Table 2 Proposed special considerations of the cardio-oncology patient during the COVID-19 pandemic
Cardio-oncology aspect of care Theoretical areas of concern Proposed Strategies to Mitigate COVID-19 Exposure
Initiating/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
• Cancer treatments may require healthcare facility/inpatient stay exposing patient to asymptomatic carriers (i.e., HCW)
• Delaying of potential critical, life-prolonging surgery as it may be deemed as “elective”
• 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
• Weighing risk-benefit of postponing/delaying timing of cancer treatments/surgery to minimize exposure to inpatient healthcare setting
• Preoperative/procedural screening and testing for COVID-19
• Telemedicine for routine follow-up cardio-oncology/oncology visits unless clinically symptomatic
• Research efforts investigating earlier utilization of immune system restorative measures post anti-tumor therapy
• Consideration of delaying myeloablative therapies and immunotherapies for patients in clinical remission if possible
• Consideration of minimizing surveillance/staging imaging during and after treatments
Cardiotoxicity 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
• Cardiac imaging and testing may cause further exposure to asymptomatic carriers • Inpatient admission and evaluation as clinically indicated for severe symptoms
• Telemedicine for patients who are asymptomatic or minimally symptomatic, or CVD risk factor modification (i.e., visits for HTN and/or dyslipidemia)
• Preemptive aggressive treatment for suspected symptoms related to CAD, arrhythmias, or CHF and deferring of imaging unless clinically necessary
• Mail ambulatory rhythm monitors to home to evaluate suspected/known arrhythmias
Cardiotoxicity 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)
• 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
• Multidisciplinary discussion with hematologist/oncologist about reducing frequency of cardiotoxicity screening, especially if prior serial testing unremarkable
• Limited imaging protocols to evaluate LVEF to minimize acquisition time
• Defer primary prevention assessment (i.e., dyslipidemia management) unless critical to care of patient
• Telemedicine visits for patients who do not require face-to-face assessment for medical issues (i.e., blood pressure/lipid management/stable CHF)
• Defer asymptomatic long-term cancer survivor surveillance (i.e., assessment of ventricular and valvular function) if no symptoms
BMT 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