COVID-19 FAQs

1. What is a pandemic?

The definition of pandemic according to the World Health Organization (WHO) is a worldwide spread of a new disease. A pandemic occurs when a new disease emerges and spreads around the world, and most people do not have immunity.

2. What is coronavirus? What are the signs and symptoms of coronavirus?

Coronaviruses are a family of viruses that can cause illnesses such as the common cold, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). In 2019, a new coronavirus was identified as the cause of a disease outbreak in China. The virus is now known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease it causes is called coronavirus disease 2019 (COVID-19).

Signs and symptoms of COVID-19 may appear two to 14 days after exposure and can include:

• Fever
• Cough
• Shortness of breath or difficulty breathing

The severity of COVID-19 symptoms can range from very mild to severe. People who are older or have existing medical conditions, such as heart disease, may be at higher risk of serious illness. This is similar to what is seen with other respiratory illnesses, such as influenza.

SOURCE: Mayo Clinic.

3. What is the best estimate for the incubation time after exposure?

According to information from the CDC, the estimated incubation period for COVID-19 ranges from two to 14 days, based on existing literature from other coronaviruses such as MERS-CoV and SARS-CoV.

EVIDENCE: CDC last reviewed: March 10, 2020, accessed March 15, 2020

SOURCE: ASCO COVID-19 Clinical Oncology FAQs

4. Are there guidelines for a practice to follow if a patient tests positive for COVID-19? If a patient is seen at an outpatient clinic, should the clinic be quarantined?

At this time, there is no published guidance available that would address the specific question of how an outpatient facility should respond if a recently seen patient is found to have COVID-19 infection beyond what is described in the CDC guidance. The CDC has published guidance for infection control and prevention in health care settings in the context of COVID-19 (Updated March 10, 2020. Accessed March 11, 2020).

The CDC also published guidance for risk assessment and public health management of health care workers who may have been exposed or who are infected with COVID-19 (Updated March 7, 2020 (Accessed March 11, 2020).

Clinicians and radiation oncology practices are encouraged to follow this guidance where possible. The practice points may be considered to guide clinic preparation and planning:

Staff Preparedness:

• Office/clinic staff may need additional training to screen patients for possible COVID-19 infection/other infections.
• Procedures to isolate potentially infected patients may need review and updating.
• Clinic staff may need additional training on the use of personal protective equipment (PPE).
• Additional PPE may need to be obtained/sourced, as staff that do not usually use it may be required to perform tasks where it is appropriate.
• Clinic staff may need additional training on how to obtain SARS-COV2 testing for patients according to current testing guidelines.

Patient scheduling:

• It may be reasonable to postpone routine follow-up visits of patients not on active cancer treatment or to conduct those appointments via telemedicine.
• Consider calling all scheduled patients one day in advance of the clinic visit to screen for COVID-19 exposure/symptoms.

Treatment planning:

• For patients with fever or other symptoms of infection, a comprehensive evaluation should be performed as per usual medical practice.
• For patients diagnosed with COVID-19 on active anti-cancer treatment, follow standard clinical management plans for delay or modification of treatment.
• Current information suggests that cancer patients have higher risk of infection and serious complications from COVID-19 than other patients. For patients without known COVID-19 infection, in most circumstances it is likely more important to initiate or continue systemic cancer treatment than to delay or interrupt treatment due to concerns about potential COVID-19 infection. However, decisions should be individualized after considering the overall goals of treatment, the patient’s current oncologic status and treatment tolerance as well as their general medical condition.

EVIDENCE: No specific evidence was identified in a PubMed search on the question of clinic-wide quarantine in an outpatient setting. An internet search located the CDC guidance, as well as guidance from other national jurisdictions and the World Health Organization (WHO). WHO guidance was considered substantially similar to the CDC’s. All searches conducted on March 11, 2020

SOURCE: ASCO COVID-19 Clinical Oncology FAQs

5. Is it recommended that patients on treatment and neutropenic but who are not hospitalized wear a mask outdoors? Is an N95 necessary?

