COVID-19 update

Below we have included extracts from the guidance and FAQs summary produced by the One Cancer Voice charities and signed off by NHS England.

The guidance is developed for organisations supporting people with all forms of cancer, however, we have focused on the areas that are most relevant to blood cancers or blood stem cell transplants, namely the general introductory advice and questions 3, 4, 12, 21 and 26.

Q&A for cancer charity support lines: UPDATE 4 June 2020

1. Summary of Government advice

The Government is advising everybody to:

• Stay alert
• Stay at home as much as possible
• Work from home if you can
• Limit contact with other people
• Keep your distance if you go out (two metres apart where possible)
• Wash your hands regularly.
• Do not leave home if you or anyone in household has symptoms of coronavirus. In the first instance, please refer to wider Government guidance on:
• Staying at home if you think you have coronavirus (self-isolating)
• Staying alert and safe (social distancing)
• Staying alert: what you can and cannot do
• Staying safe outside your home
• How to protect clinically extremely vulnerable people (shielding) The Government have a wide range of information to help people at this time, including on employment, financial support, and childcare. See www.gov.uk/coronavirus.

2. Summary of key lines for patients

Cancer services during the restoration and recovery from COVID-19.

The NHS is currently moving into the next phase of its response to the COVID-19 outbreak: to restore and recover all services for patients.

If you need to access care or treatment for suspected or diagnosed cancer, arrangements have been put in place to keep you safe from COVID-19.

If you have a worrying symptom, and you think it might be cancer, please contact your GP surgery straightaway. GP surgeries are offering online consultations and/or remote triage so that people do not have to attend in person unnecessarily.

If you have been asked to go to hospital for further investigation or for treatment if you are diagnosed with cancer, it is important that you attend.

The NHS is reorganising the way that it delivers services to keep you safe, including:

• COVID protected hubs have been established for cancer surgery across the country to keep patients safe. These are in COVID-protected areas of a hospital or on separate hospital sites. The model is now being expanded to cover diagnostics too.
• Wider measures are also being taken by all hospitals treating COVID patients to ensure that COVID and non-COVID patients are kept separate. This may include using separate entrances for COVID and non-COVID patients, ensuring staff and patients do not move between different parts of the hospital, and making sure that, as far as possible, staff are social distancing both inside and outside clinical areas.
• The staff caring for cancer patients will be vigilant for any symptoms that they or their families are showing and are required to self-isolate in line with government guidance. Staff will be tested for the virus if they are displaying symptoms. Hospitals are also introducing testing for staff not displaying symptoms where there is testing capacity to do so.
• All patients can support NHS staff to maintain COVID-protected environments by being aware of any symptoms they or their family may be displaying, and by following the advice of the clinical teams working with them. If a patient is uncertain whether they should come into the hospital, they should discuss this with their clinical team. The NHS is here for you if you need it: help us to help you.

Q&A People living with cancer now

Q3 Do I need to do anything differently as someone who is being treated / in remission from cancer/living with a chronic cancer?

People with certain cancers and those who have received or are receiving certain treatments are at risk of severe illness if they catch coronavirus (COVID-19). This includes:

• people with cancer who are undergoing active chemotherapy
• people with cancer who are undergoing radical radiotherapy for lung cancer
• people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
• people having immunotherapy or other continuing antibody treatments for cancer
• people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
• people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs.

The Government updated their guidance for these people on 31 May, and advises them to continue to take precautions in order to keep themselves safe:

1. If you wish to spend time outdoors (though not in other buildings, households, or enclosed spaces) you should take extra care to minimise contact with others by keeping 2 metres apart.
2. If you choose to spend time outdoors, this can be with members of your own household. If you live alone, you can spend time outdoors with one person from another household (ideally the same person each time).
3. You should stay alert when leaving home: washing your hands regularly, maintaining social distance and avoiding gatherings of any size.
4. You should not attend any gatherings, including gatherings of friends and families in private spaces, for example, parties, weddings and religious services.
5. You should strictly avoid contact with anyone who is displaying symptoms of COVID19 (a new continuous cough, a high temperature, or a loss of, or change in, your sense of taste or smell).

The NHS has written to people in these groups with advice and information about what to do during this time, and where to access support. This advice will be in place until at least the end of June. Please visit the Government website for more information regarding shielding advice.

If you are affected, and have a scheduled hospital or other medical appointment during this period, talk to your clinical team to ensure you continue to receive the care you need and determine which of these are absolutely essential.

Q4 Why has the shielding guidance been updated now?

The government has updated its guidance for people who are shielding taking into account that COVID-19 disease levels are substantially lower now than when shielding was first introduced. The number of cases is falling and the average rate of incidence of the virus has fallen from around 1/40 to 1/1000 cases per week, delivering greater reassurance that it is safe to cautiously reflect this in the guidance for those who have been advised to shield.

1. This means before, during or after treatment, including those being managed expectantly
2. When applying these criteria locally, clinicians should take into account the new COVID-19 NICE guidance on haemotopoietic stem cell transplantation (HSCT) which states that patients should follow shielding advice:
   • if they had an autologous HSCT within the last year
   • if they had an allogeneic HSCT within the last 2 years, or they are having continuous immunosuppressive therapy, they have chronic graft versus host disease (GvHD) or there is evidence of ongoing immunodeficiency (or for other extremely vulnerable groups based on clinical assessment).

