Adapting to the contemporary normal in cancer management and workflow during COVID-19 situation in the Philippines: Multi-cancer center collaborative approach

Abstract

•Cancer management adapting to the current state of health during COVID-19 pandemic.•Collaborative strategic action plan for cancer management and workflow in a developing country.•Algorithm in cancer center management during COVID-19 in a developing country.•Measures to be adopted in cancer management and workflow after COVID-19 pandemic. In response to the disruptive effect of coronavirus disease 2019 (COVID-19) in cancer management in the Philippines, four cancer centers created a collaborative strategic action plan in cancer management and workflow. This was aligned with the position set by the Philippine Radiation Oncology Society (PROS) [[1]Philippine Radiation Oncology Society (PROS) COVID-19 General Recommendations. Official communication. Accessed March 16, 2020.Google Scholar], and Philippine Medical Society of Oncology (PSMO) [[2]Philippine Society of Medical Oncology (PSMO) Guide on cancer care in the time of Covid-19 Pandemic. Official communication. Accessed March 19, 2020.Google Scholar]. It consists of four phases: screening, evaluation, treatment/management and disposition. Each phase includes an algorithm and core domains namely patients, personnel, doctors and infrastructure/facility. Each domain and algorithm contain strategic steps on sustaining supplies of personal protective equipment (PPE), triage creation, health and well-being of personnel, teleconsultation, treatment and safety of patients, structural changes and COVID-19 testing. Phase I shows the triage for presence or absence of COVID-19 based on exposure and symptoms. Phase II shows patient with COVID-19 exposure/symptom will be classified as no covid, suspect, probable and confirm [[3]Department of Health (DOH) Philippines decision tool for coronavirus disease 2019 (COVID-19) assessment. Feb 26, 2020 https://www.doh.gov.ph Accessed March 28, 2020.Google Scholar], while those without exposure/symptoms will proceed to the required treatment modality and be classified as new, ongoing and follow up. Phase III shows the treatment management process for those with confirmed COVID-19, and those who will proceed with chemotherapy or radiation therapy. Phase IV includes the disposition plan after intervention for confirmed COVID-19, and resumption of regular schedule for chemotherapy or radiation therapy for those without COVID-19 (Fig. 1). Everyone will be screened at the triage area and will fill up a COVID-19 screening information record (Fig. 2) based on the department of health (DOH) decision tool [[3]Department of Health (DOH) Philippines decision tool for coronavirus disease 2019 (COVID-19) assessment. Feb 26, 2020 https://www.doh.gov.ph Accessed March 28, 2020.Google Scholar]. Patient with respiratory symptoms, with history of close contact to COVID-19 positive patients, and with travel history to areas with high incidence of COVID-19 were not allowed to enter the cancer center. Evaluation will be done by the infectious control officer at the emergency room [[4]Department of Health (DOH) Philippines office of secretary department memorandum no.2020-0138. Adoption of PSMID Clinical Practice Guidelines on COVID-19. Mar 31, 3020 https://www.doh.gov.ph Accessed March 28, 2020.Google Scholar]. Only staff on duty, patients, and one relative were allowed inside the cancer center premises, and a physical distance of at least 1 meter apart is observed [[5]Cortiula F, Pettke A, Bartoleti M, Puglisi F, Helleday T. Managing COVID-19 in the oncology clinic and avoiding the distraction effect, Ann Oncol 2020;30:1-3 Article in Press.Google Scholar]. No mask, no entry policy was implemented. Patients were instructed to bring their own alcohol or hand sanitizers, and blanket during treatment. Sanitation of treatment couch, and bed was done after every patient using proven sanitizers [[6]Department of Health (DOH) office of secretary, department memorandum no. 2020-0157, Guidelines on cleaning and disinfectant in various settings as an infection prevention and control measure against COVID-19. Apr 10, 2020. https://www.doh.gov.ph Accessed March 28, 2020.Google Scholar]. Patient prioritization protocol for planning, and start of radiation therapy was based on the following case category [7Johnson K. ‘Brutal’ plan to restrict palliative radiation during pandemic. Medscape. Apr 6, 2020.Google Scholar, 8Burki TK. Cancer guidelines during the COVID-19 pandemic. Lancet Oncol 2020. Online: https://doi.org/10.106/S1470-2045(20)30217-5. Accessed March 28, 2020.Google Scholar, 9Simcock R. Thomas T.V. Estes C. et al.Global radiation oncology’s targeted response for pandemic preparedness.Clin Transl Radiat Oncol. 2020; 22: 55-68Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar, 10NICE guideline. COVID-19 rapid guideline: delivery of radiation therapy. March 28, 2020 https://www.nice.org.uk/guidance/ng162 .Accessed Mar 30, 2020.Google Scholar]:1.Urgent – superior vena cava syndrome, cord compression, pain, bleeding, life threatening symptoms, brain metastases, and patients coming from remote places were scheduled on the same day or the day after consultation.2.Semi urgent – colorectal, concurrent protocol, head and neck, cervical, and lung were scheduled two to seven days after consultation.3.Not urgent – breast, prostate, endometrial, post-operative, skin, and asymptomatic brain were scheduled eight to ten days after consultation. Patient prioritization for chemotherapy was based on tiered approach of the European Society of Medical Oncology categorized as high, medium and low priority [[11]ESMO recommendations. Cancer patient management during COVID-19 pandemic. Mar 