COVID-19 risk contagion: Organization and procedures in a South Italy geriatric oncology ward.

Dear Editor:

The novel coronavirus disease Sars-Cov-2 (COVID-19) has rapidly spread through the world, since the first cases were registered in the Hubei province of China in December 2019. Its disparate clinical conditions can lead to a severe bilateral interstitial pneumonia, and thus demand intensive care beds, overwhelming the healthcare system in every Nation. The World Health Organization declared the pandemic on March 11, 2020, when the disease spread globally, with Italy being the first nation severely affected in the Western world. Over the first trimester of 2020, the number of new cases affected drastically increased to 3.507.424, with 247.497 deaths [1]. In the first half of March the Italian Government, declared the state of emergency and imposed a national lockdown in order to help the health system to deal with the COVID-19 unprecedented diffusion. Several papers presented the great challenge that oncologists are facing during the COVID-19 pandemic advising about an over 3-fold risk of contagion in the oncologic patients [2]. El-Shakankery et al. reported the experience of the seven comprehensive cancer centers of Cancer Core Europe, a cooperation legal entity that act to maximize coherence and critical mass in oncology [2]. The authors postulated that the vulnerability due to cancer treatments, the unknown effects of delays of tumor resection surgeries or chemotherapy, and the risk related to the current limited availability of intensive care units' beds could severely expose these patients to complications. The authors further highlighted the importance of patients distancing, of delaying non-urgent outpatient visits, and of rationalizing of the oncological surgeries based on urgency of cancer cure. Furthermore, they stressed the importance of deescalating cancer regimens or to integrate them with immunostimulant factors, in order to make hospital operations “pandemic proof [2]”.

During this unprecedented pandemic outbreak, we would put a spotlight on the group of patients that probably are the frailest and often neglected—older patients with cancer. This topic is still lacking in literature despite the great social and healthcare interest. Older patients with cancer, in fact, presented an exponential contagion risk related to the immunodeficiency state belonging from the cytotoxic chemotherapy and the weakness deriving from to the multiple and potentially life-threatening comorbidities. Considering the large and rapid diffusion of the Sars-Cov-2 in Italy, the first western country severely affected and shaken by the virus breakout with the highest worldwide lethality rate (13.2%), in our division of Geriatric Oncology, we adopted all possible procedures capable of preventing the contagion among our frail patients. Accepting and executing all the dictates of Italian Government and of Ministry of Health, we recommended the use of disposable personal protective equipment for health workers and patients, we promoted the social distancing in waiting rooms and wards, we prohibited visitors to accompany patients, and health workers were alerted to minimize the time spent staying in the hospital rooms. Special attention was paid in reduction the hospital attendance, through the delay of non-urgent counselling, the adoption of a preadmission telephone triage, and the implementation of telemedicine [3].

Beyond all these general precautions, in a geriatric setting, we believe it is of utmost importance to stratify patient risk with the Comprehensive Geriatric Assessment (CGA), a multidimensional scale evaluating cognitive, functional, nutritional and welfare aspects of older subjects [4]. Among its items, the frailty analysis is crucial and useful to classify patients in fit, unfit and frail. Frail patients, even in non-pandemic state, are excluded from any chemotherapic treatment and are referred to palliative care. Fit subjects are offered standard of care cancer treatments. Certainly, dealing with a COVID-19 emergency, to minimize hospital admission, is important to consider a possible treatment delay according to the tumor biology and staging, to convert intravenous treatment to an oral regimen where possible, to adopt less toxic chemotherapy to limit complications requiring re-hospitalization. Unfit patients deserve a reflection. The evaluation of prognostic factors of toxicity related to chemotherapy is determinant in this patient subset. In our routine practice, we utilize the Cancer Aging Research Group (CARG) toxicity score, but considering the importance of risk stratification during this unprecedented emergency we shifted to the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH), a score that was better able to grade toxicity risk and provide data on the different measures within CGA [5]. The patients at high risk for toxicity were considered frail and all treatment was recommended to be avoided or delayed. Patients at medium and low risk were recommended to undergo a lower dose of cancer drugs when appropriate, prolonged treatment intervals and home supportive care to prevent hematological toxicity. Therefore, a complex tailored risk benefit analysis is advocated to choose the best treatment. It is noteworthy, that even different chemotherapic drugs contribute to or cause pneumonitis and diagnosis and managing COVID-19 infection in older patients with cancer is extremely challenging and requires a multidisciplinary approach [6].

During COVID-19 pandemic, the infection fear might leave many patients without care. The identification of subsets of patients that could benefit from lifesaving cancer treatment is mandatory, especially for older patients with cancer. Further observational studies hopefully will address this issue.

Source of Funding

None.

Authors' Contributions

All authors contributed significantly to the present research and reviewed the entire manuscript.

CG: Participated substantially in conception, design and execution of the study; also participated substantially in the drafting and editing of the manuscript.

RP: Participated substantially in conception, design and execution of the paper.

GP: Participated substantially in conception, design and execution of the paper.

AG: Participated substantially in conception, design and execution of the study; also participated substantially in the drafting and editing of the manuscript.

Declaration of Competing Interest

None.