Q12 What will happen to my cancer treatment? For example:

• Will it be postponed?
• Should I still go to hospital appointments?
• How will my hospital decide whether I am a priority for treatment? Will there be national rules?
• If treatment, including stem cell transplants, are deferred and I begin to relapse will this limit my eligibility for future lines of treatment?
• Should I start chemotherapy treatment (particularly if it is a 2nd/3rd line for "mop up") or postpone?
• As a stage 4 patient will I be given life support if I have breathing difficulties due to the virus?
• If I get the virus and recover, will this affect my cancer treatment and outlook? The NHS is currently moving into the next phase of its response to the COVID-19 outbreak: to restore and recover NHS services so that they start to operate as they did before the pandemic. This means that cancer diagnosis, treatment and care are continuing, and the NHS is working to ensure that these services return to operating as they did before. Changes are being made to the way services are delivered to keep patients and staff safe. For example:
• COVID-protected hubs have been established across the country to ensure that cancer treatment continues. The hubs support hospitals across the NHS and independent sector to work together to maximise capacity and ensure that people receive the treatment that they need. Some patients may start to see their treatment move to a different hospital as these hubs are set up.  You will remain under the care of your treating hospital and clinical specialist team and should contact them with any questions about your treatment and care.
• Most hospitals have started to use more telephone consultations as a way of helping people to avoid long waits in clinics and for treatment. You may be called to arrange your treatments in this way, and planned treatments may need to be moved to help with running a smooth service.
• Some patients may have their chemotherapy at home or have fewer radiotherapy appointments, to reduce visits to hospital while continuing with their treatment.
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• For some people, it may be safer to delay surgery. Your doctor may suggest a different treatment in the meantime, such as chemotherapy or hormonal therapy. Wider measures are also being taken by all hospitals that are treating COVID patients to ensure that COVID and non-COVID patients are kept separate.
  For example, there may be separate entrances for COVID and non-COVID patients, all patients admitted to hospital as an emergency will be tested for COVID, and patients going into hospital for surgery or another elective procedure will be asked to isolate for 14 days and be offered a COVID test wherever possible.
  
  Your clinical team are best placed to talk with you about your treatment and appointments. They will work with you to determine the best course of action in each individual situation. If you have any concerns or questions about your treatment, please speak to your clinical team.

Q21 Does having had cancer treatment in the past. for example, stem cell transplants, chemotherapy, radiotherapy, in the past – even if I am now in remission – increase my risk if I get the virus?

This depends on the type of cancer and the treatment you have had. Most people make a full recovery after cancer treatment and their immune system either recovers fully or is not affected. See Q3 for further information. Family/friends/carers of people living with cancer - please refer to the wider Government advice to protect yourselves and family/friends:

• Full guidance on staying alert and safe (social distancing)
• Staying at home if you think you have coronavirus (self-isolating)
• How to protect clinically extremely vulnerable people (shielding)

Q26 Does the clinically extremely vulnerable people category include:

• Only patients undergoing active chemotherapy for lung cancer? No. Everyone undergoing active chemotherapy is included.
• Patients who have received chemotherapy in the past three months? People’s immunity remains compromised for some time after finishing chemotherapy and clinical teams will be aware of this when considering their highest clinical risk patient lists. If you have completed chemotherapy in the last 3 months, please contact your care team to discuss your specific circumstances. In the meantime, you should follow the Public Health England guidance on ‘shielding’ - in summary, stay at home and avoid face-to-face contact until at least the end of June.
• Patients with blood disorders who are immunocompromised but not receiving chemotherapy? Yes. These patients are included within ‘people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment’.
• Patients having radiotherapy for metastatic lung tumours? Yes. These patients are included within ‘people with cancer who are undergoing radical radiotherapy for lung cancer’.
• Patients with metastatic cancer in the lungs who are not currently receiving treatment? People with metastatic cancer in the lungs could be more vulnerable and therefore at highest clinical risk from Covid-19. Vulnerability will depend on the type of cancer and treatments that you have had. If you have not received a letter, please contact your care team to discuss your specific circumstances. In the meantime, you should follow the Public Health England guidance on ‘shielding’ – in summary, stay at home and avoid face-to-face contact until at least the end of June.
• Patients having any targeted treatments (more than just antibody treatments)? Would anti-angiogenesis targeted drugs fit into that? Yes, all these treatments carry excess risk and therefore people receiving these treatments would be included. These patients are included within ‘people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors’.
• Transplant patients? Yes, if they have had a transplant within the last 6 months, and if they are taking any immunosuppression. These patients are included within ‘people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs’.
• Patients autologous as well as allogeneic transplants in the last 6 months? Yes.
• All patients with rare diseases? No, how rare the disease is not relevant. The issue is whether the disease significantly increases the risk of infection. If a patient has a rare disease and that disease significantly increases their risk of infection, they will be included in the category of clinically extremely vulnerable people.