Managing patients with cancer during the COVID-19 pandemic: frontline experience from Wuhan.

December, 2019, witnessed a massive outbreak of coronavirus disease 2019 (COVID-19) triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan, Hubei, China, which has now turned into a global public health crisis. Fighting the pandemic of COVID-19 has become the main challenge for all clinicians.

The Wuhan Union Hospital is in the eye of the storm, treating patients within three designated medical settings, including a cancer centre. Between January and March, 2020, we have treated more than 5200 hospitalised patients with COVID-19 and cared for more than 20 000 with fever at our outpatient clinics. Moreover, we have attended to more than 80 000 patients on our internet platform and operated two makeshift hospitals (so-called Fangcang hospitals), making Wuhan Union Hospital the hospital that admitted and treated the highest number of patients with COVID-19 in Wuhan. As oncologists, we are also involved in the battle to contain the relentless spread of the epidemic. From Jan 15 to Feb 25, 2020, 1186 patients with cancer (including 165 haematological malignancies) were admitted to the Cancer Center of Wuhan Union Hospital. Unlike many other patients, the immunity of patients with cancer is often compromised and they heavily depend on the availability of medical resources, which renders them extremely vulnerable to the impact of the epidemic and overwhelmed medical resources mean their lives are on the line. Therefore, we were faced with the great challenge of how to protect our patients with cancer from infection while continuing routine patient care.

Zhong Nanshan (Guangzhou Medical University, Guangzhou, Guangdong), head of the National Health Commission's team investigating the novel coronavirus outbreak, pointed out that SARS-CoV-2 carried the risk of human-to-human transmission on Jan 20, 2020. Since then, our cancer centre began to screen patients and health-care workers infected with SARS-CoV-2 in the hospital by means of nucleic acid and antibody tests in combination with CT scans. 24 patients with cancer (infection rate of 2%) and 13 of 766 health-care workers (infection rate of 1·7%) were found to have been infected with SARS-CoV-2. These rates were, respectively, 5-times and 4·3-times the rate in the population in Wuhan. We began to realise the gravity of the situation. To prevent cross-infection in the centre, we rapidly set up an isolation area. In 48 h, an isolation ward area equipped with 850 beds was established, with an increased prevention level compared with the rest of the hospital. Because of insufficient stockpile and rapid use of medical supplies, medical resources were severely depleted. At one point, protective equipment supplies could only meet the need for 2 days. Moreover, with increasing numbers of medical workers being diagnosed with COVID-19 and quarantined, the capacity for normal patient care services was conspicuously reduced. We discharged mild and convalescent patients whenever possible, who were followed up with telemedicine and telecare. The first 15 days after Wuhan lockdown, starting from Jan 23, was the toughest time we experienced, during which seven patients with blood cancer and two patients with solid tumours died of COVID-19. After our cancer centre was mandatorily designated a hospital on Feb 15, and thus only admitted patients with COVID-19, a large amount of medical supplies began to arrive and reinforcement medical teams from all parts of China joined us. Since then, no deaths or nosocomial infections occurred. Looking back, we gained a lot of experience and learned some lessons.

For the management of hospitalised patients with cancer, the top priority is the control of nosocomial infection. At the early stage of the outbreak, because of a lack of awareness on personal protection, limited knowledge about the new virus, and an inadequate supply of nucleic acid tests, the number of infected patients increased substantially and some medical staff were infected. During the middle of January, some hospitalised patients began to develop fever and diarrhoea, but were not definitively diagnosed with COVID-19 because of a shortage of tests. They interacted with other patients without COVID-19, causing cross-infection. Therefore, we escalated the preventive measures, including early stage testing of patients, caregivers, and medical staff (using nucleic acid tests, antibody tests, and CT scans); isolation of confirmed patients in a single room without visits; wearing of surgical masks by patients and caregivers; mandatory hand sanitisation; and separate disposal of patient waste. Hospital workers are at high risk of developing COVID-19 from nosocomial infection during an outbreak, as in the epidemics of SARS and Middle East Respiratory Syndrome. During a pandemic of an infectious disease, medical workers should be well informed about its status to achieve their own early detection, prompt isolation, and expeditious treatment. Medical workers should take adequate measures to effectively protect themselves from infection. When some of our medical workers were infected and isolated, we suffered from a serious shortage of medical staff. To ensure the normal operation of oncology departments, the hospital authorities redeployed and temporarily relocated 50 doctors and nurses from other not-in-service departments to oncology departments. It is worth mentioning that medical workers in the reinforcement medical teams consisted of specialists in serious infections and management of respiratory tract diseases, and they had important roles in the management of severe and critical patients in the Cancer Center of Wuhan Union Hospital.

