COVID-19 RAPID ANTIGEN TESTING: A SCREENING TOOL AND EXPOSURE-PREVENTION STRATEGY

AMONG CANCER PATIENTS UNDERGOING OUTPATIENT TREATMENT INFUSIONS IN A SECONDARY

LEVEL HOSPITAL IN ANTIQUE, PHILIPPINES
Rigel Ann Trance MD1, Mary Antonette Ong MD2

Department of Family and Community Medicine, Antique Medical Center 1

Department of Internal Medicine, Antique Medical Center 2

Corresponding Author: Rigel Ann Trance MD, Antique Medical Center, San Jose, Antique, Philippines
(+63 956 5924075 rigeltrance@gmail.com)

ABSTRACT

Background: The COVID-19 pandemic has caused a massive restructuring of the global healthcare
settings. Despite being immunocompromised, cancer patients need frequent clinic visits for
treatment. Ambulatory oncology units must strategize on providing clinical care while preventing
infection transmission. Reverse transcription polymerase chain reaction (RT-PCR), which is expert-
requiring, has a long turnout time, is expensive and not readily accessible in rural areas. Rapid
Antigen Test is relatively cheaper, readily available and has a short turnout time leading to timely
diagnosis of COVID-19 reducing exposure and infection transmission, thus preventing interrupted
chemotherapeutic regimen.

Method: Retrospective data of 30 cancer patients receiving treatment infusion at a Secondary

Hospital Oncology Unit from April- September 2021 were retrieved and evaluated. COVID-19
symptom-based screening and COVID-19 RAT were performed 24 hours prior treatment schedule.
RT-PCR Test was done to confirm positive-RAT results. Demographic profiles, cancer type,
vaccination status and treatment delay days were used for stratification.

Result: Three (10%) cancer patients tested positive for COVID-19 RATs prior to scheduled treatment
were women, had breast cancer, and unvaccinated. The RT-PCR Test confirmed the diagnosis. Two
out of three Covid-positive patients had mild symptoms while one was asymptomatic. All were
home-quarantined and monitored by the local health unit. Median duration of treatment day delay
is 47 days. One patient successfully resumed chemotherapy while others have pending schedules
citing COVID-19 re-exposure and post-COVID 19 infection anxiety. The study result allows re-
assessment of approaches to cancer care and management while mitigating the chain of infection
utilizing RAT.

Conclusion: COVID -19 Rapid Antigen Test has a promising potential as a point-of-care screening tool
and exposure-prevention strategy in the context of immunocompromised-patient management in
ambulatory settings where preventive measures are vital to reduce morbidity and mortality. RAT
Implementation guidelines and policies for Oncology Unit must be deliberated.
INTRODUCTION

Since its outbreak last December 2019, Severe Acute Respiratory Syndrome CoronaVirus – 2
(SARS –COV2) or COVID-19 continues its threat starting from Wuhan, China as a local outbreak to
becoming a pandemic. As of writing, the Philippines has recorded over 2.4 million cases of COVID-19
cases and is continuously rising, with an average 19,649 new infections each day. The country was
identified to have a high level of community transmission of 127/100,000 Filipino in a 7-day period
(CDCP, 2021; WHO, 2021)39,15. The country continues to struggle in dealing and coping with the
increase in cases, from six months into the pandemic (Ting et al, 2020) 5 up until the present.

In the Philippines, Cancer is one of the four epidemic non-communicable diseases (NCDs) or lifestyle-
related diseases (LRDs) as reported by the Department of Health. Cancer patients undergoing
chemotherapy belong to a highly vulnerable population due to their weakened immune system (Liu,
et al,2020)43,38 and because of their frequent visits to the hospital for continued treatment 19,12. They
are at high risk to develop infections (Indini et al, 2020) 42 and severe to critical events once they get
infected with COVID-19 Infection13, 15. According to Tian et al (2021)57, there is increasing evidence
demonstrating that cancer patients may have more likelihood of contracting coronavirus disease
2019 (COVID-19) although it is still lacking in terms of consistency. Furthermore, chemotherapeutic
and targeted agents can cause a number of adverse reactions including fever due to neutropenia,
diarrhea, fatigue, altered taste buds, other respiratory syndromes and pulmonary injuries presenting
with COVID-19 signs and symptoms (Corso et al, 2021)1. Thus, a symptom-based screening for
COVID-19 would be unreliable in differentiating patients who are actually infected from those who
are experiencing post-chemotherapy side effects.

According to Alhalabi et al (2020)19, managing COVID-19 as well as its complications should be

prioritized over management of cancer. In this regard, an early diagnosis of SARS-CoV-2 infection has
a vital role in minimizing spread of disease, it is therefore contended that there is a need for an
efficient strategy in detecting COVID-19 among cancer patients in addition to the standard
procedure of obtaining the clinical history in screening cancer patients prior to receiving their
treatment 21,42,43. Point of care screening is thus essential in not only providing rapid results but also
crucial especially in identifying asymptomatic COVID-19 patients halting its transmission.

The majority of rapid antigen tests have been developed and validated for the identification of SARS-
CoV-2 in patients with COVID-19 symptoms in hospital settings2,4,7,8,20,. Screening using Real time-
Polymerase Chain Reaction Assay (RT-PCR) for SARS-COV2 is the gold standard and can be used prior
to initiation of the first cycle of the treatment (CDC, 2021; WHO, 2021) 15,39 . However, for those
receiving a sequential therapy, the oncologist has the prerogative whether to repeat the RT-PCR test
or observe a 14-day COVID-19 symptom-based screening test 3,13. Rapid antigen tests (RAT), on the
other hand, are a useful choice for mass testing and identifying possibly infectious individuals
quickly, especially in decentralized settings or in situations where molecular testing is not possible or
accessible 11,15,39. Despite their lower sensitivity, they can detect current illnesses during the most
contagious stage and are faster and easier to use (Mak et al., 2020) 41. Pekosz et al. (2021)40 claims
that rapid antigen tests have higher detection limits and sensitivity than PCR tests when virus
quantities are larger. The Philippine Society of Medical Oncology has published its updated
recommendations on the management of cancer patients in the country in October 2020 suggesting
that cancer patients receiving chemotherapy should be screened prior to initiation or sequential
treatment factoring in the available tests in the locality, patient’s resources and clinical history and
treatment priority (Ting et al, 2020) 5. Types of patients vary across several scenarios that need to be
managed in the context of cancer therapy include those presentation with active COVID-19
infection, as symptomatic or asymptomatic carriers, history of COVID-19, exposed to COVID-19, or
unexposed to COVID-19 (Alhalabi et al, 2020)21.

