What to expect: Oncology’s response to coronavirus in Italy

16 Mar 2020
What to expect: Oncology’s response to coronavirus in Italy

To get a sense of how COVID-19 will affect oncology in the U.S., The Cancer Letter called Giuseppe Curigliano, associate professor of Medical Oncology at University of Milano and the head of the Division of Early Drug Development at European Institute of Oncology, Italy, who is based in the Lombardy region—the epicenter of the outbreak.

“So this is actually the perception that I have—it’s like being in a war or under a terrorist attack when usually 10% of people go in intensive care,” Curigliano said to The Cancer Letter.

“I am not scared about this because we are doctors, so this is our job,” Curigliano said. “But, you know, it’s really impressive how many new patients every day arrive in many hospitals in the city with the possibility of coronavirus, with symptoms of coronavirus—and you know already that 8%-10% of them will go into intensive care.”

Italy, which has the most cases of COVID-19 outside China, has instituted a mandatory quarantine and ban on travel for the 60 million people within the country.

Curigliano spoke with Alex Carolan, a reporter with The Cancer Letter.

Alex Carolan: How are you handling things in Milan?

Giuseppe Curigliano: First of all, I have to review the numbers, because it is quite important. Looking at the data, we have actually, in Italy, 10,140 COVID-19 cases out of 60,671 tested subjects [as of March 10]. And in the last three weeks, 631 patients died. This is quite important to be known.

Actually, at 6:00 p.m. on March 10, we had the new data of the day. We have 877 patients in intensive care for acute respiratory distress syndrome (ARDS), which means 8%–10% of positive cases are at risk to develop acute respiratory distress, conditioning the need for respiratory support.

There are 5,077 patients hospitalized for mild symptoms. I personally don’t have the data for cancer patients. I can tell you that some of my patients are positive for COVID, and some of them are actually hospitalized for ARDS. But the global number of cancer patients in Italy is not known. Of those with who tested positive for COVID-19 in China, almost 5% of them are cancer patients, with a very high fatality rate.

So, what are we doing in Italy in order to reduce the risk of our patients? We stopped follow-up visits. Any patients that were supposed to visit our comprehensive cancer center for follow up, we decided to stop the visits. We decided to give priority to patients with active disease over patients who are treated in the curative setting.

We give high priority to patients receiving treatment for an active disease. If they have to receive a neoadjuvant treatment or an adjuvant treatment, or treatment for metastatic disease, we reorganized the clinical activity to confirm the visits and the treatments. The same priority was given to patients receiving experimental treatments in clinical studies. But, you should know that some of these patients are coming from geographical areas where travel is banned. So it’s quite difficult for them to reach here.

In some of these patients, we delayed the treatment until quarantine was expired. Of course, we have to protect patients because some of them have leukopenia, lymphopenia, due to active treatment. For each patient who comes into the hospital, we test the temperature, we ask if they have coughs or symptoms that are related to coronavirus, and then we give them masks and gloves before entering in the hospital to guarantee that the hospital is a clean hospital. And the same thing for doctors.

Actually, I have some symptoms. I did the test and I am coronavirus-negative, but I protect myself with a mask, in order to also protect the patients.

AC: When you mentioned travel restrictions, are patients now unable to travel to your cancer center?

GC: No, no, actually the travel restriction is for all people in my country, with the exception of people moving for health reasons.

AC: Oh, so they are able to travel.

GC: For cancer patients, there is no travel restriction.

AC: They need a permit to travel. Is that correct?

GC: Yes. Correct.

AC: You mentioned how you protect yourself with masks when you treat patients. Could you talk about that a bit more? How do you ensure that these patients won’t be infected while they’re in the hospital?

GC: Now, you know, if we are symptomatic, we have to be tested for coronavirus. So in case we are positive, we cannot work. Any coronavirus-positive doctor should stay at home for at least two weeks.

And all the people working in the same team that had face-to-face contact, they should also be tested for coronavirus. In the experience of the hematological department, I can mention that all the doctors are tested every week, because patients in the hematological context are more frail, and so you have to be careful because they receive high-dose chemotherapy, and they can’t really defend infections that are very serious.

They do the test every week. Also hematological patients, for example, with leukemia, are tested for coronavirus before starting any treatment.

AC: Have patients expressed concerns about coming into the hospital because they don’t want to get the virus?

GC: No, because in my geographical area, Regione Lombardia—that is an area with a high rate of infection—we decided to have at least two hospitals, my hospital (European Institute of Oncology), and the National Cancer Institute, which are the hub hospitals for medical oncology patients. We are taking care of new cases, of our patients, and all the patients who are coronavirus-negative of the other hospitals in Regione Lombardia. In our hospital, only patients who are coronavirus-negative can enter.

