PMC:7253235 / 38033-45398 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7253235","sourcedb":"PMC","sourceid":"7253235","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7253235","text":"Care of the Cardio-Oncology Patient in the COVID-19 Era\nThe COVID-19 pandemic has added a significant layer and complexity of how patient care is being delivered due to concerns of bidirectional transmission, with no protective algorithm widely in place to dictate ongoing management of cancer patients [108••]. Initiating cancer treatments, such as targeted immunotherapies and chemotherapy, require special consideration in the COVID-19 era. As previously described, compromised immune systems render patients with cancer at higher risk for acquiring COVID-19 infection and the sequelae that may ensue. Cancer treatment centers and cardio-oncologists must now consider not only the patient but also the integral healthcare workers who are regularly interfacing with high-risk exposures. Devising strategies to ensure robust testing services and clearance mechanisms to protect patient and healthcare personnel is one of many methods now employed to continue ongoing treatments [48, 109, 110]. Though there are no clear evidence-based modifications in systems of care to reduce transmission risk while balancing high-standard cardio-oncology care, various strategies are proposed (Table 2). Life-prolonging surgeries and procedures can slowly be pursued and continued, although the risks of delaying any such advanced treatments—including bone marrow transplantation and chimeric antigen receptor treatment—need to be weighed carefully. COVID-19 screening and testing prior to these surgeries/procedures, while not infallible, should be considered if available due to rising concern for asymptomatic carriers. Following completing anti-cancer treatments, patients may additionally benefit from receiving immune system restorative treatments, such as filgastrim.\nTable 2 Proposed special considerations of the cardio-oncology patient during the COVID-19 pandemic\nCardio-oncology aspect of care Theoretical areas of concern Proposed Strategies to Mitigate COVID-19 Exposure\nInitiating/ongoing cancer treatments (i.e., chemotherapy, targeted therapies, immunotherapy, BMT, CAR-T), and timing of oncologic-related surgery • Compromised immune systems induced by cancer treatments may make patient more susceptible to COVID-19\n• Cancer treatments may require healthcare facility/inpatient stay exposing patient to asymptomatic carriers (i.e., HCW)\n• Delaying of potential critical, life-prolonging surgery as it may be deemed as “elective”\n• Ensuring COVID-19 testing adequacy by healthcare providers • Implementation of universal PPE and social distancing during cancer treatments in outpatient/inpatient settings, and with family members/caretakers\n• Weighing risk-benefit of postponing/delaying timing of cancer treatments/surgery to minimize exposure to inpatient healthcare setting\n• Preoperative/procedural screening and testing for COVID-19\n• Telemedicine for routine follow-up cardio-oncology/oncology visits unless clinically symptomatic\n• Research efforts investigating earlier utilization of immune system restorative measures post anti-tumor therapy\n• Consideration of delaying myeloablative therapies and immunotherapies for patients in clinical remission if possible\n• Consideration of minimizing surveillance/staging imaging during and after treatments\nCardiotoxicity experienced during cancer treatments (i.e., cardiomyopathy, arrhythmias, and ischemic events) • Further delay of cancer treatments and cardio-oncology evaluation because of COVID-19 may increase cardiac and cancer-related comorbidity and mortality\n• Cardiac imaging and testing may cause further exposure to asymptomatic carriers • Inpatient admission and evaluation as clinically indicated for severe symptoms\n• Telemedicine for patients who are asymptomatic or minimally symptomatic, or CVD risk factor modification (i.e., visits for HTN and/or dyslipidemia)\n• Preemptive aggressive treatment for suspected symptoms related to CAD, arrhythmias, or CHF and deferring of imaging unless clinically necessary\n• Mail ambulatory rhythm monitors to home to evaluate suspected/known arrhythmias\nCardiotoxicity surveillance in cancer patients during and after treatment • Some cancer treatments (i.e., anti-HER2, BRAF-MEK treatments, clinical trials) require frequent surveillance of cardiac function (i.e., every 3 months)\n• Patients with known cardiotoxicity, or with known treatments that can cause long-term cardiotoxicity (i.e., anthracyclines, radiation) may not get timely surveillance imaging • Minimize cardiac imaging to patients who are symptomatic\n• Multidisciplinary discussion with hematologist/oncologist about reducing frequency of cardiotoxicity screening, especially if prior serial testing unremarkable\n• Limited imaging protocols to evaluate LVEF to minimize acquisition time\n• Defer primary prevention assessment (i.e., dyslipidemia management) unless critical to care of patient\n• Telemedicine visits for patients who do not require face-to-face assessment for medical issues (i.e., blood pressure/lipid management/stable CHF)\n• Defer asymptomatic long-term cancer survivor surveillance (i.e., assessment of ventricular and valvular function) if no symptoms\nBMT bone marrow transplantation, CAR-T chimeric antigen receptor therapy, HCW healthcare workers, PPE personal protective equipment, CVD cardiovascular disease, CAD coronary artery disease, CHF congestive heart failure, LVEF left ventricular ejection fraction\nAdditionally, the transition to telemedicine to conduct interval cardiovascular and oncologic appointments can potentially protect patients from unnecessarily harmful nosocomial exposures [111, 112]. Certain chronic conditions (i.e., hypertension, stable/compensated congestive heart failure) may not necessarily require a face-to-face visit, whereas highly symptomatic patients should still be seen in the cardio-oncology clinic, preferably on the same day as their cancer outpatient visits. Deferring primary prevention assessments, for example, cholesterol monitoring, unless otherwise indicated can augment protective mechanisms in place. Cardiovascular-related blood draws, if necessary, should be coincided with cancer-related treatments.\nIn addition, the specter of cardiotoxicity related to certain cancer treatments also requires a reexamination of risk and benefit with respect to frequent cardiac monitoring due to previously mentioned concerns. Peri-chemotherapeutic events and development of cardiomyopathy, ischemia, and life-threatening arrhythmias are further worsened by simultaneous COVID infection. Reducing reliance on frequent cardiac imaging in otherwise asymptomatic patients and providing in-mail ambulatory rhythm monitors for patients symptomatic with possible arrhythmias will further assist in mitigating exposure risk. Limited cardiac-imaging protocols (i.e., focused just on ventricular function and/or pericardial disease) if necessary for symptomatic patients or those necessitating cardiotoxicity surveillance can also be devised to reduce exposure time in the healthcare setting. In addition, for patients at low risk of cardiotoxicity and/or with prior serial-documented normal cardiac function, it can be considered to defer serial cardiac imaging in certain treatments (i.e., anti-HER2 without anthracyclines, BRAF-MEK treatments), in multidisciplinary discussions with oncology if the patient is asymptomatic 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