distancing, the lack of beds in intensive care units, the increased workload [5], the reduction of the oncology workforce caused by the re-allocation of healthcare providers into COVID-19 units or quarantine at home, and shortages of personal protective equipment [6]. Another important factor to consider is that cancer patients were afraid to go to the hospital even when they needed and sometimes decided to cancel their appointments. Stay-at-home campaigns may have reinforced people’s awareness about the importance of self-isolation as an effective preventive measure for reducing virus spread and the risk of infection. However, they may also have increased the perception of hospitals as places where people get infected. This could have added further uncertainty to patients whose illness anxiety has already been negatively influencing their mental well-being [7]. Moreover, participants reported the fear that their cancer disease would be regarded as of secondary importance. In light of this consideration, health professionals should help patients in prioritizing their own health needs [8]. Participants reported to take several measures to reduce their infection risk, including hand washing, use of facemasks and gloves. Since cancer patients usually feel more vulnerable than the general population and are more used to hypervigilance and protective measures, it is not surprising that they adopted preventive behaviours promptly. However, only 54% believed to be at higher risk for COVID-19 infection and 51% for complications. The scarcity of information about who was at higher risk and the reassuring attitudes of many clinicians may have contributed to this perception. Besides, participants had clear in mind the importance of maintaining a positive attitude in light of difficult circumstances. In fact, cancer patients could be considered experts in adapting to the new normal. Among spontaneous preventive behaviours, about one-third of participants reported taking supplements as remedies to reduce the likelihood of being infected. These included vitamins C and D, which were not specifically recommended by health professionals due to the lack of evidence from clinical trials still ongoing [9]. On the one hand, this is not surprising as patients feel that they should be doing something on their own and are thereby continuously searching for supplements able to protect their body’s cells and tissues from oxidative damage and dysfunction while supporting healthy immune function. On the other hand, self-care strategies such as a well-balanced diet, regular exercise, and good relationships seem underestimated for their potential to support the immune response, without interfering with the actual cancer treatment. In conclusion, we would like to stress again what expressed by Trapani et al. [1]: “Understanding and implementing the scopes and goals of the global responses and enforcing community flexibility, and not merely advocating for a patient-centred approach. The resilience, capacities, skills and resources of the context must be recognized, and these must be built on to deliver protection and solutions while supporting the community's own goal. The ultimate goal now is to end COVID-19 as one global community”. To success in COVID-19 and cancer, the understanding of the unanswered health needs of cancer patients is pivotal, and it is needed a multi-professional call to action to build a sound strategy in every context. Conflicts of Interest and Source of Funding The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.