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Introduction

This document has been developed to provide guidance on the implementation and management of COVID-19 surveillance testing in outpatient cancer services. It is not intended to replace policy, processes, or guidelines in place at individual services but may inform existing guidelines.

The Clinical Excellence Commission (CEC) Recommendations for COVID Surveillance Testing in NSW HealthCare Facilities Version 1.4 recommends that patients attending chemotherapy/radiotherapy appointments undergo surveillance COVID-19 rapid antigen testing (RAT) during periods when the system is at Red (as per the NSW COVID-19 Risk Monitoring Dashboard).

Definitions

COVID-19 testing is used to detect SARS-CoV-2, or an immune response to SARS-CoV-2. For the purposes of this document types of tests are defined as:

Type of Test Definition / description
Rapid Antigen Test (RAT)A rapid antigen test is used to detect the presence of viral protein from SARS-CoV-2 and provide a result within 15-30 mins. Testing should be performed in accordance with the manufacturer's instructions.
Self-administered RATA self-administered RAT is conducted unsupervised. An individual collects the sample, performs the test, and interprets the results at home without the involvement of a health practitioner.
Point of Care (POC) RATA POC RAT is performed at a health service by a health practitioner, or trained person under their supervision. This method is to ensure an adequate sample is collected, with correct interpretation of results.
Polymerase chain reaction (PCR)Polymerase chain reaction (PCR) are a nucleic acid test that require laboratory technicians to process results. They are generally considered better at detecting the presence of the SARS-CoV-2 virus than rapid antigen tests.

Equipment

Cancer services should follow local procurement guidelines for orders for Rapid Antigen Test kits. HealthShare are working to provide further communications and guidance on procurement or RATs. Information will be updated when available

Patients attending outpatient cancer services

Outpatient cancer services will provide patients with a self-administered RAT kit including instructions prior to their scheduled appointment.

Self-administered rapid antigen test (RAT)

Patients will be advised to perform a self-administered RAT on the day of their appointment (where possible) and provide confirmation of thee test result to the clinic in advance of the appointment. If a patient requires a carer to accompany them to the appointment, the carer should also perform a RAT and provide a negative result prior to attending the service.

Test results

Negative result

If a patient receives a negative result, the patient can then proceed with the scheduled appointment.

Positive result

If a patient receives a positive result, the patient is required to notify the cancer service by telephone. The cancer service will determine the next steps as per local procedures and provide the patient with guidance on PCR testing, isolation, and continuation of care.

The cancer service will advise the patient to register the positive RAT result on the Service NSW website in line with the NSW Health Guidelines. Registering positive test results via the Service NSW website or app is mandatory.

Invalid

If a patient receives an invalid result, the patient is required to notify the cancer service by telephone. The patient may then be asked to repeat the test or perform a PCR test prior to the appointment.

The cancer service will provide further advice to patient in line with local procedures.

Patients unable to perform a self-administered RAT(including those without RAT kits)

Some patients may be unable to perform a self-administered RAT. In this instance the cancer service will:

  • allow a carer or support person to assist the patient in performing a RAT or;
  • request that the patient attends the cancer service and completes a Point of Care (POC) RAT at the facility

The availability to undertake a POC RAT will depend on local staffing, policy, and infrastructure.

If Point of Care (POC) Rapid Antigen test (RAT) is required:

Each cancer service will determine how POC RATs will be administered at their facility in line with local procedures.

General considerations

Cancer services to ensure:

  • protocols to manage the safety of both the person performing the test and the person being tested should be in place, including access to a dedicated clinic room if required
  • staff performing tests should be adequately trained in how to perform the test and interpretation of test results
  • staff performing the tests should wear appropriate Personal Protective Equipment (PPE) (e.g gloves, P2/N95 mask, gown, eye protection)
  • any accidents or incidents are reported to the supervisor and followed up according to local workplace requirements.

POC test results

Negative result

If a patient receives a negative POC RAT result, the patient can then proceed to the scheduled appointment.

Positive result

If a patient receives a positive POC RAT result, the cancer service will:

  • advise the patient that their POC RAT is positive
  • transfer the patient to a safe location in line with safety/protocols for infection control
  • provide advice to the patient on continuation of care and/or isolation requirements
  • record the positive POC RAT in accordance with local processes.

A repeat COVID test by PCR may be required at the request of the facility to confirm the result.

Symptomatic patients with negative test results

Self-administered RAT

Patients that are symptomatic but have returned a negative self-administered RAT should contact the cancer service directly by telephone. The cancer service will provide advice in line with local procedures.

Patients may be asked to perform another RAT in 24 hours or have a PCR test before continuation of care.

POC RAT

Patients who are symptomatic but returned a negative POC RAT may be asked to have a rapid PCR test performed onsite with local Infectious Diseases/Respiratory team approval.

Patient population

Guidelines recommend to routinely test all cancer patients prior to systemic therapy, radiation therapy and haematopoietic cell therapy as infected patients may be asymptomatic, mildly symptomatic, or may not report symptoms from fear of being denied treatment.

