The need of COVID19 free hospitals to maintain cancer care.

To the Editor

In Italy 371,000 new cases of cancer were diagnosed in 2019 and 80% of them were surgical candidates. Surgery represents the cornerstone of cancer treatment and for many patients the only chance of cure. Due to the COVID-19 pandemic which lead us to manage only emergent cases, the number of surgeries decreased in the last 30 days.

During the present health crisis our oncological patients are challenged on two fronts: the risk of Coronavirus infection and the risk of postponing cancer care.

More than ever, now it is necessary to identify safe pathways for cancer patients, in which contacts with COVID patients and with doctors involved COVID patients’ care is minimal. In Italy today, with the exception of stand-alone cancer hospitals (such as the 8 Cancer Centers of the country) hospitals and healthcare facilities are unable to undergo the reorganization needed to face this crisis in the crisis, mostly due to the fact that the Coronavirus pandemic is draining most of our human and structural resources. On the other hand, hospitals are becoming the major source of infection. At the end of March 2020 the number of healthcare workers positive to COVID-19 virus are over 6000 and more than 70 died. For these reasons, we think that it is necessary to rapidly reorganize the health care facilities based on essential and shared principles in order to be able to continue to offer specialized and high-standard cancer care to our patients during this health crisis that will unfortunately last few more months.

In order to lower the Coronavirus spreading in facilities dedicated to cancer care, it is necessary to screen patients for COVID-19 48 hours before surgery. It is important to know that asymptomatic patients are the large majority of the infected, thus basing indications only on epidemiologic criteria it is not enough. Moreover, the immunosuppression due to the surgical stress and to the cancer itself would further jeopardize the safety of COVID-19 cancer patients and in turn, inadequate management of these patients would further spread the disease to other admitted patients and to their caregivers.

Ideally, patients COVID-19 negative should proceed with the regular surgical pathway “COVID-free”, while patients who tested positive, albeit asymptomatic, should be home quarantined or sent to dedicated facilities. When the infection is resolved, after proper restaging, the patients can proceed to surgery.

On the other hand, healthcare personnel need to be safeguarded through periodic screening and adequate DPIs. Protecting the healthcare workers will result in more medical and paramedical personnel able to serve and containment of the infection.

As realized in Lombardy, several hospitals in the Nation should be identified based on their surgical oncology practice and considered as COVID-free. In large hospitals managing both COVID and non-COVID patients, a COVID-free pathway should be warranted, in order to decrease the risk of contagion and to spare the surgeons/anesthetists as well as medical oncologists and radiation oncologists (and health care personnel) that can take care of cancer patients. Healthcare workers dedicated to cancer patients need to be spared from activities that would increase their risk of contagion and need to be devoted to cancer care.

The rationalization of the resources will need to take into account the biology and the aggressiveness of the tumor, the timing from preoperative treatment, the extent of surgery, the need for further medical therapies, patients’ general conditions, and the necessity for intensive care postoperative monitoring.

The reorganization of hospitals and medical facilities has to be prompt and in line with these principles, should start nationally and adapt to the territorial reality. Moreover, based on the rapidly evolving knowledge of the Coronavirus pandemic we need to be ready to reformulate our recommendation, to adapt the hospital reorganization and the screening measures, based on the constantly developing situation.

If these criteria are not met the risk of taking care of our oncological patients is unacceptable for them and for us.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.