Comment on “The experience on coronavirus disease 2019 and cancer from an oncology hub institution in Milan, Lombardy Region” and reflections from the Italian Association of Oncology Nurses

We thank Trapani et al. [] for their contribution aimed at sharing the experience of the reorganisation of cancer care to respond to novel coronavirus disease (COVID-19) in the Lombardy Region (Italy). Trapani et al. [] described the Italian cancer mortality and an interim analysis of nine patients with cancer and COVID-19, mainly managed using home-based management. We agree with the authors in identifying the continuum of care as the key to success in COVID-19 and cancer management, as well as the strong need of keeping the connection between health needs and cancer management. Forasmuch, in accordance with what is highlighted by Trapani et al. [], the Italian Association of Oncology Nurses (AIIAO) is mapping the situation of the self-isolated patients with cancer at home in the context of the COVID-19.

On 9th March 2020, the Italian authority locked down the country to contain the spread of COVID-19. Specific recommendations were provided to people living with cancer, who were encouraged to stay at home in self-isolation, especially elderly and immunocompromised patients, because they were considered at an increased risk of COVID-19 infection and severe events []. Moreover, non-urgent visits were postponed, and several specialist cancer wards were converted into isolation units for patients with COVID-19 infection or closed because of staff shortage []. Furthermore, patients with cancer are in urgent need of blood monitoring, chemotherapy, scans, transplants and surgery, which, if delayed indefinitely, could mean loss of the window to treat. In this context, we started an online survey to describe the situation of the self-isolated patients with cancer at home in the context of the COVID-19. Thus far, we have performed an interim analysis for data collected between 29th March and 3rd May 2020. Accordingly, 195 patients completed the survey. They were mainly women (n = 148, 75.9%), with a mean age of 50.3 (standard deviation, SD = 11.2, range = 25–78) years and a high level of education (university or postgraduate = 66, 34%). The majority of patients had haematological malignancies (n = 100, 51.3%), followed by patients with breast cancer (n = 51, 26.2%) and other solid tumours (n = 44, 22.6%). The majority were from the north of Italy (38.9%), 34.7% from the south and 26.4% from central regions. Table 1 shows patients' beliefs, behaviour and access to care.

Overall, an important number of patients reported that their cancer disease was not under control (29%). This is especially alarming given that three patients of four experienced difficult access to safe cancer care 62%), especially regarding follow-up visits, which were often postponed. Patients with cancer not only were considered at higher risk for COVID-19 infection but also had to pay the price for an emergent imperative to reduce cancer care activity associated with several factors []. These included the need to respect imperative social distancing, the lack of beds in intensive care units, the increased workload [], the reduction of the oncology workforce caused by the reallocation of healthcare providers into COVID-19 units or quarantine at home and shortages of personal protective equipment [].

Another important factor to consider is that patients with cancer were afraid to go to the hospital even when they needed and sometimes decided to cancel their appointments. Stay-at-home campaigns may have reinforced people's awareness about the importance of self-isolation as an effective preventive measure for reducing virus spread and the risk of infection. However, they may also have increased the perception of hospitals as places where people get infected. This could have added further uncertainty to patients whose illness anxiety has already been negatively influencing their mental well-being []. Moreover, 44% of participants reported the fear that their cancer disease would be regarded as of secondary importance. In light of this consideration, health professionals should help patients in prioritising their own health needs [].

Participants reported to take several measures to reduce their infection risk, including hand washing, use of facemasks and gloves. Because patients with cancer usually feel more vulnerable than the general population and are more used to hypervigilance and protective measures, it is not surprising that they adopted preventive behaviours promptly. However, only 54% believed to be at higher risk for COVID-19 infection and 51% for complications. The scarcity of information about who was at higher risk and the reassuring attitudes of many clinicians may have contributed to this perception. Besides, participants had clear in mind the importance of maintaining a positive attitude in light of difficult circumstances. In fact, patients with cancer could be considered experts in adapting to the new normal.

Among spontaneous preventive behaviours, about one-third of participants reported taking supplements as remedies to reduce the likelihood of being infected. These included vitamins C and D, which were not specifically recommended by health professionals due to the lack of evidence from ongoing clinical trials []. On the one hand, this is not surprising as patients feel that they should be doing something on their own and are thereby continuously searching for supplements able to protect their body's cells and tissues from oxidative damage and dysfunction while supporting healthy immune function. On the other hand, self-care strategies such as a well-balanced diet, regular exercise and good relationships seem underestimated for their potential to support the immune response, without interfering with the actual cancer treatment.

In conclusion, we would like to stress again what was expressed by Trapani et al. []: ‘Understanding and implementing the scopes and goals of the global responses and enforcing community flexibility, and not merely advocating for a patient-centred approach. The resilience, capacities, skills and resources of the context must be recognized, and these must be built on to deliver protection and solutions while supporting the community's own goal. The ultimate goal now is to end COVID-19 as one global community’. To succeed in COVID-19 and cancer management, the understanding of the unanswered health needs of patients with cancer is pivotal a multi-professional call to action to build a sound strategy in every context is needed.