Hospital Healthcare Europe had the pleasure of speaking with Professor Giuseppe Curigliano, who offered his insight of how the COVID-19 pandemic has affected oncology services at his hospital
How has the continuum of care and throughput been impacted by the pandemic?
Professor Curigliano started by noting that in Italy there has been a completely different situation to other countries. At the height of the pandemic there were over 20,000 cases of the virus with over 1000 people dying every day and by February 2020, all hospitals were effectively overwhelmed by COVID-19 patients, requiring intensive care beds and other forms of assistance. However, he said that since May 2020, the situation had been completely different with the number of cases ranging from 300 to 1000 per day, which has meant that the management of oncology patients has returned to normal and today he is seeing the same number of patients as in December 2019, before the pandemic struck.
Professor Curigliano felt that one of the main reasons why oncology services were able to return to normal so quickly after the initial onslaught of the pandemic was that very early on, the health authorities took the decision to reorganise services. For example, it was decided that Professor Curigliano’s hospital, which is a specialised cancer centre, should be deemed a dedicated cancer hub, to be used solely for the management of cancer patients. In contrast, because of the sheer volume of infected patients, many hospitals were turned into treatment centres and demarcated into COVID-secure and COVID-free areas. In practice, this meant that many cancer patients were unable to receive treatment at their usual hospital but could access therapy at Professor Curigliano’s centre.
Although the centre was deemed a cancer treatment hub, it was still necessary to ensure that the centre remained COVID-free. As a result it was necessary to introduce precautionary measures and every patient who came to the hospital for chemotherapy or surgery was tested upon arrival using a PCR swab. Those who tested positive were not allowed to stay at the hospital and were sent home and asked to quarantine for two weeks. The centre also instigated an active surveillance programme among the healthcare staff and which involved PCR swab testing every two weeks to ensure that the doctors and nurses did not bring the virus into the centre.
Although in the UK a second wave of COVID-19 is approaching, Professor Curigliano says that due to the action of the health authorities, Italy currently has the lowest number of cases in Europe.
What new protocols or guidelines have been deployed to protect patients and clinicians during the pandemic?
With the World Health Organization (WHO) producing guidelines for healthcare staff at the start of the pandemic, Professor Curigliano felt that there was no need to develop any further or specific guidance or policies for his centre and the WHO guidance was simply translated into Italian and implemented at the centre.
As in all countries, as the pandemic unravelled, there was a complete suspension of all face-to-face consultations. Though some patients were too unwell to attend the centre, many were actually fearful of catching the virus and preferred to stay at home. Consequently and in order to provide some level of continuity of care, Professor Curigliano described how he and colleagues quickly moved to undertaking video consultations using mytime and this became widely adopted from March 2020. The online consultation was used not only for new referrals, but for patient follow-ups. It proved
to be an invaluable means for discussions with patients, especially when it was necessary to discuss any potential toxicities or side-effects that might arise from ongoing therapy. Professor Curigliano said that a large number
of virtual consultations were undertaken. In the main, patients appeared to be happy with this mode of consulting, particularly as it provided them with access to their physician, who was able to answer any questions that they might have regarding either their condition or treatment, while having the added bonus that they did not have to leave their home.
The use of a virtual platform was also extended to meetings among clinical staff for case discussions. In addition, the technology also enabled clinicians to view any necessary patient imaging or scans and blood test results. Professor Curigliano feels that this way of working has been very useful and is still being used for case discussions.
The pandemic posed many problems for clinicians and two particular problems for oncology patients. Prior to the pandemic, many patients visited the centre on a regular basis to receive infusion chemotherapy. Additionally, as subsequent chemotherapy treatment cycles are dependent upon satisfactory blood test results, which would normally be undertaken at the centre, it was necessary to find an alternative solution to avoid a large number of patients visiting the centre. As Professor Curigliano explained, this was quickly resolved by arranging for blood tests to be carried out at a number of local hospitals. For example, for patients who lived several kilometres from the oncology centre, it was agreed that rather than having to visit the centre, blood samples could be taken at a hospital closer to their home, where COVID- and non-COVID pathways were quickly established and these samples then posted to the oncologist to review.
Although a very small number of patients continued with infusion chemotherapy at the centre, Professor Curigliano described how in an effort to limit the number of individuals visiting the centre and receiving infusion therapy, his centre decided to make a wholesale change to the treatment programme for many of their patients. In a number of cases, this involved a switch from infusion to oral alternatives and some patients were changed to subcutaneous treatments that could be self-administered. Each of these new treatments were then dispensed at the hospital pharmacy and posted out to patients.
As a result of the shift changes to services, Professor Curigliano feels that while initially there had been some delays in patient screening, there were no delays in the provision of treatment and in fact, he said that no patients died during the COVID-19 pandemic period because of treatment toxicities and believes that this was entirely due to the early decision to make his hospital a dedicated cancer centre, allowing the staff to focus on providing chemotherapy rather than treating COVID-19 patients.
How would you summarise the impact of the pandemic and what are the key learnings?
Professor Curigliano felt that there were several important lessons from the pandemic. Firstly and perhaps most important, was the need to re-organise services as soon as possible once authorities realised that they were dealing with a pandemic. This enabled appropriate allocation of resources dedicated to the care of those with COVID-19 but also to other specialities such as cardiovascular disease and cancer. Secondly, as some staff had succumbed to the virus, it was necessary to ensure that those treating patients were issued with personal protective equipment to reduce their own risk of infection and finally, it was important to introduce an effective test and trace system so that infected patients can be identified and quickly isolated.
How quickly do you anticipate regaining momentum post-pandemic?
As Professor Curigliano mentioned, the early swift action of the Italian authorities meant that any hiatus to services was quickly resolved and that since May 2020, things were back to normal. Though virtual consultations were introduced out of necessity, he does feel that this form of consultation will remain as part of his service, post-pandemic and he himself is happy to use remote consulting. In addition, the ability to view tumours and scans on-screen also reduces the need for patient attendance at the centre, especially as they are placed together in large groups in the waiting areas. However, moving forward, virtual consultations will probably only be used for patient follow-ups, as new referrals can now be seen at the centre. He said that since May 2020 they are routinely seeing between 200 and 1000 cases per day and while it remains unclear whether the country will be hit by a second wave of COVID-19, Professor Curigliano thinks that his centre is ready and prepared to deal with it if the need arose.
Giuseppe Curigliano MD PhD
Associate Professor of Medical Oncology, University of Milan; European Institute of Oncology, Milan, Italy