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Treating Gastrointestinal Cancer During the Coronavirus Disease 2019 Pandemic in Europe

  • Maike Collienne
    Affiliations
    Department of Oncology and Hematology, Asklepios Klinik Altona, Asklepios Tumorzentrum Hamburg, Hamburg, Germany
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  • Dirk Arnold
    Correspondence
    Address for correspondence: Dirk Arnold, MD, PhD, Department of Oncology and Hematology, Asklepios Klinik Altona, Asklepios Tumorzentrum Hamburg, Paul-Ehrlich-Strae 1, Hamburg 22763, Germany
    Affiliations
    Department of Oncology and Hematology, Asklepios Klinik Altona, Asklepios Tumorzentrum Hamburg, Hamburg, Germany
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      Keywords

      In Europe, the first cases of coronavirus disease 2019 (COVID-19) were reported in several countries (eg, Italy, Germany, Spain, France, United Kingdom) in January 2020. By the end of March 2020, COVID-19 had spread to every European country, and the World Health Organization had declared COVID-19 a pandemic. As of June 3, 2020, a total of 1,981,431 infections and 176,269 deaths from COVID-19 had been registered in Europe.
      European Centre for Disease Prevention and Control
      COVID-19 situation update worldwide, as of 3 June 2020.
      Since the start of the pandemic, treating cancer has been challenging. To protect patients and to provide the best care possible, the normal routines had to be changed. Many consultations normally conducted in person were postponed or performed remotely, patient treatment plans were reevaluated, and clinical trials continued, albeit under difficult conditions.
      Because well-defined plans for a pandemic were lacking in many hospitals and health care systems all around Europe, different strategies against COVID-19 were implemented. The specific strategies depended on the spread and intensity of the virus and the pre-existing health care systems.
      In Italy, the first European country with a huge number of cases, the government reorganized the health care system to establish a separation between COVID-19 and COVID-19–free hospitals. In Northern Italy (ie, the Lombardy region), cancer care was coordinated using a “hub-and-spoke” method, with cancer centers defined as the “hubs” and general hospitals as the “spokes.” Thus, patients could undergo their investigations and, in part, receive their systemic treatment near to their residence instead of commuting to a more centralized cancer center, reducing the need for travel. The results of testing and further recommendations were discussed remotely. Furthermore, systemic therapies were switched from intravenous to oral administration, and the treatment cycles were lengthened or postponed, as deemed appropriate.
      • Brandes A.A.
      • Ardizzoni A.
      • Artioli F.
      • et al.
      Fighting cancer in coronavirus disease era: organization of work in medical oncology departments in Emilia Romagna region of Italy.
      • Curigliano G.
      How to guarantee the best of care to patients with cancer during the COVID-19 Epidemic: the Italian experience.
      • Fratino L.
      • Procopio G.
      • Di Maio M.
      • et al.
      Coronavirus: older persons with cancer in Italy in the COVID-19 pandemic.
      In addition to protecting our patients with cancer, the health care staff also had to be shielded from COVID-19. The availability of diagnostic swabs for health care workers was very limited at the beginning. Furthermore, asymptomatic patients, who placed the staff at risk (however unwittingly), had also been detected in the designated COVID-19–free hospitals. In a survey of 12 medical oncology departments in the Emilia Romagna region, 6.9% of the staff members had been infected with COVID-19.
      • Brandes A.A.
      • Ardizzoni A.
      • Artioli F.
      • et al.
      Fighting cancer in coronavirus disease era: organization of work in medical oncology departments in Emilia Romagna region of Italy.
      However, most of the oncologists were able to continue working in their department.
      • Indini A.
      • Aschele C.
      • Cavanna L.
      • et al.
      Reorganisation of medical oncology departments during the novel coronavirus disease-19 pandemic: a nationwide Italian survey.
      In the United Kingdom, the National Healthcare System (NHS) established cancer centers as hubs (similar to the Italian design) that were declared COVID-19–free hospitals in London, Manchester, and Leeds.
      • Hiom S.
      How coronavirus is impacting cancer services in the UK.
      Furthermore, the NHS and private hospitals worked in collaboration to achieve the best cancer care possible. However, screening services were, just as in many other countries in Europe, placed on hold in Wales, Scotland, and Northern Ireland. Cancer Research UK estimated that ∼200,000 screenings weekly had not been performed. Thus, more than ∼10,000 cancer diagnosis per month were missed across the United Kingdom.
      • Hiom S.
      How coronavirus is impacting cancer services in the UK.
      In addition, risk assessments for cancer cases were collected centrally and reported to help general practitioners in differentiating between low- and high-risk situations. Moreover, to directly support patients, the NHS contacted those patients assessed as high risk to offer assistance in medical care and daily life.
      In Spain, different health care systems exist in parallel; these were already well connected before the pandemic.
      • Ong M.
      COVID-19 lesson from Spain: like the U.S., we failed to take this seriously before it came to us—we have to learn.
      As a consequence, sharing information between cancer centers, general hospitals, and primary physicians was rather simple. Hence, oncologists were able to guide their patients well informed through this crisis and had always the opportunity to react to changes quickly. Just as in many other countries, elective surgery was reduced or stopped owing to the lack of intensive care unit capacity. Under these circumstances, surgical procedures were postponed, and neoadjuvant treatments were established, if appropriate. Also, clinical trials specifically focused on COVID-19 were preferentially processed and launched to assess for possible drugs against COVID-19.
      • Ong M.
      COVID-19 lesson from Spain: like the U.S., we failed to take this seriously before it came to us—we have to learn.
      In Germany, the medical oncology departments are generally situated within general hospitals. Therefore, the greatest priority was to separate the patients with cancer from all other patients to reduce the risk of COVID-19 spreading. Hence, diagnostic swabs were established in many hospitals at an early point in the pandemic. Also, the case rate in Germany was not as high as in Italy or Spain.
      European Society for Medical Oncology
      ESMO-CoCARE Registry.
      Thus, treatment approaches, including systemic treatment, radiotherapy, and surgical procedures, were allowed to continue. In tumor board discussions, decisions on individual concepts were made with special regard to each cancer type, its standard therapy, and COVID-19. However, in general, only a few processes and standards had required adaptation.
      In conclusion, a tremendous heterogeneity of cancer care exists across Europe. In addition to nationwide recommendations for treating gastrointestinal cancer during the pandemic, the European Society of Medical Oncology has reported guidelines for different cancer types stratifying them as high, intermediate, and low risk. Moreover, detailed information about cancer and COVID-19 in Europe are expected from the international collaborative registry ESMO-CoCARE.

      Disclosure

      The authors have stated that they have no conflicts of interest.

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