Standard screening procedures such as the Rapid Antigen Testing this for early detection and
diagnosis of COVID-19 have not been implemented yet in many hospitals despite the Philippine
Society of Medical Oncology (PSMO) guidelines suggesting that for symptomatic cancer patients
undergoing immunosuppressive treatment, RAT maybe done as an alternative to RT-PCR testing
provided that testing should be done during the first week of illness (Ting et al, 2020) 5. However, the
latter may lead to increased socio-economic burden as well as potential for treatment delay which
will impair treatment adherence and potential for cancer progression. For asymptomatic patients, a
14 day self- quarantine may be observed 5,13. There is therefore a necessity for meticulous strategies
to promote cancer care whilst limiting potential for COVID-19 transmission.

Prior to the implementation of Rapid Antigen Testing as a mandatory protocol in Antique Medical
Center for pre-admission of patients in general in April 2021, its Dialysis Unit has experienced
temporary facility shutdown for staff quarantine and proper disinfection due to late detection of
Covid-positive patients, causing disruption in the flow of hospital work and operation. The Oncology
Department of Antique Medical Center is the sole facility in the entire province providing medical
care for people diagnosed with cancer. Thus, a policy mandating all cancer patients receiving out-
patient treatment infusion at the institution to undergo COVID-19 Rapid Antigen Test 24 hours prior
to treatment schedule.

Having been established only this year, the RT-PCR molecular laboratory in San Jose, Antique is only
capable of running 25 to 80 samples per day with a turnout time of 24-96 hours. With the increasing
number of cases in the province, and the limited testing kits for RT-PCR, most of the hospitals
resorted to using Rapid Antigen Test for COVID-19 to screen and diagnose symptomatic and
4
asymptomatic patients with COVID-19 Infection. However, Jarrom et al (2020) asserted that more
evidence is needed about the effectiveness of testing in mild or asymptomatic cases. Fernandez-
20
Montero et al (2021) also claimed that rapid antigen tests have not been sufficiently evaluated in
asymptomatic patients to be used as a massive population screening tool.

Thus, the current research aimed to evaluate Covid-19 Rapid Antigen Testing (RAT) as a screening
tool and exposure-intervention strategy among cancer patients undergoing outpatient treatment
infusions in a Secondary Level Hospital in the Philippines. It also intended to bridge knowledge gaps
on the crucial role of RAT in preventing COVID-19 disease spread and transmission.

OBJECTIVES

General objective:

To evaluate COVID-19 Rapid Antigen Testing as a screening tool and exposure-prevention

strategy among cancer patients undergoing outpatient treatment infusions in a
secondary level hospital in Antique, Philippines.

Specifically this study aimed to:

1. Describe the profile of cancer patients undergoing outpatient treatment infusions

from April 2021 to September 2021
2. Report COVID-19 RAT results of cancer patients in the outpatient oncology unit from
April 2021 to September 2021.
 3. Report COVID-19 RT-PCR results of COVID-19 RAT positive cancer patients in the
outpatient oncology unit from April 2021 to September 2021.
4. Determine the number of treatment delay days of COVID-19 positive cancer patients
from April 2021 to September 2021.
5. Identify which cycle of treatment was disrupted among COVID-19 positive cancer
patients from April 2021 to September 2021.

SIGNIFICANCE OF THE STUDY

The burden of cancer incidence and mortality is rapidly increasing across the globe (Sung et al,
2021)48. And at the same time, the grave impact of COVID-19 pandemic extends to different contexts
and settings including management of cancer patients in the Philippines especially in terms of
diagnosis and treatment 3,5,15,. Taking into account the increased risk of infections and the negative
consequences in cancer patients (Ting et al, 2020) 5 in this time of pandemic, managing COVID-19 and
its complications should be prioritized over management of cancer (Alhalabi et al, 2020) 19. This
study may serve as a basis for developing uniform local COVID-19 screening protocols or guidelines
for outpatient oncology units to better safeguard the health of the vulnerable patients who
frequently visit the outpatient oncology unit and contribute to the goal of our LGUs in preventing
the spread of COVID-19.

Being a shared environment, Outpatient Oncology units are high risk spaces for COVID-19
transmission among cancer patients. With the lack of concrete and uniform local guidelines for
COVID-19 screening among ambulatory care units in secondary level hospitals, this study may serve
as a groundwork in enforcing COVID-19 RAT as screening tool in a secondary level hospital in
Antique.

Data presented in this study can further serve as a basis for COVID-19 screening protocols in other
medical settings among other ambulatory care units such as dialysis units, rehabilitation units, etc.
Results from this study can pave the way for government projects to include waiving the fees for
RAT among cancer patients who are undergoing active treatment.

METHODOLOGY

In an Outpatient Oncology Unit (OOU), as in Antique Medical Center, the hospital staff deals with
ambulatory cancer patients who are fit to receive oncology-related treatment infusions that can be
administered for eight hours or less. Normally, patients and their caregivers have to use a shared
treatment area such as room and toilet. Due to the sudden surge in COVID-19 cases in Antique
beginning April of 2021, a mandatory screening protocol was implemented to identify COVID-19
positive patients and, at the same time, to deny their access at the outpatient oncology unit to
prevent disease spread and transmission. COVID-19 symptom-based screening and COVID-19 RAT
taken within 24 hours of scheduled treatment was the routine combination in the medical
institution. COVID-19 RT-PCR were further required as a confirmatory test to positive COVID-19 RAT
results.
This descriptive, quantitative research study utilized retrospective data from OOU Logbooks inclusive
of the period April 1, 2021, and September 27, 2021 which were carefully and thoroughly reviewed
and evaluated. Patients presented to OOU with COVID-19 RAT positive tests were identified as
respondents of the study. Approval for research of the current study was granted by the Antique
Medical Center Research Ethics Board. Waived informed consents were also secured as all patients
with cancer and their accompanying caregivers were mandated to undergo COVID-19 rapid antigen
testing.
Descriptive statistical tools were utilized for data analysis and presentation of results. Frequency
count and percentage were used to present the demographic profile of cancer patients undergoing
outpatient treatment infusions from April to September 2021 across Rapid Antigen Test Results.
Median was used to determine average age, isolation days observed until with negative RT-PCR
result, and also treatment delay days.

