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Journal Pre-Proof: Journal of Geriatric Oncology
Journal Pre-Proof: Journal of Geriatric Oncology
PII: S1879-4068(20)30237-X
DOI: https://doi.org/10.1016/j.jgo.2020.05.008
Reference: JGO 956
Please cite this article as: C. Gambardella, R. Pagliuca, G. Pomilla, et al., COVID-19 risk
contagion: Organization and procedures in a South Italy geriatric oncology ward, Journal
of Geriatric Oncology (2019), https://doi.org/10.1016/j.jgo.2020.05.008
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COVID-19 risk contagion: Organization and procedures in a South Italy geriatric oncology
ward.
Claudio Gambardella1 , MD, Raffaele Pagliuca1 , MD, Giuseppe Pomilla1 , MD, Antonio
Gambardella2 , MD.
1
Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi
Vanvitelli", Naples, Italy
2
Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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Corresponding Author:
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Claudio Gambardella, MD
Dear Editor:
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The novel coronavirus disease Sars-Cov-2 (COVID-19) has rapidly spread through the world, since
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the first cases were registered in the Hubei province of China in December 2019. Its disparate
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clinical conditions can lead to a severe bilateral interstitial pneumonia, and thus demand intensive
care beds, overwhelming the healthcare system in every Nation. The World Health Organization
declared the pandemic on March 11, 2020, when the disease spread globally, with Italy being the
first nation severely affected in the Western world. Over the first trimester of 2020, the number of
new cases affected drastically increased to 3.507.424, with 247.497 deaths. [1] In the first half of
March the Italian Government, declared the state of emergency and imposed a national lockdown in
order to help the health system to deal with the COVID-19 unprecedented diffusion. Several papers
presented the great challenge that oncologists are facing during the COVID-19 pandemic advising
about an over 3-fold risk of contagion in the oncologic patients. [2] El-Shakankery et al reported the
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experience of the seven comprehensive cancer centers of Cancer Core Europe, a cooperation legal
entity that act to maximize coherence and critical mass in oncology. [2] The authors postulated that
the vulnerability due to cancer treatments, the unknown effects of delays of tumor resection
surgeries or chemotherapy, and the risk related to the current limited availability of intensive care
units’ beds could severely expose these patients to complications. The authors further highlighted
the importance of patients distancing, of delaying non-urgent outpatient visits, and of rationalizing
of the oncological surgeries based on urgency of cancer cure. Furthermore, they stressed the
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order to make hospital operations “pandemic proof”. [2]
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During this unprecedented pandemic outbreak, we would put a spotlight on the group of patients
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that probably are the frailest and often neglected—older patients with cancer. This topic is still
lacking in literature despite the great social and healthcare interest. Older patients with cancer, in
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fact, presented an exponential contagion risk related to the immunodeficiency state belonging from
the cytotoxic chemotherapy and the weakness deriving from to the multiple and potentially life-
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threatening comorbidities. Considering the large and rapid diffusion of the Sars-Cov-2 in Italy, the
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first western country severely affected and shaken by the virus breakout with the highest worldwide
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lethality rate (13.2%), in our division of Geriatric Oncology, we adopted all possible procedures
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capable of preventing the contagion among our frail patients. Accepting and executing all the
dictates of Italian Government and of Ministry of Health, we recommended the use of disposable
personal protective equipment for health workers and patients, we promoted the social distancing in
waiting rooms and wards, we prohibited visitors to accompany patients, and health workers were
alerted to minimize the time spent staying in the hospital rooms. Special attention was paid in
reduction the hospital attendance, through the delay of non-urgent counselling, the adoption of a
Beyond all these general precautions, in a geriatric setting, we believe it is of utmost importance to
stratify patient risk with the Comprehensive Geriatric Assessment (CGA), a multidimensional scale
evaluating cognitive, functional, nutritional and welfare aspects of older subjects [4]. Among its
items, the frailty analysis is crucial and useful to classify patients in fit, unfit and frail. Frail
patients, even in non-pandemic state, are excluded from any chemotherapic treatment and are
referred to palliative care. Fit subjects are offered standard of care cancer treatments. Certainly,
possible treatment delay according to the tumor biology and staging, to convert intravenous
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treatment to an oral regimen where possible, to adopt less toxic chemotherapy to limit
considering the importance of risk stratification during this unprecedented emergency we shifted to
the Chemotherapy Risk Assessment Scale for High‑Age Patients (CRASH), a score that was better
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able to grade toxicity risk and provide data on the different measures within CGA [5]. The patients
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at high risk for toxicity were considered frail and all treatment was recommended to be avoided or
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delayed. Patients at medium and low risk were recommended to undergo a lower dose of cancer
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drugs when appropriate, prolonged treatment intervals and home supportive care to prevent
hematological toxicity. Therefore, a complex tailored risk benefit analysis is advocated to choose
the best treatment. It is noteworthy, that even different chemotherapic drugs contribute to or cause
pneumonitis and diagnosis and managing COVID-19 infection in older patients with cancer is
During COVID-19 pandemic, the infection fear might leave many patients without care. The
identification of subsets of patients that could benefit from lifesaving cancer treatment is
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mandatory, especially for older patients with cancer. Further observational studies hopefully will
Keywords: COVID-19; pandemic; severe acute respiratory syndrome corona virus 2; geriatric
oncology.
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Declarations
Acknowledgment: N/A
Authors' contributions
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All authors contributed significantly to the present research and reviewed the entire manuscript.
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CG: Participated substantially in conception, design and execution of the study; also participated
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AG: Participated substantially in conception, design and execution of the study; also participated
References
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time. Lancet Infect Dis 2019. published online Feb 19. https://doi.org/10.1016/S1473-
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triage before surgical ward admission and telemedicine during COVID-19 outbreak in Italy.
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Effective and easy procedures to reduce in-hospital positivity. Int J Surg, 2020. In press. doi:
10.1016/j.ijsu.2020.04.060.
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Conroy S. What is Comprehensive Geriatric Assessment (CGA)? An umbrella review. Age
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5. Ortland I, Mendel Ott M, Kowar M, Sippel C, Jaehde U, Jacobs AH, Ko YD. Comparing the
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performance of the CARG and the CRASH score for predicting toxicity in older patients
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10.1016/j.jgo.2019.12.016.
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6. Abdel-Rahman, O. & Fouad, M. Risk of pneumonitis in cancer patients treated with immune
checkpoint inhibitors: a meta-analysis. Ther Adv Respir Dis 10, 183–193 (2016).