24, 2020. https://www.esmo.org/guidelines/cancer-patient-management-during-covid-19-pandemic. Accessed March 28, 2020.Google Scholar]. Walk-in and new patients were scheduled during the clinic hours of the attending oncologist. Physical check-up of patient was limited, and teleconsultation was encourage using the platform https://doxy.me [12DOH office of secretary memorandum circular no. 2020-0016. Guidelines on use of telecommunication Apr 7, 2020 https://www.doh.gov.ph Accessed March 28, 2020.Google Scholar, 13Welch Brandon M. Doxy.me 2013. https://doxy.me.Google Scholar]. Patients classified as suspected/probable/confirmed COVID-19 will follow the infectious control committee protocol based on DOH-Philippine Society of Molecular and Infectious Diseases guidelines [[4]Department of Health (DOH) Philippines office of secretary department memorandum no.2020-0138. Adoption of PSMID Clinical Practice Guidelines on COVID-19. Mar 31, 3020 https://www.doh.gov.ph Accessed March 28, 2020.Google Scholar]. Oncologist and referring physician will consider the risk for both patient and staff and decide the need to pursue chemotherapy or radiation therapy [5Cortiula F, Pettke A, Bartoleti M, Puglisi F, Helleday T. Managing COVID-19 in the oncology clinic and avoiding the distraction effect, Ann Oncol 2020;30:1-3 Article in Press.Google Scholar, 8Burki TK. Cancer guidelines during the COVID-19 pandemic. Lancet Oncol 2020. Online: https://doi.org/10.106/S1470-2045(20)30217-5. Accessed March 28, 2020.Google Scholar, 14Liang W. Guan W. Chen R. et al.Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.Lancet Oncol. 2020; 21: 335-337Abstract Full Text Full Text PDF PubMed Scopus (2809) Google Scholar]. IgM and IgG Rapid Diagnostic Test (RDT) was used as an initial test for COVID-19 because real time reverse transcription-polymerase chain reaction test (rRT-PCR) which is the gold standard for confirmation of COVID-19 is not readily available and accessible. Patient with negative RDT results but with significant symptoms must be re-tested using rRT-PCR [[4]Department of Health (DOH) Philippines office of secretary department memorandum no.2020-0138. Adoption of PSMID Clinical Practice Guidelines on COVID-19. Mar 31, 3020 https://www.doh.gov.ph Accessed March 28, 2020.Google Scholar]. A dedicated nurse on full PPE will handle confirmed infected patients for chemotherapy in an isolation room with a separate entrance and exit. No relatives nor visitors will be allowed. In case radiation therapy maybe life-saving, COVID-19 patients will be the last one to be treated and/or on a separate machine if available. Otherwise, priority in delaying or stopping radiation therapy is considered. Clinical staff, cashier, and coordinators reports on a skeletal force while administrative, marketing, human resources, and finance will work from home as part of the modified working shifts. Limited supplies of PPE were outsourced and the rest comes from donations. Ultraviolet light was used to sanitize PPE and washing was done so they can be re-use. The prescribed suit specifications were:1.Administrative personnel wear surgical mask.2.Cashier and secretaries wear surgical mask and goggles/face shields.3.Radiation therapist, and nurses wear surgical mask/N95, gloves, goggles/face shield, hair cap, isolation gown/coverall, and shoe cover/booties. Separate PPE are use during CT planning and brachytherapy.4.Oncologist wear surgical mask/N95, isolation gown and goggles/face shield. Depression anxiety & stress scale tool was used for mental health evaluation [[15]Lovibond SH, Lovibond PF. Manual for the depression anxiety & stress scales 1995 (2nd Ed.) Sydney: Psychology Foundation.Google Scholar]. Free meals, shuttle service, increased in hazard pay and weekly online meeting were provided to boost the morale of all personnel. Modified treatment protocol for chemotherapy follows the PSMO recommendations [2Philippine Society of Medical Oncology (PSMO) Guide on cancer care in the time of Covid-19 Pandemic. Official communication. Accessed March 19, 2020.Google Scholar, 16COVID-19 Clinical Oncology Frequently Asked Questions (FAQs) March 12, 2020. https://www.asco.org/asco-coronavirus-information. Accessed March 19, 2020.Google Scholar], and radiation therapy follows the PROS recommendations including hypofractionation regimen for certain cases [[1]Philippine Radiation Oncology Society (PROS) COVID-19 General Recommendations. Official communication. Accessed March 16, 2020.Google Scholar]. Chemotherapy and brachytherapy were transformed into sterile area. Transparent acrylic or plastic shield for the triage, reception, cashier and nursing area were constructed for protection between personnel and patient. This collaborative cancer management strategic action plan and workflow attempts to answer the uncertainties of this pandemic despite faced with meager resources. It may guide cancer centers from developing countries on how to adapt during these current adversities. We recommend adopting the following in the contemporary normal period:1.Establish a triage with a screening tool for emerging and re-emerging infectious diseases.2.Mandatory COVID-19 testing for all personnel and patients.3.Structural changes to provide adequate spaces, natural ventilations, dedicated entrance and exits, and dressing room for staff.4.Acquisition of a second radiation therapy machine to accommodate patients that requires isolation.5.Wearing of protective suits as part of the standard of care.6.Digital advancements like remote planning and delivery of plan solutions, electronic patient information and teleconsultations.7.Create an infectious response team who will be trained in handling affected cancer patients. All authors declare no conflict of interest