RESULTS AND DISCUSSION

Table 1 Demographic Profile of Cancer Patients Undergoing Outpatient Treatment

Infusions from April to September 2021 across Rapid Antigen Test Results
Characteristics Overall cohort Positive COVID-19 RAT Negative COVID-19 RAT

Age (Median, Range) (59, 19-83)

Below 40 years old 4 (13.3%) 1 (3.3%) 3 (10.0%)
40-60 years 13 (43.3%) 1 (3.3%) 12 (40%)
Above 60 years old 13 (43.3%) 1 (3.3%) 12 (40.%)
Sex
0 (0.0%)
Male 10 (33.3%) 10 (33.3%)
0 (0.0%)
Female 20 (66.7%) 3 (10.0%) 17 (56.7%)
Types of Cancer
Breast 16 (53.3%) 3 (10.0%) 13 (43.3%)
Colon 3 (10.0%) 0 (0.0%) 3 (10.0%)
Rectal 2 (6.7%) 0 (0.0%) 2 (6.7%)
Lymphoma 2 (6.7%) 0 (0.0%) 2 (6.7%)
Nasopharyngeal 2 (6.7%) 0 (0.0%) 2 (6.7%)
Others 5 (16.7%) 0 (0.0%) 5 (16.7%)
Vaccination Status
Fully Vaccinated 4 (13.3%) 0 (0.0%) 4 (13.3%)
First Dose 1 (3.3%) 0 (0.0%) 1 (3.3%)
Unvaccinated 25 (83.3%) 3 (10.0%) 22 (73.3%)
Outcome
Hospital 0 (0.0%) 0 (0.0%) 0 (0.0%)
Home Quarantine 3 (10.0%) 3 (10.0%) 0 (0.0%)
Death 0 (0.0%) 0 (0.0%) 0 (0.0%)

Table 1 presents the demographic characteristics of patients screened for COVID- 19 using Rapid
Antigen Test from April to September 2021 across age, sex, type of cancer, vaccination status, and
outcome.

For the period of April until September 2021, a total of 30 cancer patients were screened using Rapid
Antigen Test for COVID-19 at least 24 hours prior to receiving their scheduled treatment. In the
country, cancer still remains a national health priority and one of the leading causes of morbidity
and mortality among Filipinos, according to the Department of Health. It is mostly a disease that
strikes people in their forties and fifties. (National Cancer Institute,2021) 50. The table further
revealed that the median age among cancer patients in Antique is 59 (range, 19-83), and that there
is a preponderance of female cancer patients (n=20, 66.67%) than males. Moreover, the results of
the study disclosed that as to the type of cancer, the majority of the patients were diagnosed with
breast cancer (n=16, 53.3%) while others have colon cancer (10.0%), rectal cancer (6.7%), lymphoma
(6.7%), nasopharyngeal (6.7%) and) other types (16.7%) such as endometrial, cervical, prostate,
lymphoblastic leukemia, and lung. According to Ngelangel and Wang (2002) 47, 75% of all cancers
occur after age 50 years. Breast cancer is the most frequently diagnosed cancer globally (Sung et al.,
2021)46. Furthermore, the breast cancer incidence in the Philippines is among the highest in Asia
(APOCP, 2009)35 and the most prevalent cancer diagnosed among women in 140 of 184 countries (IARC
2013)48. The Philippines was specified as the leading cancer site in females (Lagarde et al, 2019)49.

In terms of vaccination status, only 4 of the patients (13.3%) actively receiving treatment were fully
vaccinated and only one (3.3%) has received the first dose. The remaining population (83.3%) are
still unvaccinated. As to outcome, all three patients (10%) who tested positive for SARS-CoV-2
infection were advised to quarantine at home and were endorsed to the local rural health unit for
monitoring. According to the Department of Health (2021)38, although “vaccination is not
mandatory, the government highly encourages the public to get vaccinated and be protected against
preventable disease”. Antonelli et al (2021)53 reported that vaccinated participants were more likely
to be completely asymptomatic and that almost all symptoms were reported less frequently in
infected vaccinated individuals than in infected unvaccinated ones.

Table 2. Profile and Clinical Outcome of Rapid Antigen Test Positive Patients

Patient Age Sex Type of Cancer RAT Symptoms Vaccination Status Current Status Clinical Outcome
Result
No.1 33 F Breast (+) Cough Unvaccinated Stable HQ*
No. 2 46 F Breast (+) None Unvaccinated Stable HQ*

No. 3 78 F Breast (+) Nasal catarrh Unvaccinated Stable HQ*

*HQ = Home Quarantine

Table 2 reports the individual profile, clinical outcome and treatment delay days of COVID-19 Rapid
Antigen Test positive patients screened from April to September 2021. Three (10%) cancer patients
tested positive for RAT were all women, diagnosed with breast cancer, and were unvaccinated. All of
them were endorsed for home quarantine to their respective barangay for proper monitoring and
isolation while waiting for their RT-PCR Test Schedule. Daily monitoring of the patients was carried
out by the Brgy. Health Emergency Response Team.

