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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.

General principles and mitigation strategies

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:

  • Minimise face to face visits including monitoring, treatment administration and staging, with shift to telehealth and community based care where available.
  • Decisions around prioritisation of patients is to be made as part of a MDT and documented, ensuring each patient is considered on an individual basis. General approach to prioritisation:
    • Categorise patients by treatment intent and risk-benefit ratio associated with treatment.
    • Consider alternative and less resource-intensive treatment regimes.
    • Seek alternative methods to monitor and review patients receiving systemic therapies.
  • Prior to a patient attending for treatment +/- clinic visit patients should have a negative PCR or RAT test depending on the logistic circumstances of the facility. Patients should be encouraged to perform the RAT test at home. See Getting tested for COVID-19 and Rapid antigen tests for COVID-19
  • Patients who are close contacts should follow guidance about isolation and testing and be managed by the facility as though they were positive. Treatment should be delayed unless it is high priority treatment on the basis of curative intent or high treatment benefit, these discussions should occur with the treating specialist
  • Screen for symptoms of COVID-19 and triage patients for admission. If necessary admission should be direct to oncology/haematology departments rather than through emergency departments. Important to note:
    • Immunocompromised patients may have atypical presentations of COVID-19.
    • Symptoms of COVID-19, neutropenic sepsis and pneumonitis may be difficult to differentiate at initial presentation.
    • Optimal glycaemic management for patients with steroid induced hyperglycaemia and diabetes as at higher risk of complications.
    • For suspected checkpoint inhibitor-related pneumonitis prioritise COVID-19 testing for early decision regarding corticosteroid therapy.
    • Treat suspected neutropenic sepsis as an acute medical emergency, with empiric antibiotic therapy immediately.
    • Recipients of autologous and allogeneic stem cell transplantation should be screened and tested for COVID-19 prior to commencement of conditioning. See BMTSANZ COVID19 Consensus Position Statement.
    • NSW donors for allogeneic stem cell transplants and where possible overseas and interstate donors should be screened and tested for COVID-19. Testing should done in a way that ensures that the results are back prior to the recipient (patient) starting conditioning. It is recommended donors self-isolate for at least 14 days prior to donation to avoid the risk of exposure to COVID-19.
  • Clinical Trials: Modify trial practices to be COVID safe and compliant with local facility recommendations. Where possible liaise with sponsors to facilitate teletrials practices.
  • To reduce staff to staff transmission, if working from home is not possible, it is advisable to split critical clinical teams where possible to reduce the risk of 100% absence of that team. For radiation therapy split RT staffing into patient contact (treatment and CT) and non-patient contact (planning) staff.
  • Local sites should develop plans for managing under conditions of reduced staffing, including, the need for transfer to other facilities, and/or the need for movement of patients between public and private settings.

Personal Protective Equipment (PPE)

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:

  • staff are to ensure that they have completed up to date training on PPE
  • staff are to wear prescribed PPE
  • any staff member who is concerned about their safety must raise their concerns immediately with their manager.

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 administration of systemic anticancer therapy (hazardous drugs)

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.

PPE for staff working in radiation therapy

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).

Systemic anti-cancer treatments (SACT)

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.

Radiation oncology

Provision of radiation therapy should be guided by the principles addressed by:

Resources also available on eviQ.

Deep inspiration breath hold (DIBH)

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

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

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.

Document information

Developed by

Cancer and blood and marrow community of practice.


Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

For use by

Current as at: Friday 28 January 2022
Contact page owner: Health Protection NSW