Cancer care in the time of COVID-19.

As of March 18, 2020, the number of confirmed cases of coronavirus disease 2019 (COVID-19) had reached 191 127, with 7807 deaths. Europe is now the epicentre of the pandemic. France, Italy, and Spain have imposed lockdowns and as The Lancet Oncology went to press, there were rumours that London might take similar action. The EU has introduced stringent border controls and schools have been closed across the continent. It is unclear how long the emergency measures will remain in place.

Health-care institutions worldwide are taking precautions. The Seattle Cancer Care Alliance (WA, USA), for example, has postponed non-urgent appointments and is screening patients on entry. Patients with fever or suspicious respiratory symptoms are provided with masks. Exactly how susceptible cancer patients are to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has yet to be established. But patients with compromised immune systems are thought to be particularly vulnerable. Individuals who are undergoing active treatment with chemotherapy or radiotherapy are deemed to be at heightened risk of severe illness from COVID-19, as are those with cancers of the blood or bone marrow.

“As far as we are aware, the policy in the UK remains to treat patients with cancer in the same way as under normal circumstances”, Alan Boyd (Academy of Medical Royal Colleges, London, UK) told The Lancet Oncology. England, Scotland, and Wales have cancelled elective surgeries, but that is unlikely to affect most cancer patients.

“The coronavirus outbreak is a rapidly evolving situation, and it is placing unprecedented strain on health-care systems”, stated Emlyn Samuel, head of policy at Cancer Research UK. “Trusts are making decisions around clinical trials on a case-by-case basis, following Government advice. For many this may mean pausing the set-up of new trials and recruitment to existing trials, but there are still some trials running”. The UK Medicines and Healthcare products Regulatory Agency has issued guidance on managing trials during the pandemic. It suggested delivering the medication under investigation to patients' homes to avoid unnecessary trips to the clinic.

Boyd points out that there are no indications that the pandemic is causing drug shortages. “We are confident that Government is putting plans in place to secure the supply chain of cancer medicines and medical devices, and is assessing how the global impact of the virus could affect the NHS”, added Samuel. Still, maintaining supply chains in the midst of an international public health emergency is no small task. DKMS is a collection of charities working in seven countries around the world to recruit donors for people in need of blood stem-cell transplants. It has registered almost 10 million donors worldwide, and provides around 40% of stem-cell donations used by patients in the UK.

“We are having all manner of difficulties in terms of gaining access to countries, and arranging the couriering of the stem cells”, explains Jonathan Pearce, CEO of DKMS UK. “Travel restrictions are a particular problem; in some cases, we have managed to get exemptions for couriers, including between Europe and the USA, but that is not happening everywhere.” Matters are further complicated by time constraints. Stem cells have to be transplanted within 72 h of their being donated. “We are in a situation where there is the potential for an operation to be derailed because of delays”, said Pearce.

DKMS is exploring the possibility of having the stem cells transported in cargo flights. In the UK, it has established a collection and drop-off hub near Heathrow airport, from where onward travel to hospitals in the UK can be arranged. “We are doing what we can, but it is not straightforward”, said Pearce.

Moreover, the outbreak itself complicates efforts to obtain donations. The process first requires donors to attend hospital for preparation and blood tests. The donation can take a couple of days. “Donors are understandably concerned about travelling, and especially spending so long in a hospital”, notes Pearce. “And if the UK goes into lockdown, will we be able to have exemptions for stem-cell donors?”

If potential donors are infected with SARS-CoV-2, they will not be able to make a donation until they have fully recovered. DKMS is trying to ensure patients have back-up donors, in case the intended donor is ruled out. “It is surmountable but complicated, and it is taking up a lot of time”, said Pearce. The disruption looks set to continue. Public Health England is reportedly preparing for the COVID-19 pandemic to stretch into spring 2021.