The World Health Organization and its partners have directed and committed their efforts in
accelerating the development of COVID-19 vaccines (WHO, 2021)17. According to the COVID-19 Case
Tracker of the Department of Health of the Philippines, approximately more than 2 million cases
nationwide have already been reported to date while almost 46 million total doses were already
administered15. Ioannu et al (2021)58 asserts vaccination against COVID-19 is among the most
effective preventive measures to stop disease spread. In the US, unvaccinated Americans have died
at 11 times the rate of those fully vaccinated since the delta variant became the dominant strain
(Dyer, 2021)51. In the study of Martinez-Baz (2021)59, the incidence of SARS-CoV-2 infection was
higher in unvaccinated contacts than in those vaccinated with one or two doses. Similarly,
Muthukrishnan et al (2021)52 found that mortality rate among those fully vaccinated was
significantly higher among the unvaccinated.
Table 2 further details that Patient No. 1 had a cough and sought consultation at the oncology unit.
She was prescribed medication and tested positive for RAT prior to her subsequent cycle for
chemotherapy. Patient No. 3 experienced nasal catarrh and no other symptoms. Patient No. 2
remained asymptomatic. None of the patients required hospitalization.

With three Covid-19 positive cancer patients detected from April to September 2021, the COVID 19
RAT was able to aid early detection and diagnosis of SARS-CoV-2 infection. Rapid Antigen Testing,
which is based on immunochromatography, and involves spotting antibodies onto nitrocellulose
membranes that interact with specific antigens in the patient sample (Peeling et al, 2021), mitigated
disease spread and transmission by preventing further potential exposure to infected individuals and
prohibiting access to the Outpatient Oncology Unit (OOU), and thus any temporary unit shutdown
which could lead to disruption of hospital operation was also stalled. Screening tools and testing
procedure thus play a pivotal role in control of the COVID-19 pandemic (Peña et al, 2021)54 since
early detection facilitates containment of the spread of COVID-19 (Canas et al, 2021)53.

Table 3. Confirmatory Test with Real Time-Polymerase Chain Reaction for COVID-19

PATIENT RAT RESULT RT-PCR RESULT

No.1 (+) (+)

No. 2 (+) (+)

No. 3 (+) (+)

Table 3 presents the comparison of Rapid Antigen Test and RT-PCR Test Results for COVID-19, with
the latter as a confirmatory test for positive antigen test results.

As per recommendation by the guidelines set by the World Health Organization and the different
Oncology Societies, patients who tested positive for COVID 19- RAT were subjected to RT-PCR.
Nasopharyngeal and oropharyngeal swab samples were collected from the patients four days after
by trained personnel of the Municipal Health Office. Samples were then sent to the accredited RT-
PCR capable Molecular Laboratory located at Angel Salazar Memorial General Hospital. Test results
were released after 48-72 hours. All three patients tested positive for COVID-19 on RT-PCR Test.
Center for Disease Control and Prevention recommended the administration of Rapid antigen tests
(RAT) for SARS-CoV-2 as they are inexpensive compared to real-time RT-PCR, and immediate results
are readily available within 15 minutes which could assist in the evaluation of chains of infection and
their interruption (Peña et al, 2021)54.
Table 4. Treatment Delay Days of COVID-19 Positive Cancer Patients

Isolation Days Observed

Cancer Type of Until with Negative RT-PCR Number of RT-PCR
Patient Treatment Delay Days
Type Treatment Infusions Result test done Until
N=3 (median = 42 days)
N=3 (median = 16 days) Viral Clearance

No.1 Breast Chemotherapy 29 days Twice 35

Cancer

No. 2 Breast Targeted Therapy 14 days One 77

Cancer

No. 3 Breast Targeted Therapy 16 days One 42

Cancer

Table 4. presents the profile of COVID-19 Positive Patients from April to September 2021 across
treatment delay days.

Treatment delay days were then counted from the time the patient missed a scheduled treatment
due to RAT positive result until the day of treatment resumption. Treatment delay days varied from
35 to 77 days, with a median of 47 days. None of the patients were receiving oral systemic
chemotherapy. Two out of three patients were receiving targeted therapy while only one was
receiving Chemotherapy Treatment for Breast Cancer. Upon completion of their home quarantine,
the patients were retested for viral clearance using the RT-PCR Test for COVID-19 in accordance with
the guidelines set by the Department of Health of the Philippines. Upon negative RT-PCR results for
COVID-19, only then were the patients scheduled for resumption of treatment. Patient No. 2
observed 29 days of isolation. Following DOH guidelines, she was tested for RT-PCR after 2 weeks,
however, viral RNA for COVID-19 was still detected. An additional 2 weeks of isolation was then
recommended prior to repeating the RT-PCR test to ensure viral clearance with a medical certificate
from an infectious specialist. She resumed her chemotherapy 35 days after testing positive for
COVID-19 RAT. Although the other two patients tested negative for RT-PCR for COVID 19 after
completing 14-16 days of isolation, the therapeutic regimen was further delayed and was scheduled
for October 2021. After being infected with COVID-19, Patient No. 2 started experiencing anxiety
and opted to postpone initiation of the therapeutic regimen until she is psychologically ready and
stable. Patient No. 3 opted to defer resumption of therapy because her caregiver contracted COVID-
19 infection. Identified as a close contact, she needs to observe home quarantine for 14 days and
will be subjected to RT-PCR Test for COVID-19.

A positive test result in asymptomatic patients may prompt medical doctors to assess or weigh a
delay of or alteration in the planned treatment of a patient, and to coordinate with rural health units
for necessary safety and isolation procedures. Treatment delay among these immunocompromised
cohorts is crucial and can have grave effects on them, as it was found to be statistically significantly
associated with disease progression 1,9,14,18,56. In as much as treatment should not be delayed, early
detection of Covid-19 infection using antigen tests should be prioritized to prevent consequent chain
of infections or aggravation of the illness or condition while managing cancer care in the COVID-19
era.
Figure 1. Cycle Treatment Disruption Among COVID-19 Positive Patients

Figure 1 represents the schedule of treatment received by COVID-19 Rapid Antigen Test positive
patients from April to September 2021.