In situations where resources are limited, it may be appropriate to only test those asymptomatic patients undergoing treatment with highly immunosuppressive therapies or those having anti-CD20 monoclonal antibodies for haematologic malignancies, which are associated with B-cell depletion. Noting that these conditions/treatments are also associated with a suboptimal response to COVID-19 vaccination.

Treatment options for positive SARS-CoV-2 infection

After initial evaluation, risk stratification and patient counselling, outpatient management is appropriate for majority of positive patients who are having treatment with immunosuppressive therapies.

For those patients who are not deemed critical or require immediate services or treatment, and who are at highest risk of progression to severe disease, hospital admission or death; evidence1,2 suggests that neutralising monoclonal antibodies (nMABs) or oral antivirals significantly improve clinical outcomes in non-hospitalised patients. Both classes are to be commenced as soon as possible following COVID-19 diagnosis and within 5 days of symptom onset.

Eligibility criteria

Patients are eligible if:

  • SARS-CoV-2 infection is confirmed with a positive diagnostic test within the last 5 days AND
  • Onset of symptoms of COVID-19 within the last 5 days

Note: A positive RAT is sufficient to establish indication for the use of nMABs or oral antivirals. The positive RAT should be confirmed via PCR/rapid PCR prior to treatment. However, treatment should not be withheld if there is a delay in receiving the PCR result.

Monoclonal antibodies:

  • Sitrovimab as a single 500 mg intravenous (IV) infusion. Sitrovimab is the preferred monoclonal antibody in areas where Omicron is the prevalent circulating variant.
  • Casirivimab and imdevimab, as a single 600-600 mg IV infusion, can be given subcutaneously if IV is not feasible or would delay treatment. Preliminary testing suggests that it is unlikely to be active against the Omicron variant.

Where an nMAB is contraindicated or the administration of an nMAB is not possible, patients may be treated with a five-day course of oral antiviral therapy if the onset of symptoms is in the last 5 days. Treatment must not be extended beyond 5 days and patients advised to complete the whole course of treatment even if their symptoms improve and/or they feel better.

Antiviral therapy

  • Molnupiravir at a dose of 800mg (four 200mg capsules) taken orally every 12 hours for 5 days.
  • Nirmatrelvir/ritonavir. Dose is 300 mg nirmatrelvir (two 150 mg tablets) with one 100 mg ritonavir tablet taken together orally twice daily for 5 days.

For detailed information see:

Frequency of testing

For patients attending appointments intermittently as day only visits testing will only be required on the day of attendance.

Patients attending for multi-day anti-cancer therapy, including those protocols with continuous infusions e.g. flurouracil pump or daily radiation therapy, should self-test, if able, test at a minimum of every 72 hours. However, local protocol specific recommendations should be followed.

Logging Positive result in Patient record / EMR

eHealth has been working with Oncologist and infectious disease experts to build a system to record and make COVID positive results visible across districts.

Clinicians will be asked to record their patient's positive RAT result in the Cerner EMR. This process will trigger relevant alerts and send result to the Patient Flow Portal.

Recording positive RATs is not available in the Oncology Information System.

Culturally and Linguistically Diverse Communities

In language written instructions for taking RATs are now available in 15 priority languages, these include:

Visit: What type of rapid antigen tests should I use?

Translation services for Positive CALD patients

Anyone who receives a positive rapid antigen test is now required to register with Service NSW.
Registering via the Service NSW website or app is mandatory.

If Culturally and Linguistically Diverse Communities patients require support registering their result a free telephone interpreter services is available.

Patients can call the Translating and Interpreting Services on 131 450, state the language they require in English and ask the interpreter to connect them to Service NSW on 13 77 88

Monitoring for symptoms and getting tested

Managing COVID-19 safely at home

View videos in:

Other important support and information

  • NSW Health has partnered with Sonder to provide a personal wellbeing service with 24/7 multilingual chat and phone access to a range of mental health, medical and wellbeing support services
  • Free translation and interpreter 24-hour helpline TIS National 131 450
  • NSW Health Isolation Support Line on 1800 943 553
  • NSW Health COVID-19 Care at Home Support Line on 1800 960 933
  • National COVID-19 Vaccine Helpline 1800 020 080
  • Service NSW 13 77 88

References

  1. Bernal AJ, Gomes da Silva MM, Musungaie DB, et al. Molnupiravir for Oral Treatment of Covid-19 in Non-hopitalised Patients [published online ahead of print, 2021 Dec 16]. N Engl J Med. 2021;
  2. Gupta A, Gonzalez-Rojas Y, Juarez E, et al. Early Treatment for Covid-19 with SARSCoV-2 Neutralizing Antibody Sotrovimab [published online ahead of print, 2021 Oct 27]. N Engl J Med. 4

Useful information

Document information

Developed by

Cancer and blood and marrow transplant Community of Practice

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning

For use by

Outpatient cancer services


Current as at: Monday 18 July 2022
Contact page owner: Health Protection NSW