Oncology and haematology patients are frequently immunosuppressed due to their conditions and the associated treatments and are therefore currently considered to have increased risk of morbidity and mortality with COVID-19.
Modification to usual services is necessary and policy decisions about any modifications to usual care and management must occur at an organisation level. All treatment decisions should be made on a case-by-case basis with input from both patients and the multidisciplinary team (MDT).
This guidance is intended to assist with, rather than replace, clinical decision-making for individual patients and should be used alongside existing recommendations from:
Given the rapidly changing situation, this guidance remains under constant review. Importantly, there can be no ‘one size fits all’ approach and deviation from standard protocols should be carefully discussed with individual patients, with a clear risk: benefit analysis documented in the case.
During the COVID-19 pandemic, it is very likely that clinical care will need to be prioritised, risk assessed, deferred and reduced due to capacity issues across the system.
General measures for consideration:
For care of patients with known or suspected COVID-19 positive infections, follow specific guidance from the
Clinical Excellence Committee (CEC) including CEC guidance for Hospital Community and Home visits.
All staff should adhere to local and facility policies and State/Territory legislation and guidelines.
In all circumstances:
No staff are to undertake or be expected to undertake tasks requiring PPE if the PPE is not available for use.
Personal protective equipment (PPE) shortages are currently posing a challenge across NSW during the COVID-19 pandemic. It is anticipated that facilities who deliver systemic anticancer treatments (hazardous drugs) across NSW may, at times, have difficulty accessing the required PPE, especially gowns and seek alternate ways to provide patient care and/or optimise current supply.
For optimisation strategies and recommendations see
eviQ Education: COVID-19 and Personal Protective Equipment.
Online PPE training is mandatory for all NSW Health clinical and support staff who work in and around patient areas. Training is available through
My Health Learning.
PPE for the safe handling and waste management of hazardous drugs, should not deviate from
current practice, which is based on current evidence and best practice.
In alignment with the
guidance developed by the Head and Neck Cancer group, all patients with known or suspected COVID-19 positive infections or have acute respiratory symptoms should wear a surgical mask.
Radiation therapists who need to position head and neck cancer patients should wear PPE in accordance with local infection control department and State/Territory guidelines.
The American Society for Radiation Oncology (ASTRO) support the use of
Droplet and contact precautions.
Droplet and contact precautions (including eye protection) are essential for any patient with positive or suspected COVID-19. Follow specific guidance from the
Clinical Excellence Committee (CEC).
Consider whether SACT can be given in alternative and less immunosuppressive regimens, different locations or via other modes of administration to minimise patient exposure and maximise resources.
Provision of radiation therapy should be guided by the principles addressed by:
Resources also available on
Pre-screening for COVID-19 symptoms and exposure history prior to planned in-person clinic visits is required. Pre-treatment testing for COVID-19 is not required for asymptomatic patients.
The decision to use DIBH techniques during the COVID-19 pandemic should be at a local level, due to the potential risk of droplet or direct oral-device contamination and to minimise the number of devices requiring decontamination. An alternative approach is to use DIBH techniques with voluntary breath hold, which will help avoid cardiac dose without the need for additional equipment and the therapist infection risks. The necessity for DIBH should be considered during the simulation process.
For radiation staff involved the use of DIBH techniques for patients who are NOT suspected of having COVID-19, usual infection prevention and control precautions, should be observed, according to clinical circumstances. i.e. use of a N95 respirator or additional COVID-19 specific precautions are not required.
Preferably, all equipment used should be either single-use or single-patient-use disposable and disposed of as clinical waste.
Palliative care will play a critical role during the COVID-19 pandemic. It is important that there is early referral and collaboration with specialist palliative care services (including community services) and clear lines of responsibility for treatment decisions are established. The
NSW Palliative Care Community of Practice is coordinating development of guidance. All clinicians will need to contribute to provision of palliative care.
Cancer surgery is considered category 1 and should continue to be performed however, depending on the NSW Heath alert status, general surgical capacity may be constrained by access to operating theatres, anaesthetic support, and availability of intensive care beds. Non-urgent Category 2 and Category 3 surgery should continue taking into account local workforce and PPE availability. Depending on the stage of the alert level and local resources decisions may be made to fast-track cancer surgery or defer with neoadjuvant therapies if alternatives exist. For local disease management problems consider alternatives such as stereotactic radiation if surgery or interventional radiology procedures are unavailable. Referral to alternate facilities for care should be considered in critical circumstances providing appropriate measures to minimise the risk of virus transmission are in place.
Cancer and blood and marrow community of practice.
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.