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Page 2 of 11 Vong et al. J Cancer Metastasis Treat 2020;6:54 I http://dx.doi.org/10.20517/2394-4722.2020.116

INTRODUCTION
Since the identification of a cluster of novel viral pneumonia cases caused by the severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) that was first reported in Wuhan, China, in December 2019,
coronavirus disease 2019 (COVID-19) has spread rapidly across the world. As of early August 2020, global
cases of COVID-19 have exceeded 18 million, with close to 700,000 deaths and case fatality ratios (CFRs)
[1]
ranging from 0.1% to 15% across different countries . Singapore saw its first imported case on 23 January
2020, and had one of the highest numbers of reported COVID-19 cases outside of China in February 2020.
There has since been 52,000 confirmed cases and 27 deaths as of early August 2020 locally. Early supportive
care and monitoring are the cornerstones of clinical management for the majority of patients with mild
illness. In patients with severe illness, dexamethasone and remdesivir are 2 drugs that have been shown in
[2]
[3]
randomised phase 3 trials thus far to reduce mortality and improve time to recovery , respectively.
Building on past experience with the severe acute respiratory syndrome (SARS) outbreak in 2003,
Singapore has systemically strengthened its ability to manage emerging infectious diseases outbreaks.
Since 7 February 2020, Singapore has been in Disease Outbreak Response System Condition (DORSCON)
Orange, the second highest national alert level signifying that SARS-CoV-2 has not spread widely in
Singapore and is still being contained . A multi-agency taskforce was formed to coordinate the national
[4]
response to the outbreak. National public health measures implemented include aggressive contact tracing,
mandatory stay home notices for returning travellers, travel restrictions, telecommuting, mandatory mask-
wearing and safe distancing measures at public spaces, workplaces and schools.

The National Centre for Infectious Diseases (NCID) is a 330-bed purpose-built facility officially opened
in September 2019, designed to augment Singapore’s capabilities in infectious disease management and
[5]
prevention . It has been the epicentre of the national response to COVID-19. The provision of clinical
services at NCID is supported by the National Healthcare Group (NHG) and Tan Tock Seng Hospital
(TTSH), which is situated next to NCID within the Novena campus located in central Singapore. TTSH is
Singapore’s second largest tertiary care hospital with over 1,700 beds. The medical oncology department at
TTSH is the third largest oncology provider amongst tertiary public hospitals in Singapore, and also works
closely with other clinical departments and services in TTSH.

The COVID-19 pandemic poses several unique challenges for oncology services, and in particular the
management of patients with thoracic malignancies. A key challenge faced by oncologists is the balance
of the risk of increased severity of COVID-19 in lung cancer patients versus the consequences of delay
in diagnosis and time-sensitive oncological treatment which may occur due to reasons such as changes
in health-seeking behaviour and reallocation of healthcare resources to COVID-19. A global survey of
medical oncologists has demonstrated that COVID-19 has significantly influenced decision-making by
[6-8]

oncologists andsignificant reductions in cancer-related patient encounters have also been reported . We
herein describe several key experiences relevant to the field of thoracic oncology during the COVID-19
pandemic from the perspective of our department and as guided by available data in the literature.

FACILITY AND MANPOWER SEPARATION AND CROSS-DEPARTMENTAL COLLABORATION
COVID-19 is spread primarily via droplets and is highly infectious with a basic reproduction number
(R ) of 2.0-2.5, with established community transmission that has threatened to overwhelm healthcare
0
[9]
systems globally . Disease severity ranges from mild illness in the majority (80%) of patients to severe
[9]
illness requiring mechanical ventilation and intensive care . Patients with advanced age and comorbidities
including cancer, chronic respiratory disease (COPD), uncontrolled hypertension and diabetes are at
[10]
increased risk of severe illness and mortality from COVID-19 . Infection with SARS-CoV-2 can cause
considerable disruption to oncological treatment plans. These factors underscore the critical need for