It shows the treatment cycle schedule received by the three COVID-19 Positive Patients for the
period of April to September 2021. Patient No. 1( represented by a green pole) has completed two
cycles of Doxorubicin and Cyclophosphamide until she started complaining of dry cough a week
before her next schedule of treatment. She tested positive for COVID-19 RAT a day prior to her
treatment. Patient No. 2 (represented by a dark blue pole) was scheduled for initiation of Targeted
Therapy with Trastuzumab when she tested positive for RAT. Patient No 3 (represented by a light
blue pole) having completed five cycles of Trastuzumab, tested positive a day prior to her sixth cycle.

None of the other cancer patients receiving treatment in the Oncology unit developed COVID-19
signs and symptoms. No additional cancer patient has tested positive on COVID-19 RAT.

CONCLUSION

The key to combat this pandemic lies in early identification of cases, immediate isolation,
appropriate management of exposed and infected individuals and observation of the minimum
standard infectious protocol of social distancing, handwashing and wearing of face masks and
faceshield. Providing the necessary therapeutic management for cancer patients while limiting, if not
preventing, their exposure to the possibility of COVID-19 Infection in an outpatient oncology unit is
essential. Early detection with the use of a fast, cheap, and reliable screening test is therefore
imperative.

With positive antigen test results confirmed by RT-PCR testing, rapid identification of SARS-CoV-2-
infected people is crucial . Rapid Antigen Test for COVID -19 has a promising potential as a point-of-
care screening tool and exposure-prevention strategy especially in the context of patient care and
management among immunocompromised population in ambulatory setting and shared spaces
where exposure and transmission of COVID-19 virus need to be mitigated to prevent further disease
spread or increase in cancer morbidity and mortality. RAT Implementation policy for Oncology Unit
must be deliberated. However, clinical correlation of the patient, financial capacity, as well as
availability of testing kits passing the recommended standard, and informed consents should
likewise be taken into consideration.
RECOMMENDATIONS

The RT-PCR test for COVID-19 is still the gold standard in confirming COVID-19 infection but
molecular testing is not feasible or easily accessible. The study may serve as a basis for developing
concrete screening guidelines for oncology units that may be implemented as standard protocols to
mitigate disease transmission while providing patient care among these immunocompromised
populations. Rapid Antigen Tests (RAT) may be considered a potential, urgent and necessary
screening tool to prompt timely diagnosis of SARS-CoV-2 infection and appropriate management of
cancer treatments, in addition to the standard procedure of symptom-based and exposure screening
for COVID-19 at point-of-care. In a wider lens, the results of the study may also be taken as a
suggestion for the local and national authorities to fund accredited testing centers so that COVID-19
RAT fees may be waived for cancer patients who frequently use shared facilities. On the other hand,
due to small sample size included within a short duration of time, the results and conclusions of the
study may be applicable only to the population being studied, and may not be generalizable to other
settings and larger populations. However, data collection may be continued to gather more evidence
for further evaluation of COVID-19 RAT results at the OOU, and for validation of the findings of this
paper. The current study may be replicated to a larger scale to further investigate, strengthen, or
establish the role of COVID-19 RAT as a screening tool among other vulnerable cohorts requiring
regular treatments such as those undergoing dialysis. Due to its low sensitivity when used among
asymptomatic individuals in communities with low prevalence, careful consideration should also be
made when using COVID-19 RAT in mass testing. Screening strategies should be individualized per
institution taking into account the available resources, epidemiological trends, as well as the
financial capability of the population being catered. Public health surveillance should be a
collaborative effort among the different community stakeholders with the government.

ACKNOWLEDGMENT
We are immensely grateful to the tireless efforts of the following: Arnie Joy Vallejo, Daphnie
Arguelles, Dr. Melvin S. De la Serna, Sr. Teresita Parreño and all oncology patients of Antique
Medical Center.