To treat the growing number of patients with suspected COVID-19 infection, confirmed cases were admitted as early as possible and non-confirmed cases were redirected to other hospitals. We set up a free-of-charge online fever clinic on Feb 1, and received 12 000 visits per day at the peak, including visits by many patients with cancer. For offline services, we opened a separate area of the hospital as a fever clinic, expanded it, and placed 46 beds in the observation area. Because patients with cancer are physically debilitated and tend to have compromised immune systems, they have to be carefully evaluated before admission. Stable patients (ie, those without progression or deterioration in tumour burden or severe complications after treatment) generally should not be hospitalised; patients scheduled for elective operations should, whenever possible, be admitted after the pandemic. Patients with chronic tumours can consult their doctor via internet or telephone, with medicines mailed to the patients. Routine screening and nucleic acid tests can be put off until the pandemic is over. We operated a 24 h emergency department for patients who needed emergency care or are in a serious condition. We also opened a green passage (ie, a quick and efficient service) for pregnant women and patients with cancer who have to be treated immediately. Apart from these measures, when not enough beds are available, patients with suspected or mild-symptom disease can be referred to Fangcang hospitals, but should be under close watch. If their conditions deteriorate, they can be sent to designated hospitals. For instance, nine patients admitted after Feb 15 were transferred to our hospital from Fangcang hospitals and received excellent treatment.

Patients with cancer are a special group of patients because treatment of their primary disease cannot be discontinued However, to decrease the risk of infection with SARS-CoV-2, postoperative chemotherapy could be postponed. With patients on radiotherapy, concurrent chemotherapy could be withheld for some time, including preradiotherapy preparation (such as pretreatment imaging for tumour localisation and treatment planning). For patients on chemotherapy, especially elderly, debilitated patients, the chemotherapy protocol should be adjusted, the dose reduced, or both. The fatality rate was six (46·2%) of 13 patients with blood cancer and two (10·0%) of 20 patients with solid tumours in our centre. Patients with blood cancer were more predisposed to SARS-CoV-2 infection than were patients with solid tumours (in hospitalised patients, the rate of SARS-CoV-2 infection was ten [6·1%] of 165 patients with blood tumours and 14 [1·4%] of 1021 patients with solid tumours). The higher fatality rate in patients with blood cancer might be ascribed to aggressive chemotherapeutic protocols, agranulocytosis, and impaired immunity. Given the risk of infection and shortage of blood products, these patients should avoid intense chemotherapy or haematopoietic stem cell transplantation. Among the 33 patients with cancer with COVID-19 (figure 1 ), eight treated by targeted therapies (kinase inhibitors and proteasome inhibitors) and two receiving immune checkpoint inhibitors had more favourable outcomes than those treated with chemotherapy. With patients who are at home or visiting online clinics, chemotherapy-free alternatives involving oral or targeted drugs—which do not require in-hospital administration—should be given whenever possible. One patient tried to die by suicide after he became infected with SARS-CoV-2 following stem cell transplantation. Although his blood virus tests turned negative after an initial positive result, the long isolation and the pain due to graft-versus-host disease psychologically affected the patient. Therefore, psychological intervention is extremely important for patients with COVID-19 who have experienced other issues, physically and mentally, apart from their primary disease.

Figure 1

Categorisation of patients with cancer with COVID-19 and treatments they received

ALL=acute lymphoblastic leukaemia. AML=acute myeloid leukaemia. CLL=chronic lymphocytic leukaemia. HSCT=haematopoietic stem cell transplantation. ICIs=immune checkpoint inhibitors.

It is worth mentioning that telemedicine has an important role in the diagnosis and treatment of patients with cancer in home care. Our online clinic services cover video consultations, text-picture counselling, and medicine delivery, among others. This approach substantially reduced people congregating in hospital. Patients with newly diagnosed cancer or those on anti-tumour therapy should use internet or telephone services as the first choice to contact their doctors, refraining from going directly to hospital, to avoid infection. Doctors should comprehensively evaluate the condition of patients to give the most effective or optimal treatments. Patients and their family members should be made aware that cooperating with their doctor and being compliant with the treatment prescribed will lead to the best outcomes. During this epidemic, we attended more than 80 000 patients online, including 2688 patients with cancer. By comparing the numbers of the patients who sought medical help online, we found that each of 24 oncologists who provided these services, on average, attended 19 patients online and 97 clinic visitors during the first 2 weeks before Jan 20. Conversely, during the 2 weeks after Jan 20, the number of online patients rose to 42 whereas the number of clinic visitors dropped to 36 (figure 2 ). We believe, in the future, telemedicine will be an important practicing mode for oncologists or other clinicians during pandemics.

Figure 2

Average number of online and clinic visitors per week per oncologist

Between January and March, 2020, we witnessed the infection and deaths of a large number of people because of lack of protection, shortage of beds, and inadequate isolation. We should learn from our mistakes and stay alert. A well established public health system is essential for continuity of care during a massive epidemic. To prevent the epidemic from returning, we should be well informed about COVID-19, do early screening, protect our medical workers, properly equip our hospitals for both routine service and future crises and expand our services to internet platforms. As oncologists, we hope that society extends its compassion towards patients with cancer during the COVID-19 pandemic.