COVID-19 rapid guideline: delivery of systemic anticancer treatments

The purpose of this guideline is to maximise the safety of patients with cancer and make the best use of NHS resources during the COVID-19 pandemic, while protecting staff from infection. It will also enable services to match the capacity for cancer treatment to patient needs if services become limited because of the COVID-19 pandemic.

# Communicating with patients and minimising risk

# All patients
Communicate with patients and support their mental wellbeing, signposting to charities and support groups where available, to help alleviate any anxiety and fear they may have about COVID19. # Patients with symptoms of COVID19 at presentation
Be aware that patients having systemic anticancer treatments are immunocompromised and may have atypical presentations of COVID19. Also, symptoms of COVID19, neutropenic sepsis and pneumonitis may be difficult to differentiate at initial presentation. 
If patients have fever (with or without respiratory symptoms), suspect neutropenic sepsis because this can be rapid and life-threatening, and follow the NICE guideline on neutropenic sepsis, which recommends:
referring patients with suspected neutropenic sepsis immediately for assessment in secondary or tertiary care
treating suspected neutropenic sepsis as an acute medical emergency and offering empiric antibiotic therapy immediately. # Systemic anticancer treatments

# Shared decision making with individual patients
Do not routinely delay starting systemic anticancer treatment (SACT), or pause SACT that is already underway, because of the risk of contracting COVID-19. 
Discuss the risks and benefits of SACT with people with cancer and their family members and carers, taking into account current dominant COVID-19 variants and COVID-19 prevalence. Topics to cover include:
that most people who have SACT do not go on to have worse outcomes from COVID-19 infection, should they develop it
that the risks of deferring SACT are likely to be greater than the risks of increased COVID-19 severity
that people with myeloma or other types of haematological cancer who have immunomodulatory SACT may have worse outcomes from COVID-19
factors that may affect their risk of becoming severely ill with COVID-19, including vaccination status, underlying conditions, increasing age, male sex, ethnicity and cancer symptoms
how to reduce the risk of catching COVID-19 while having SACT
local access to current treatment options for COVID-19Reach a shared decision with the person about their treatment. Follow relevant national guidance on communication, providing information (including in different formats and languages) and shared decision making, for example, NICE's guideline on shared decision making. 
For people with myeloma or other types of haematological cancer, discuss treatment strategies with a specialist team (such as, haematology and/or subspecialised myeloma teams) before giving immunomodulatory SACT. 
If a person who is going to have (or has started) SACT has tested positive for COVID-19:
if possible, delay the start of SACT (or pause the treatment if already underway) until any significant COVID-19 symptoms have resolved
if delayed or paused, reach a shared decision with the person about when to start or resume SACT (discussions should include the factors described in recommendation 3.2, and take into account any local guidance on testing for SARS-CoV-2)
ensure the risk to other patients and healthcare staff is minimised when the person attends hospital for SACT, in line with local policies. # Modifications to usual service

# Treatment breaks
NHS England are developing a revised treatment break policy. These recommendations will be updated when this is published.
It is proposed that the current treatment break policy, which applies to both Cancer Drugs Fund (CDF) and non-CDF treatments, will not be applied during the COVID19 outbreak. 
Where a treatment break is needed, clinicians should complete the approval form to restart treatment, indicating that the patient had a break because of COVID19. The request will be approved even if their disease has progressed, providing the clinician indicates there is a reasonable chance that disease control can be regained on restarting treatment. It is expected that the response to treatment will be reviewed 2 or 3 cycles after restarting. If disease control has not been regained treatment should be stopped. # Recommendations for research
We have made the following recommendations for research.

# Risk of systemic anticancer treatment in people with cancer and COVID-19
Are patients with cancer and COVID-19 who are receiving/have recently received systemic anticancer treatment (SACT) (that is, within the 4 weeks preceding a diagnosis of COVID-19) at increased risk of severe COVID-19 illness or death? 
It is recommended that this research should also consider:
if there are specific types of SACT carrying increased risk of poor outcomes from COVID-19
if there are specific types of cancer for which SACT may carry increased risk of poor outcomes from COVID-19
if there is a difference in any risk of poor outcomes from COVID-19 between people who have received SACT alone, radiotherapy alone, or both SACT and radiotherapy
if there is a difference in any risk of poor outcomes from COVID-19 between children and young people who have received SACT and adults who have received SACT.

# Duration of risk of systemic anticancer treatment in people with cancer and COVID-19
Are people who have had SACT recently (that is, within the 4 weeks preceding a diagnosis of COVID-19) at increased risk of poor outcomes from COVID-19 compared with those who had SACT less recently?