REFERENCES

1. Corso, C. R., Mulinari Turin De Oliveira, N., & Maria-Ferreira, D. (2021). Susceptibility to
SARS-CoV-2 infection in patients undergoing chemotherapy and radiation therapy. Journal of
Infection and Public Health, 14(6), 766–771. https://doi.org/10.1016/j.jiph.2021.03.008
2. Dinnes J, Deeks JJ, Berhane S, Taylor M, Adriano A, Davenport C, Dittrich S, Emperador D,
Takwoingi Y, Cunningham J, Beese S,Domen J, Dretzke J, Ferrante di Ru(ano L, Harris IM,
Price MJ, Taylor-Phillips S, Hoo- L, Leeflang MMG, McInnes MDF, Spijker R,Van den Bruel A,
Cochrane COVID-19 Diagnostic Test Accuracy Group.Rapid, point-of-care antigen and
molecular-based tests for diagnosis of SARS-CoV-2 infection. Cochrane Database of
Systematic Reviews 2021, Issue 3. Art. No.: CD013705. 10.1002/14651858.CD013705.pub2.
3. Mendoza, MJ, Tan, HN, Hernandez, AR, Dala, BC, Sacdalan, DB, Sacdalan, D, Cornello, G, and
Ignacio, J. (2020). Medical Oncology care Amidst the COVID-19 Pandemic at the National
University Hospital in the Philippines. ecancer 2020, 14:1066
https://doi.org/10.3332/ecancer.2020.1066
4. Jarrom, D., Elston, L., Washington, J., Prettyjohns, M., Cann, K., Myles, S., & Groves, P.
(2020). Effectiveness of tests to detect the presence of SARS-CoV-2 virus, and antibodies to
 SARS-CoV-2, to inform COVID-19 diagnosis: a rapid systematic review. BMJ Evidence-Based
Medicine, bmjebm-2020. https://doi.org/10.1136/bmjebm-2020-111511
5. Ting, FI, Mendoza, MJ, Sacdalan, DB, Abarquez, HS, Uson, AJ on behalf of the Philippine
Society of Medical Oncology (2020). Updated General Recommendation in Cancer
Management during the COVID-19 pandemic in the Philippines. ecancer 2020, 14:1128;
www.ecancer.org; DOI: https://doi.org/10.3332/ecancer.2020.1128
6. Al-Shamsi, Humaid, Coomes, Eric and Alrawim Sadir (2020). Screening for COVID-19 in
Asymptomatic Patients with Cancer in a Hospital in the United Arab Emirates. (Reprinted)
JAMA Oncology October 2020 Volume 6, Number 10 https://jamanetwork.com/ on
09/28/2021
7. Yin N, Debuysschere C, Decroly M, Bouazza F-Z, Collot V, Martin C, Ponthieux F, Dahma H,
Gilbert M, Wautier M, Duterme C, De Vos N, Delforge M-L, Malinverni S, Cotton F,Bartiaux M
and Hallin M (2021) SARS-CoV-2 Diagnostic Tests: Algorithm and Field Evaluation From the
Near Patient Testing to the Automated Diagnostic Platform. Front. Med. 8:650581. doi:
10.3389/fmed.2021.650581
8. Sethuraman, Nandini, Jeremiah, Sundararaj Stanleyraj, Ryo, Akihide (2020). Interpreting
Diagnostic Tests for SARS-CoV2. JAMA June 9, 2020 Volume 323, Number 22 (2249-2251).
doi:10.1001/jama.2020.8259
9. Yu, Jing, Ouyang, Wen, Chua, Melvin, Xie Conghua (2020). SARS-CoV-2 Transmission in
Patients
With Cancer at a Tertiary Care Hospital in Wuhan, China. JAMA Oncology July 2020 Volume
6, Number 7 doi:10.1001/jamaoncol.2020.0980
10. Khandker, S.S.; Nik Hashim, N.H.H.; Deris, Z.Z.; Shueb, R.H.; Islam, M.A. Diagnostic Accuracy
of Rapid Antigen Test Kits for Detecting SARS-CoV-2: A Systematic Review and Meta-Analysis
of 17,171 Suspected COVID-19 Patients. J. Clin. Med. 2021, 10, 3493.
https://doi.org/10.3390/jcm10163493
11. Wei, J; Wu, M; Liu, J; Xu, W; Xia, P; Peng, L, Huang, Y; Liu, C; Xia, Z; Chen, C and Zhao, Y.
(2020). Characteristics and outcomes of COVID-19 infection in 45 patients with breast
cancer: A multi-center retrospective study in Hubei, China. The Breast 59 (2021) 102-109
https://doi.org/10.1016/j.breast.2021.06.006
12. Al-Shamsi, H; Alhazzani, W; Alhuraji,A; Coomes, E; Chemaly, R; Almuhanna, M; Wolff, R;
Ibrahim, N; Chua, M; Hotte, S; Meyers, B; Elfiki, T; Curigliano,G; Eng,C; Grothey,A and Xie, C
(2020) A Practical Approach to the Management of Cancer Patients During the Novel
Coronavirus Disease 2019 (COVID-19) Pandemic: An International Collaborative Group The
Oncologist 2020;25:e936–e945 www.TheOncologist.com
13. Vaugnat et al (2020). COVID-19 in Breast Cancer Patients: A cohort at the Institut Curie
hospitals in the Paris Area. Breast Cancer Research (2020) 22:55
https://doi.org/10.1186/s13058-020-01293-8
14. Ferrara, M.; Langiano, E.; Falese, L.; De Marco, A.; De Vito, E. Quality of Life and Psychosocial
Impacts of the Different Restrictive Measures during One Year into the COVID-19 Pandemic
on Patients with Cancer in Italy: An Ecological Study. Int. J. Environ. Res. Public Health 2021,
18, 7161. https://doi.org/10.3390/ijerph18137161
15. World Health Organization (2020). Transmission of SARS-Cov-2: implications for infection
prevention precautions. Scientific Briefing 9 July 2020. WHO/2019-
nCoV/Sci_Brief/Transmission_modes/2020.3
16. Porte, L; Legarraga, P; Vollrath,V; Aguilera,X; Munita, J; Araos, R; Pizarro, G; Vial, P;
Iruretagoyena, M; Dittrich, S; Weitzel, T (2020). Evaluation of a novel antigen-based rapid
detection test for the diagnosis of SARS-CoV-2 in respiratory samples. International Journal
of Infectious Diseases 99 (2020) 328–333 https://doi.org/10.1016/j.ijid.2020.05.098
17. Scohy, A; Anantharajah, A; Bodeus, M; Kabamba-Mukadi,B; Verroken,A; Rodriguez-
Villalobos,H (2020). Low performance of rapid antigen detection test as frontline testing for
 COVID-19 diagnosis Journal of Clinical Virology 129 (2020) 104455
https://doi.org/10.1016/j.jcv.2020.104455
18. Harada, et al (2020). SARS-CoV-2 testing for asymptomatic adult cancer patients before
initiating systemic treatments: a systematic review ecancer 2020, 14:1100;
www.ecancer.org; DOI: https://doi.org/10.3332/ecancer.2020.1100
