Introduction

COVID-19 outbreak is a major health problem caused by a novel infectious disease (SARS-CoV-2 coronavirus) that appeared in December 2019 in the city of Wuhan in China.

Today, more than 12 million of COVID-19 cases have been confirmed worldwide, including more than 500,000 deaths. In Morocco, the first case of COVID-19 was identified on March 2, 2020, with a progressive increase to reach 15,443 cases on July 11. Cancer patients, mainly those who have received surgery or chemotherapy, are more likely to develop COVID-19 infection and to develop severe forms of the disease. It is important to note that frail, elderly, or patients with chronic diseases such as heart disease, diabetes, and chronic respiratory syndromes are at higher risk (× 3.5 to 5 times) of developing severe forms of the infection [1]. During the COVID-19 pandemic, national and international societies recommend continuing the management of cancer patients despite the spread of the virus in the world. They established guidelines to adapt patient care and to limit the risk of contamination by the virus while preserving their chances of recovery [2,3,4,5,6,7] (http://smc.ma/recommandation-cancer-et-covid-19-smc/). For example, Table 1 summarizes special recommendations implemented for patients diagnosed with breast cancer during the COVID-19 pandemic [4]. In the present paper we summarize our recommendations for patients with cancer during the post-COVID-19 phase.

Table 1 Recommendations for breast cancer management during the COVID-19 outbreak
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Post-COVID-19 Era

The post-COVID-19 era requires the implementation of new recommendations for the management of cancer patients that may be applicable until the end of 2020—beginning of 2021. In short term, it is necessary to adapt medical care to the regional health environment, according to availability of medical and non-medical staff and equipment resources, which implies that the recommendations made should be adapted to the particularity of each region and each establishment [8].

During the post-COVID-19 phase, all patients should be considered as COVID-19 positive until proven otherwise. Thus, a national strategy for screening of COVID-19 infection should be considered before admission of patients in cancer centers, to protect cancer patients and medical staff from COVID-19 disease [6, 8].

In addition, caution should be undertaking, as the epidemiological situation today will not be the same in the upcoming weeks.

General Recommendations

It is recommended to follow the same measures established by the WHO during COVID-19 era to protect cancer patients from COVID-19 infection (https://www.who.int/emergencies/diseases/novel-coronavirus-2019):

  • Washing hands frequently with an alcohol-based disinfectant or with soap and water.

  • Maintaining a social distance of at least 1 m between patient and anyone who coughs or sneezes.

  • Avoid touching the eyes, nose, and mouth.

  • Compulsory wearing a mask.

  • In case of fever, cough, and breathing difficulties, consulting a doctor early.

  • Stay informed and follow the advice given by professionals, Ministry of Health and local authorities, as they can provide reliable information on the spread of COVID-19 in the region.

On the other hand, it is recommended to respect the general post-COVID-19 measures established by the WHO (https://www.who.int/emergencies/diseases/novel-coronavirus-2019):

  • Compliance with barrier measures.

  • Testing, isolating each suspected case, then referring them to COVID-19 positive dedicated units.

  • Implementing preventive measures to protect patients and caregivers.

  • Educating caregivers and patients about the new standard measures.

Prevention of risks of contamination by suspect cases in cancer centers should be based on a systematic evaluation of clinical symptoms suggestive of COVID-19 disease, temperature taking at the entrance of the establishment, on a PCR test, and possibly coupled with a chest CT scan and serologies, depending on availability, in addition to biological workup to evaluate eosinopenia, lymphopenia, and increased of inflammation parameters [8].

Educating patients about the new context, the risk-benefit balance, the existence of a prioritization system for cancer care is an essential prerequisite (following the priorities proposed in Table 2).

Table 2 Recommendations for multidisciplinary management of cancer patients by priority during the post-COVID-19 phase
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The decision on the priorities for surgery should be undertaking in a multidisciplinary team (MDT) meeting in accordance with recommendations established by national and international societies [3, 4, 7, 8]. The possibility of adapting the treatment sequence will depend on the disease stage and the acceptable time to defer surgery. Postponing surgery should only be considered in the case of difficulties to access to operating rooms in case of occupancy of the structure by COVID-19 patients.

General recommendations to limit contamination of patients in cancer centers while maintaining the chances of appropriate care [3,4,5, 7,8,9] are as follows:

  • Prioritize teleconsultations as much as possible.

  • Limit accompanying persons.

  • Limit unnecessary hospitalizations.

  • Postpone treatment of non-invasive cancers and localized low-grade cancers for 6–12 weeks.