See FAQ Updates from June 2020 for updates to information with strike through.

At this time, no specific evidence or guidance on mask use in cancer patients has been published. There is no guidance or evidence to suggest that N-95 masks are required. Patients and clinicians are urged to follow the U.S. CDC’s general recommendations on mask wear.
 
 However, for staff interfacing with direct high-volume patient care such as radiation therapists, the work group consensus recommends the following:

• Encourage routine non-95, surgical masking of radiation therapists for all patients, if your health system can support this from the standpoint of PPE supply.
• Encourage minimum of droplet precautions for any COVID-19 positive or COVID-19 suspected patient.
• Encourage patient and therapist hand-washing prior to and after entry into the vault for all patients. 

EVIDENCE: No specific evidence identified in PubMed searches conducted March 11, 2020. Internet search identified CDC mask wear guidance (Updated March 10, 2020. Accessed March 11, 2020).

SOURCE: ASCO COVID-19 Clinical Oncology FAQs

6. How should radiation oncology departments prepare for significant resource depletion and/or staff shortages with the COVID-19 outbreak?

It is important to have clear protocols for COVID-19 and COVID-19-suspected (Patient Under Investigation (PUI) or screen positive patients) who are not undergoing aerosol-generating procedures (e.g., on a ventilator, receiving anesthesia that requires an airway, etc.). Work with your ID team to establish these protocols ASAP. Droplet precautions should be used for these patients and limiting the personal protection equipment (PPE) to only required clinical staff (e.g., medical students are being excused from seeing these patients). Separate protocols may be required for patients undergoing aerosol generating procedures in your department insofar as these are high risk (e.g., vent-dependent patients, anesthesia requiring intubation, etc.). In some cases, more resource intensive airborne precautions may be needed for these patients (e.g., CAPR or N95 with a face mask and eye protection, ideally in a negative pressure room, etc.).

Minimum staffing requirements for your department should be determined, scaled to your patient volume, for all of your patient-facing personnel (nurses, therapists, physicists, physicians, trainees). A “work from home” approach has been implemented in many practices where patient-facing personnel only come in when they have clinical activities that require on-site presence. Clinic staff may be asked to work from home when their presence on-site is not required. This will help minimize the risk to patients and may help preserve the workforce by limiting their risk of COVID-19 exposure at work from fellow colleagues. Once minimum staffing requirements are determined, the absolute minimum staffing required for safe patient care should be ascertained. Creation of minimum staffing requirements will also allow consideration of contingencies in the event of severe workforce depletion (e.g., threshold for referring patients elsewhere, etc.)

Work aggressively to minimize risk. Emphasize to staff and colleagues the importance of self-screening (unless you have an active screening program implemented) and self-isolation if they have respiratory symptoms (fever, cough, shortness of breath, etc). Most clinicians and staff try to “work through it” when ill due to their commitment to patient care and fellow colleagues, but this is not appropriate during this pandemic. Staying at home when clinic staff have respiratory symptoms is the best way to protect patients as well as colleagues. SEE ALSO FAQs #13 and #15

SOURCE: Institutional experience, multiple sites

7. Should I wear gloves during a routine physical exam on an asymptomatic patient with no risk factors?

There is no reason to do so at this time. Be vigilant re: hand hygiene and wiping down any equipment that touches the patient (stethoscope, etc.). Additionally, any equipment that touches mucosa/secretions of the patient must be sterilized (rhinolaryngoscope, etc.).

SOURCE: Institutional experience, multiple sites

8. Should we be delaying new consult/starts of patients who can be triaged for two to three months (e.g., prostate cancers on ADT) when significant community spread of COVID-19 is detectable in our area? Should we delay new starts of more indolent cancers (e.g., skin cancers, new adjuvant breast radiation, new prostate radiation, etc.)?