19. Alhalabi, Omar; Iyer, Swami; and Subbiah, Vivek (2020). Testing for COVID-19 in patients
with cancer. EClinicalMedicine 23 (2020) 100374
https://doi.org/10.1016/j.eclinm.2020.100374
20. Fernandez-Montero et al. (2021)Validation of a rapid antigen test as a screening tool for
SARS-CoV-2 infection in asymptomatic populations. Sensitivity, specificity and predictive
values EClinicalMedicine 37 (2021) 100954 https://doi.org/10.1016/j.eclinm.2021.100954
21. Fillmore, N. et al (2021). Prevalence and Outcome of COVID-19 Infection in Cancer Patients:
A National Veterans Affairs Study JNCI J Natl Cancer Inst (2021) 113(6): djaa159 doi:
10.1093/jnci/djaa159
22. van Marcke et al. (2021) Safety of systemic anti-cancer treatment in oncology patients with
non-severe COVID-19: a cohort study BMC Cancer 21:578 https://doi.org/10.1186/s12885-
021-08349-8
23. Zhen-Dong Guo,et al (2020) Aerosol and Surface Distribution of Severe Acute Respiratory
Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020 Emerging Infectious
Diseases • www.cdc.gov/eid • Vol. 26, No. 7, July 2020
https://doi.org/10.3201/eid2607.200885
24. Buonanno, G; Stabile, L; Morawska, L. (2020). Estimation of airborne viral emission: Quanta
emission rate of SARS-CoV-2 for infection risk assessment Environment International 141
(2020) 105794https://doi.org/10.1016/j.envint.2020.105794
25. Lee, Byung Uk (2020). Minimum Sizes of Respiratory Particles Carrying SARS-CoV-2 and the
Possibility of Aerosol Generation Int. J. Environ. Res. Public Health 2020, 17, 6960;
doi:10.3390/ijerph17196960
26. Jayaweera, Mahesh; Perera, Hasini; Gunawardana, Buddhika and Manatunge, Jagath (2020).
Transmission of COVID-19 virus by droplets and aerosols: A critical review on the unresolved
dichotomy Environmental Research 188 (2020) 109819
https://doi.org/10.1016/j.envres.2020.109819
27. Colavita, F., Vairo, F., Meschi, S., Valli, M. B., Lalle, E., Castilletti, C., Fusco, D., Spiga, G.,
Bartoletti, P., Ursino, S., Sanguinetti, M., di Caro, A., Vaia, F., Ippolito, G., & Capobianchi, M.
R. (2021). COVID-19 Rapid Antigen Test as Screening Strategy at Points of Entry: Experience
in Lazio Region, Central Italy, August–October 2020. Biomolecules, 11(3), 425.
https://doi.org/10.3390/biom11030425
28. Ngo Nsoga, M. T., Kronig, I., Perez Rodriguez, F. J., Sattonnet-Roche, P., da Silva, D., Helbling,
J., Sacks, J. A., de Vos, M., Boehm, E., Gayet- Ageron, A., Berger, A., Jacquerioz-Bausch, F.,
Chappuis, F., Kaiser, L., Schibler, M., Renzoni, A., & Eckerle, I. (2021). Diagnostic accuracy of
Panbio rapid antigen tests on oropharyngeal swabs for detection of SARS-CoV-2. PLOS ONE,
16(6), e0253321. https://doi.org/10.1371/journal.pone.0253321
29. Liu, C., Zhao, Y., Okwan-Duodu, D., Basho, R., & Cui, X. (2020). COVID-19 in cancer patients:
risk, clinical features, and management. Cancer biology & medicine, 17(3), 519–527.
https://doi.org/10.20892/j.issn.2095-3941.2020.0289
30. Quaquarini, E., Saltalamacchia, G., Presti, D., Caldana, G., Tibollo, V., Malovini, A., Palumbo,
R., Teragni, C. M., Balletti, E., Mollica, L., Biscaldi, E., Frascaroli, M., Bernardo, A., &
Sottotetti, F. (2020). Impact of COVID-19 Outbreak on Cancer Patient Care and Treatment:
Data from an Outpatient Oncology Clinic in Lombardy (Italy). Cancers, 12(10), 2941.
https://doi.org/10.3390/cancers12102941
31. Nichetti, F., Bini, M., Ambrosini, M., Ottini, A., Rametta, A., Leporati, R., Polastri, D., Pircher,
C., Dotti, K., Ferrari, L., & de Braud, F. (2020). COVID-19 risk for patients undergoing
 anticancer treatment at the outpatient clinic of the National Cancer Institute of Milan: the
COVINT study. ESMO open, 5(Suppl 3), e000883. https://doi.org/10.1136/esmoopen-2020-
000883
32. WHO (2020). Antigen-detection in the diagnosis of SARS-CoV-2 infection using rapid
immunoassays. Interim Guidance. 11 September.Available at
https://www.who.int/publications/i/item/antigen-detection-in-the-diagnosis-of-sars-cov-
2infection-using-rapid-immunoassays.
33. Khan et al (2021). Safety and efficacy of COVID-19 vaccination in patients receiving systemic
anticancer therapy. Journal of Clinical Oncology 39, no. 28_suppl (October 01, 2021) 245-245
DOI: 10.1200/JCO.2020.39.28_suppl.245
34. Rajan S, Akhtar N, Sharma S, Chakrabarti D, Kumar V. COVID-19 vaccination for cancer
patients: Evidence, priority, and practice. Vaccine. 2021;39(36):5075-5077.
doi:10.1016/j.vaccine.2021.07.063
35. American Cancer Society (2021). COVID-19 Vaccines in People with Cancer. cancer.org |
1.800.227.2345
36. Wenxin Xu, Andrew Piper-Vallillo, Poorva Bindal, Jonathan W. Wischhusen, Jaymin M. Patel,
Daniel Botelho Costa, Mary Linton Bounetheau Peters (2020) Time to COVID-19 RT-PCR
clearance among patients with cancer.DOI: 10.1200/JCO.2020.38.29_suppl.49 Journal of
Clinical Oncology 38, no. 29_suppl (October 10, 2020) 49-49.
37. Research Institute for Tropical Medicine (2021). SARS-Cov2 Rapid Antigen Test (Ag) Test.
https://ritm.gov.ph/covid-19-kit-evaluation/completed-evaluations/sars-cov-2-rapid-
antigen-ag-test/
38. Department of Health (2021). COVID-19 Tracker doh.gov.ph
39. Center for Disease Control and Prevention(2021). Testing Overview.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing-overview.html
40. Andrew Pekosz, Valentin Parvu, Maggie Li, Jeffrey C Andrews, Yukari C Manabe, Salma Kodsi,
Devin S Gary, Celine Roger-Dalbert, Jeffry Leitch, Charles K Cooper, Antigen-Based Testing