  • Favor chemotherapy protocols administered every 3 weeks.

  • Systematic use of granulocyte colony-stimulating factors (GCSF) to prevent severe neutropenia in case of risk greater than 10%.

  • Prioritize oral therapies (hormone therapy and oral chemotherapy) as much as possible.

  • Favor hypo-fractionated radiotherapy protocols, in particular for breast, prostate, and rectum cancers.

Teleconsultation has become a new opportunity for triage of patients into those who should be physically examined, and those who should benefit from additional workup before their admission physically to limit their exposure to the hospital environment and therefore to reduce their risk of contamination. The main limitation of teleconsultation during follow-up is the impossibility of examining patients, but as long as the epidemic situation is not controlled, teleconsultation remains preferable [3,4,5, 7,8,9].

Therapeutic management should be discussed in an MDT meeting. The use of videoconferences is to be preferred whenever possible. If not possible, it is recommended to limit the number of participants and the duration of the MDT meetings.

Modalities for Reconsidering Priority of Cancer Care During the Post-COVID-19 Era

It is recommended to establish new schedules in order to avoid overloads of appointments (chemotherapy/radiotherapy) that may be deferred at the level of each unit. Prioritize patients in need of urgent care. Two separate situations should be considered, depending on COVID-19 status: COVID-19 negative and COVID-19 positive.

Management of COVID-19-Negative Patients

Management of COVID-19-negative patients should be discussed according to the priority of care (Table 2).

Definition of Priorities [9]

Clinical Setting of High Priority (H)

Patients with high priority have a disease which immediately threatens the vital prognosis, a clinically unstable or completely intolerable situation for which even a short delay would considerably modify the patient’s prognosis.

Assuming effective treatment, these patients have priority, even if resources are limited, requiring urgent treatment to save their lives or control the progression of their illnesses or relieve their symptoms.

Clinical Setting of Medium Priority (M)

Patients who do not have an immediately life-threatening disease but for whom treatment or management procedures should not be delayed more than 1–3 months without any impact on their outcomes.

Clinical Setting of Low Priority (L)

Patients for whom treatment or management procedures can be postponed for more than 3 months.

Examples of Certain Recommendations According to Priority (Table 2)

Urgent Treatments Which Cannot Be Postponed

Chemotherapy

Curative chemotherapy: germ cell tumors; neoadjuvant or adjuvant chemotherapy for high-risk breast cancer (HER2+ or triple-negative breast cancer); symptomatic metastatic cancers: breast cancer with visceral crisis; small cell lung carcinoma; advanced ovarian cancer, etc.

Radiotherapy

Radiotherapy for emergencies: spinal cord compression, symptomatic brain metastases, bleedings, etc.; radiotherapy for locally advanced lung cancer; radiotherapy for locally advanced cervical cancer; locally advanced head and neck cancers; breast cancer at high risk of relapse….

Treatments Which May Be Postponed for 1–3 Months

Chemotherapy

Adjuvant chemotherapy in case of intermediate-risk disease: luminal B breast cancer; colon cancer with stage T3N0 or T3N1; adjuvant chemotherapy for operable lung cancer.

Radiotherapy

Adjuvant radiotherapy for intermediate-risk breast cancer: adjuvant radiotherapy for operable endometrial cancer.

Management of COVID-19-Positive Patients

A dedicated circuit should be implemented for COVID-19-positive patients whose management cannot be postponed. Otherwise, management should be postponed for 4 weeks in the case of non-serious forms. In severe forms of COVID-19 disease that required a long stay in intensive care units, the management should be discussed on a case-by-case basis in a multidisciplinary team meeting after the resolution of the COVID-19 infection [1].

Conclusions

During the post-COVID-19 era, new recommendations for the management of cancer patients have been implemented in Morocco as well as in Western countries.

Medical care should ensure optimal treatment while minimizing the risk of COVID-19 transmission.

It is recommended to follow the protective measures established by the WHO to protect cancer patients from COVID-19 infection.

A national strategy for screening program of COVID-19 infection should be implemented before admission of patients in cancer centers, to protect cancer patients and medical staff.

Optimal treatment should be discussed in a multidisciplinary team meeting, and any decision made should be discussed and shared with the patient.

Management of COVID-19-negative patients should be made according to the priority of care defined by the gravity of the cancer disease.

A dedicated circuit should be implemented for COVID-19-positive patients whose management cannot be postponed.

Further clinical studies are needed to guide cancer patient care during the post-COVID-19 era.