New patient consults and new patient starts may be triaged on a case-by-case basis according to the urgency of the situation following discussion with the multidisciplinary care team. Examples of non-urgent cases that may be delayed for up to two months include prostate cancer patients; certain breast cancer patients, e.g., hormone receptor positive; and benign CNS patients, such as meningiomas or schwannomas. Patients with benign conditions requiring immediate post op radiotherapy, such as keloids or heterotopic bone, should discuss rescheduling with their surgeon. Care must be taken to avoid delays in consultation and treatment which may adversely affect potentially curable cancer patients. Staff reductions may force longer delays in planning and/or scheduling. Palliative care patients may also experience delays, with the exception of life- or function-threatening situations, e.g., spinal cord compression, cranial nerve compression, superior vena cava syndrome, airway obstruction, hemoptysis.

SOURCE: Institutional experience, multiple sites

9. Should we assess patients via telephone or telemedicine to avoid entering the clinic?

Many institutions/practices are converting routine clinic visits, such as follow-ups to telephone or telemedicine encounters, including second opinion consultations. For patients who are being referred well in advance of when a definitive course of radiotherapy would be offered, deferring consultation to a later date, after discussion with the referring physician, or using telemedicine/telephone has become the norm.

SOURCE: Institutional experience, multiple sites

10. What measures should we take regarding routine follow-up visits for patients in surveillance who are not feeling ill? When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as scheduled?

From currently available data, all cancer patients are at higher risk of COVID-19 related mortality, and older people (men more than women) appear to be at higher risk of COVID-19 related mortality than younger people. Thus, efforts to reduce the risk of exposure of COVID-19 to all patients are needed, for example with reduction in the frequency of follow-up visits and replacing in-person visits with telephone or remote telemedicine follow-up.

All asymptomatic routine follow-up patients may be rescheduled for three months or longer. The majority of patients who have recently completed radiotherapy can safely have their follow-up extended by two to three months or more, with telemedicine as needed.

There are published data on nurse-led telephone follow-up and virtual PSA monitoring suggesting that prostate cancer patients can be monitored remotely unless symptomatic or with concerns for clinical progression.

A small study randomizing lung cancer patients to symptom-based follow-up versus routine imaging found a survival benefit favoring symptom-based strategy. Whether telephone follow-ups can substitute in the short term for in-person visits is unknown.

EVIDENCE: Casey et al. (2017), Boyajian et al (abstract ASTRO 2018), Denis et al (2019)

SOURCE: Institutional experience

11. How should patients be assessed prior to entering the clinic? What questions should patients be asked when being screened? What should be done with screening-positive patients?

Ideally, patients should be screened by clinic staff before the patient comes to the radiation department/clinic. For any patients with symptoms of COVID-19 infection (fever, cough, increased shortness of breath), administrative staff should discuss with nursing and/or radiation oncologists to recommend appropriate triage based upon each facility’s current operating procedures to address potential new cases of coronavirus infection.

If symptomatic patients arrive in clinic, or pre-screening is not possible, screening should be performed on arrival by administrative staff, and nursing should be contacted about triage for any potential positive patients. Screening positive patients should be isolated in a special waiting room or separate exam room while appropriate staff is consulted re: next steps (i.e., treat/no treat). The patient's PCP should be contacted for further instructions. Do not send the patient to the PCP's office unless instructed to do so.

SOURCE: Institutional experience, multiple sites

12. What are some practical steps that can be done to protect clinic staff?

See FAQ Updates from June 2020 for updates to information with strike through.

Each clinic must determine what is possible and what facilitates essential patient care. The first step is to create a plan for your facility. The following are practical first steps to consider:

Screen staff:

• Educate staff to red flag symptoms (fever, cough, shortness of breath).
• Mandate self-reporting of symptoms and exposures by all staff.
• Symptomatic staff should remain home and await further instruction re: when to return to work, testing, etc..
• Proactively screen staff each day and mark them as screened on their badges (similar to flu stickers) or some similar method of tracking.