but Not Real-Time Polymerase Chain Reaction Correlates With Severe Acute Respiratory
Syndrome Coronavirus 2 Viral Culture, Clinical Infectious Diseases, 2021;, ciaa1706,
https://doi.org/10.1093/cid/ciaa1706
41. Mak, G. C., Cheng, P. K., Lau, S. S., Wong, K. K., Lau, C., Lam, E. T., Chan, R. C., & Tsang, D. N.
(2020). Evaluation of rapid antigen test for detection of SARS-CoV-2 virus. Journal of Clinical
Virology, 129, 104500. https://doi.org/10.1016/j.jcv.2020.104500
42. Indini A, Rijavec E, Ghidini M, Bareggi C, Cattaneo M, Galassi B, Gambini D, Grossi F.
Coronavirus infection and immune system: An insight of COVID-19 in cancer patients. Crit
Rev Oncol Hematol. 2020 Sep;153:103059. doi: 10.1016/j.critrevonc.2020.103059. Epub
2020 Jul 9. PMID: 32711241; PMCID: PMC7347348.
43. Liu, C., Zhao, Y., Okwan-Duodu, D., Basho, R., & Cui, X. (2020). COVID-19 in cancer patients:
risk, clinical features, and management. Cancer biology & medicine, 17(3), 519–527.
https://doi.org/10.20892/j.issn.2095-3941.2020.0289
44. Philippine Society of Medical Oncology (2021). COVID-19 Vaccine and Patients with Cancer.
https://pcp.org.ph/index.php/covid-19-vaccines/1211-covid-19-vaccine-and-patients-with-
cancer-the-philippine-society-of-medical-oncology-psmo-position-statement
45. Ngelangel, C. A., & Wang, E. H. M. (2002). Cancer and the Philippine Cancer Control
Program. Japanese Journal of Clinical Oncology, 32(suppl 1), S52–S61.
https://doi.org/10.1093/jjco/hye126
46. Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F.
(2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality
Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 71(3), 209–
249. https://doi.org/10.3322/caac.21660
47. Epidemiology and Clinicopathology of Breast Cancer in Metro Manila and Rizal Province,
Philippine. (2009). Asian Pacific Journal of Cancer Prevention, 10(1), 167-172.retrieved from
http://journal.waocp.org/article_24894.html
48. International Agency for Research on Cancer . Press release no. 233 latest world cancer
statisti15cs, global cancer burden rises to 14.1 million new cases in 2012: marked increased
in breast cancer must be addressed. Geneva: World Health Organization; 2013.
49. Lagarde, J., Laurino, M. Y., San Juan, M. D., Cauyan, J., Tumulak, M., & Ventura, E. R. (2019).
Risk perception and screening behavior of Filipino women at risk for breast cancer:
implications for cancer genetic counseling. Journal of community genetics, 10(2), 281–289.
https://doi.org/10.1007/s12687-018-0391-3
50. National Cancer Institute (2021).Risk Factors: Age. https://www.cancer.gov/about-
cancer/causes-prevention/risk/age
51. Dyer, O. (2021). Covid-19: Unvaccinated face 11 times risk of death from delta variant, CDC
data show. BMJ, n2282. https://doi.org/10.1136/bmj.n2282
52. Muthukrishnan, J., Vardhan, V., Mangalesh, S., Koley, M., Shankar, S., Yadav, A. K., & Khera,
A. (2021). Vaccination status and COVID-19 related mortality: A hospital based cross
sectional study. Medical journal, Armed Forces India, 77(Suppl 2), S278–S282.
https://doi.org/10.1016/j.mjafi.2021.06.034
53. Antonelli, M., Penfold, R. S., Merino, J., Sudre, C. H., Molteni, E., Berry, S., Canas, L. S.,
Graham, M. S., Klaser, K., Modat, M., Murray, B., Kerfoot, E., Chen, L., Deng, J., ÖSterdahl, M.
F., Cheetham, N. J., Drew, D. A., Nguyen, L. H., Pujol, J. C., . . . Steves, C. J. (2021). Risk factors
and disease profile of post-vaccination SARS-CoV-2 infection in UK users of the COVID
Symptom Study app: a prospective, community-based, nested, case-control study. The
Lancet Infectious Diseases. Published. https://doi.org/10.1016/s1473-3099(21)00460-6
54. Peña, M., Ampuero, M., Garcés, C., Gaggero, A., García, P., Velasquez, M. S., Luza, R.,
Alvarez, P., Paredes, F., Acevedo, J., Farfán, M. J., Solari, S., Soto-Rifo, R., & Valiente-
Echeverría, F. (2021). Performance of SARS-CoV-2 rapid antigen test compared with real-
time RT-PCR in asymptomatic individuals. International Journal of Infectious Diseases, 107,
201–204. https://doi.org/10.1016/j.ijid.2021.04.087
55. Peeling, R. W., Olliaro, P. L., Boeras, D. I., & Fongwen, N. (2021). Scaling up COVID-19 rapid
antigen tests: promises and challenges. The Lancet Infectious Diseases, 21(9), e290–e295.
https://doi.org/10.1016/s1473-3099(21)00048-7
56. Pandy, J. G., Maaño, O., Balolong‐Garcia, J. C., & Datukan, J. T. Y. (2021). Risk factors and
clinical outcomes of systemic cancer treatment delays in Filipino patients with solid tumor
malignancy during the COVID ‐19 pandemic: A single tertiary center study. Cancer Reports.
Published. https://doi.org/10.1002/cnr2.1426
57. Tian et al (2020). Clinical Characteristics and Risk Factors associated with COVID-19 disease
severity in patients with cancer in Wuhan, China: a multicentre, retrospective, cohort study.
The Lancet Oncology Volume 21 (7) P893-903 July 1 2020. https://doi.org/10.1016/S1470-
2045(20)30309-0
58. Ioannou GN, Green P, Fan VS, et al. Development of COVIDVax Model to Estimate the Risk of
SARS-CoV-2–Related Death Among 7.6 Million US Veterans for Use in Vaccination
Prioritization. JAMA Netw Open. 2021;4(4):e214347.
doi:10.1001/jamanetworkopen.2021.4347
59. Martínez-Baz I, Miqueleiz A, Casado I, et al. Effectiveness of COVID-19 vaccines in preventing
SARS-CoV-2 infection and hospitalisation, Navarre, Spain, January to April 2021. Euro
Surveill. 2021;26(21):2100438. doi:10.2807/1560-7917.ES.2021.26.21.2100438