AC: If you are a cancer patient who tests positive for coronavirus, can you not go into that hospital?

GC: No, because there are some hospitals that are COVID hospitals. All patients who are positive can go just to hospitals in which they are awaiting patients that are coronavirus-positive. And the two hubs, that are my hospital and the National Cancer Institute, should be clean. So it’s mandatory that we are clean.

AC: Do you find that cancer patients are more at risk to catch the coronavirus than others?

GC: Yes, they are. Just today, a patient of mine with lung cancer receiving a treatment with a RET inhibitor, so with an experimental agent, developed a coronavirus infection because he’s living in the Bergamo city, where there is a spread of the virus, and he was just hospitalized for pneumonitis induced by coronavirus.

We have to be very careful because we do a lot of education with patients, but sometimes, of course, the risk is very high for them because they have lymphopenia or leukopenia.

AC: How are you communicating with patients about the virus? What do you tell them?

GC: What do we do every day? Patients are very aware, actually, because there is a national campaign against the coronavirus. But every day we call all the patients who have to visit the next day. We ask them by phone if they have fever, if they have coughs or any symptoms—and they can come directly to the hospital only if they have no symptoms related to coronavirus.

Once they arrive in the hospital there is a checkpoint, external to the hospital, where temperature is measured and an exam is done. If everything is OK, they come directly into the hospital. They are very happy about this because they know very well that if we deliver any treatment inducing leukopenia, and they are positive for coronavirus, they are at risk, of course.

AC: There are two hospitals in your region that will take care of coronavirus negative patients?

GC: Yes, in Regione Lombardia, not in all of Italy. We decided to have two hub hospitals for new patients with cancer, and so there are many hospitals in which you had hospitalized a lot of patients with coronavirus, that are not cancer patients. For Regione Lombardia, it is two hospitals—one of these hospitals is my hospital. It must be a clean hospital to take care of all the cancer patients, the new cancer patients of Regione Lombardia.

If you have a new cancer patient in Bergamo, he cannot be treated in a hospital in Bergamo because there are many patients with coronavirus. Who will take care of him? He will come to our hospital. We are the hub for many hospitals that actually are fighting against the coronavirus in intensive care, in order to get a clean hospital for new cancer patients.

AC: Could you describe the atmosphere in your city and your institution? What is it like?

GC: You know, the atmosphere in Milan is spectral. There is no one walking in squares and roads. Doctors, we are working—we are at risk, of course. My wife is an intensive care doctor. Every week she undergoes a coronavirus test, and we wait during the weekend for the results. And I know very well that if she will be positive, I have to be tested also, and if I would be positive also, I will go into quarantine.

I am not scared about this because we are doctors, so this is our job. But, you know, it’s really impressive how many new patients every day arrive in many hospitals in the city with the possibility of coronavirus, with symptoms of coronavirus—and you know already that 8%-10% of them will go into intensive care.

So this is actually the perception that I have—it’s like being in a war or under a terrorist attack when usually 10% of people go in intensive care.

This is exactly the atmosphere that we are living in, and there is no one working overall. When I come to the hospital at 7 a.m., usually, in the past, you need more than half an hour due to traffic. Now, I actually arrive at the hospital in 10 to 15 minutes.

It’s a spectral atmosphere where no one is walking or working, because, in Milano, the only activities that open are the hospital, the store where you can buy food, and the pharmacies. Nobody else is working for 15 days. It’s a complete lockdown. Universities are closed, schools are closed, any other activity that is not a hospital, a food market, or a pharmacy is closed. It’s like being at war.

AC: How do you plan to respond as this progresses? Do you see the situation changing soon?

GC: Social isolation and containment is the only way. Social isolation and containment. You should know that 12% of coronavirus-positive are doctors and nurses. The only way to stop these epidemics is to stay at home, don’t go around. If we stay at home, we can stop this.

AC: And do you have any advice for oncologists and doctors in the U.S. as we respond to this here?

GC: To be prepared. The only thing that is very important is to be prepared. My advice is—in case you have specific areas of the country where there is an increase of the spread—to start social isolation and containment measures as soon as possible, to recommend to cancer patients to be careful, to protect themselves and to protect their family, in order to avoid the spreading that is so high like in Milano and the Regione Lombardia area.

We did not start the social isolation as soon as possible like they did in China. And we hope that measures that we did now will reduce the spread in the next weeks.

AC: Is there anything else you’d like to add?

GC: You know, the only thing that I would like to add, is that coronavirus is not a simple flu. It’s a severe, very serious disease in which you have a risk of 10% to go into an intensive care unit, with the median of hospitalization of three weeks.

The more you’re high at risk, like our cancer patients, the more probability you have of dying. There is a high fatality rate in cancer patients. My advice is to be very careful, because this is not the flu.

Reproduced with kind permission from The Cancer Letter