Prevention

• Increase disinfection according to CDC guidelines.
• Protect janitorial staff with safe handling of trash and linens.
• Consider masks and gloves for therapists who are in contact with patients.
• Consider wearing clean scrubs daily rather than dress clothes.
• At this time, no specific evidence or guidance on mask use in cancer patients has been published. There is currently no guidance or evidence to suggest that N-95 masks are required for these patients.
• Patients and clinicians are urged to follow the U.S. CDC's recommendations on mask wear.
• For staff interfacing with direct high-volume patients care such as radiation therapists, the work group consensus recommends the following:
  • Encourage routine non-95, surgical masking of radiation therapists for all patients, if your health system can support this from the standpoint of PPE supply.
  • Encourage droplet precautions for any COVID-19 positive or COVID-19 suspected patients.
  • Strongly encourage patient and therapist hand-washing prior to and after entry into the vault.

Social distancing

• Allow non-essential staff to work from home when possible.
• Consider shift work using skeleton crews of minimally essential personnel. If one team is infected or quarantined, a second and third line team can step in to continue patient care. Practices with multiple physicians may wish to consider a rotating schedule with at least one radiation oncologist out of clinic and available for back-up.
• Keep six feet apart in clinic and workspaces where possible.
• If space allows, consider individual staff working out of exam rooms or offices, rather than team stations.
  SEE ALSO FAQs #6 AND #15

SOURCE: Institutional experience, multiple sites

13. What is the best way to disinfect the clinic?

According to CDC guidelines: The necessary frequency of cleanings is unclear, but it is recommended that individual clinics work to clean their facility at least once daily, but as often as feasible with staffing. As mentioned, carefully clean stethoscopes/exam tools in the clinic. Consider bagging all patient positioning devices and blocks in the treatment room with thorough cleaning before and after treatment. All high-volume contact surfaces need regular cleaning including counters, cell phones, light switches, faucet and toilet knobs, doorknobs and door faces, and keyboards.

SOURCE: CDC

14. How can we limit patient volume in the clinic to decrease the risk to staff?

There is no “one size fits all” recommendation; it depends largely on the patient population and case mix of an individual practice.

Here are a few measures that one can take to decrease risk to staff:

• Limit the number of people allowed to accompany the patient (e.g., no more than one)
• Consider asking patients with a mobile phone to wait in their car until their scheduled treatment time or until staff contacts the patient to come inside. This limits the number of people in close proximity in the waiting area.
• Defer non-urgent patients or utilize temporizing measures (e.g., length of neoadjuvant ADT for intermediate/high risk prostate cancer patients, practicing short-term active surveillance for low-risk prostate cancer patients seeking treatment, etc.)
• Use hypofractionated or short-course regimens when appropriate (e.g., 800 x1 for palliative)
  SEE ALSO FAQs #6 AND #13

SOURCE: Institutional experience, multiple sites

15. What sort of education should we be providing to patients and their families?

First, educate yourself with the CDC guidelines for healthcare professionals. Educate patients and families on red-flag symptoms such as fever, cough, or shortness of breath. Reinforce the importance of prevention with social separation (maintaining three to ten feet distance from others in public) and good hygiene (hand washing, covering their cough, avoiding touching their face). Tell them that symptoms can occur two to 14 days after exposure, and ask them to report exposure to symptomatic or test-positive persons or recent international, cruise, or air travel.

Encourage patients to continue their life-saving treatments, and comfort them and their families in this stressful time. Educate them on your department’s policy for their personal care if they become sick.

SOURCE: Institutional experience, multiple sites

16. How should we treat patients who are infected with COVID-19?

The answer to this is complex and evolving. It will require physician discretion personalized to each patient and clinic.

