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covid 19As of 25th March 2020, the total number of cases with confirmed novel coronavirus, SARS-CoV 2, causing COVID 19, is 375,498 confirmed deaths.

Given the data from the epicenter of the pandemic, China, the number of cases is likely to increase over the next 2 to 4 weeks. It has just been announced by the Cabinet Secretary for Health in Kenya, Mutahi Kagwe, that we have confirmed 25 cases in Kenya (2). There is already significant social and economic impact of the pandemic here in Kenya and the impact on health care systems is likely to increase over the coming weeks.

All published data confirm that any age group can be infected. However, more severe cases are seen in those older than 50 years, those with other medical conditions such as cardiovascular disease, hypertension, diabetes and chronic lung disease (1).

Cancer patients are a unique population given that the nature of the disease does not lend itself to delayed diagnosis or treatment which may worsen outcomes of patients. Also patients are likely to need continuous hospital care given most cancer treatments such as chemotherapy and radiotherapy are hospital based. In addition, adverse effects from treatment may require outpatient visits as well as admission to hospital, for example, neutropenic sepsis.

There is limited data as to the effect of COVID-19 on cancer patients. A report from China indicated that the case fatality rate was 7.6% as compared to the overall rate of 3.8% in those without medical conditions and 13.2% in those with cardiovascular disease (3). The second data set was for a cohort of 18 cancer patients (1% of the study population) which reported a higher incidence of severe disease in cancer patients (4). Interpretation of this data is limited by the small number of patients included.

The following guidelines may be useful for clinicians caring for cancer patients.

General guidelines

As the virus is spread primarily through droplets, the recommendations by the Ministry of Health in Kenya (5) should be adhered to strictly:

COVID-19: Ministry of Health

In addition,

  • Cancer patients should be advised to avoid unnecessary travel
  • Alert health care workers if one has a recent history of travel to an area with confirmed cases and has fever, cough and/or shortness of breath
  • All cancer patients should inform their treating physicians if they are suffering from respiratory symptoms or have a confirmed infection with COVID-19 prior to attending to hospital visits.
  • Patients should as much as possible adhere to scheduled appointments and avoid unnecessary clinic visits
  • Unnecessary admissions to hospital where possible should be avoided
  • Physicians and multi-disciplinary teams managing cancer patients are encouraged to explore alternatives to clinic visits like telephonic follow up, telemedicine, home visits
  • Multi-disciplinary teams are encouraged to increase their institutional psychological support for patients during this period

Specific guidelines for cancer patients

  1. Cancer patients who have completed treatment and are on routine follow up or oral non immunosuppressive treatments such as endocrine treatment

    Clinic visits should be delayed if feasible to avoid unnecessary travel and exposure for this category of patients. Patients should ensure they have enough medication with them to last at least 3 months. Any routine surveillance tests should be postponed if this will not impact the follow up of these patients. Cancer physicians are encouraged to discuss with their patients the need for hospital visit for routine surveillance

  2. Cancer patients requiring surgery

    Delay in cancer surgery may have a negative impact on the outcome for patients. Wherever possible, the surgery should proceed if this will not stretch the hospital resources negatively. All patients requiring surgery must be discussed at the multi-disciplinary meeting. In addition, surgeries that require admission to intensive care units need to have a broader discussion with hospital based anesthesia, critical care teams and/or infectious disease teams to ensure patient safety and minimize transmission. meeting. Enhanced recovery after surgery (ERAS) principles should be applied where feasible to minimize hospital stays.

  3. Cancer patients on oral or intravenous chemotherapy, targeted therapy or immunotherapy

    There is no current evidence to suggest that these treatments should be delayed. In some cases, delaying cancer treatment can have a negative effect on patients for example in acute myeloid leukemia, lymphoma, breast cancer amongst others. There is however the potential for immunosuppression and risk for severe disease if COVID 19 is acquired during this time.

    Safe hygiene practice should be adhered to during hospital visits.

    • Ensure the waiting area is well ventilated and observe the 1 metre distance between patients. Overcrowding should be avoided.
    • Sanitizer must be present at the entrance of the waiting area with a minimum 70% alcohol and must be used for every person entering the unit/office
    • Use of electronic money transfer for payment of services is encouraged to avoid risk of transmission with currency notes and coins
    • Chemotherapy units should observe at least 1 metrebetween patients and limit the number of people accompanying the patient to hospital
    • Clinicians are reminded to wash hands using soap and water before and after every encounter with patientsusing the 7 steps of handwashing
    • Staff are encouraged to wear scrubs whengiving chemotherapy and get them laundered daily
    • All clinic surfaces such as desktops, laptops, countertops, examination couches, chemotherapy chairs should be decontaminated regularly with a 0.5% chlorine based solution
    • As such, there is no guideline as to the need for face masks for patients during the hospital visits.
    • Patients who are already diagnosed with COVID-19 and were due for chemotherapy should have their treatments delayed.
  4. Cancer patients requiring radiotherapy

    At this time, there is no evidence to suggest withholding radiotherapy. It is suggested that treatments can be made shorter using hypo-fractionation where possible. Safe hygiene practice should be adhered to and machines cleaned appropriately (6).

  5. Work up and staging for potential new cancer patients

    Cancer diagnostics and staging should not be delayed to avoid disease progression and mental anguish for newly diagnosed patients. Where possible, hospital visits for tests should be limited.

  6. Screening for cancer (7)

    Routine screening for cancer such as mammography, pap smear, colonoscopy and alike should be postponed to a later date. This is to avoid unnecessary travel and reduce risk of exposure.

As the situation evolves, updated recommendations will be shared. All suggestions should be emailed to the This email address is being protected from spambots. You need JavaScript enabled to view it.

References

  1. WHO - Rolling updates on coronavirus disease (COVID-19)
  2. Press release CS Kagwe 24th March 2020 1600hr
  3. Page 12 Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 28th February 2020
  4. Liang W et al: Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncology, 2020-Volume 21, Issue 3, Pages 335-337
  5. Coronavirus Disease - 2019: Advice to Travellers Arriving in Kenya (Ministry of Health)
  6. COVID-19 Recommendations and Information
  7. National-Cancer-Screening-Guidelines-2018

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