Any treatment of infected patients should balance the risks for each clinic, but will require:

1. Reassessment of the patient’s goals of care. Consider cancelling or delaying cancer treatment until the patient has recovered.
2. Appropriate personal protective equipment (PPE) available for treating staff.
3. Terminal cleaning of RT vaults, masks, blocks and clinics according to CDC guidelines as discussed above.
4. Consider placing all treatment devices (e.g.,blocks, masks, etc.) in bags with labels to prevent cough droplets from contaminating them, wipe down and change bags daily.
5. Careful handling of all trash and laundry to protect clinic and janitorial staff transmission. EVS staff must also have access to appropriate PPE.

In the absence of CDC guidance specific for oncology clinics, the following considerations may be employed if there is a need to provide care to a suspected or confirmed COVID positive patient.

• Isolating these patients to one section of the department or one treatment unit. Some practices have allocated specific entrances/exits for these patients (e.g., a service or ambulance entrance) to minimize exposure to other patients and staff (extrapolated from CDC Hemodialysis guidance).
• After-hours or end-of-day shifts for infected patient treatments. Conversely, creating a period of time early in the day for highly vulnerable but non-infected patients. (e.g., patients >60-years with compromised respiratory function, airway issues or impaired immunity).
• In a multi-center practice, consider triaging of suspected or confirmed COVID positive patients to one center to consolidate and minimize exposure risk to non-infected patients and staff. This may not be feasible until testing is more broadly accessible.
• Deferring treatment of infected patients until asymptomatic for at least 72 hours. Some institutions suggest two negative swabs.
• Deferring treatment of patients requiring respiratory support for COVID associated cardiopulmonary symptoms until they are stable.
• Increased use of hypofractionation where possible.
• Personalizing altered fractionation plans for patients who have interrupted treatment.

SOURCE: Institutional experience, multiple sites

17. What changes are recommended for RO residency programs?

Each residency program should assess their own clinical operations to determine what is feasible and maintains both resident education and safety. Multiple programs are encouraging social distancing with remote work (e.g., consult prep, treatment planning), teleconferencing for didactics, and shifts of in-person resident clinical duties. An evolving, resident self-reported document of policies hosted by ARRO can be found here.

SOURCE: ARRO

18. Are there any issues related to quality and safety that my department should consider due to COVID-19-based changes to our process of care?

There are simple steps that can be taken to mitigate the chance for unexpected deviations in care. Department leaders should ensure that all staff understand any related changes in department workflow or processes of care, and a reminder of the expectation to maintain quality and safety. Uncertainty about what is expected can lead to confusion, putting both patients and staff at risk. It should be made clear to all staff that if any particular decision or step in the process of care seems unclear or out of place, it should be discussed with the radiation oncologist prior to treatment. Ideally, there should be a clear line of communication from staff to department leadership to express any concerns about quality and safety and to have those concerns addressed immediately. Workflow changes, such as working remotely, should be accommodated in a way to create the smallest impact on clinical decisions. For example, viewing images from home on a small laptop may not be ideal. In these cases, careful consideration as to what work can effectively be done remotely should be discussed and addressed. Special considerations for reduced staffing levels should also be considered. Lastly, staff leadership should clearly explain to department personnel any policy or process changes that differ from the standard operating procedures of their clinic. SEE ALSO FAQs #6, #13, #15

SOURCE: ASTRO Clinical Affairs and Quality Council

19. Can we use a linear accelerator to sterilize PPE?

At this time, ASTRO does not recommend the use of clinical linear accelerators to sterilize PPE. While ionizing radiation is used for sterilization of blood and food products, this is achieved using industrial irradiators that use gamma irradiation at doses rates far greater than that which can be safely delivered with a linear accelerator found in a radiation oncology clinic. In addition, it is not clear what dose would be required for sterilization of a live virus, such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Until more data is available and the appropriate dose and procedures are known, the increased risk of potentially re-using a mask that is not completely sterilized far outweighs the benefit of attempting to sterilize PPE with a clinical linear accelerator.

SOURCE: ASTRO Clinical Affairs and Quality Council