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

criteria were subsequently expanded to include all persons with ARI aged 13 and above in view of increase
in community transmission of COVID-19.

Figure 1 illustrates a management algorithm for cancer patients in TTSH presenting with ARI or
radiological findings of pneumonia. For patients on cytotoxic chemotherapy, it is important to exclude
secondary infections and neutropenic sepsis which is a life-threatening oncological emergency. Patients
with incidental infective changes (not attributable to cancer) noted on routine CXR or CT scans done for
response assessment are advised to proceed with COVID-19 testing under the SASH protocol, with non-
urgent outpatient appointments postponed to at least 5 days later. Cases where the need for SARS-CoV-2
testing and disposition are unclear are discussed with the COVID-19 consultant on-call. Currently, routine
testing of lung cancer patients without fever or ARI before initiation of systemic therapy has not been
implemented in our practice.

CHANGE OF PRACTICE IN THE TREATMENT OF LUNG CANCER PATIENTS
Advances in the pace and scope of research, as well as collaboration across hospitals and oncology centres
regionally and worldwide in the creation of multicentre COVID-19 registries, have been critical in
[20]
providing up-to-date knowledge about COVID-19 and its impact on cancer care and delivery . Oncology
societies such as the European Society for Medical Oncology (ESMO), National Comprehensive Cancer
Network (NCCN) and the International Association for the Study of Lung Cancer (IASLC) have also issued
guidelines on lung cancer management during the COVID-19 pandemic [21-23] . While providing a relevant
overarching framework, it is also important to recognise that variations in healthcare resources and severity
of the COVID-19 outbreak across countries affect generalisability of these guidelines. Individualisation of
treatment options remains critical.

The massive rise of COVID-19 infections in Singapore has caused an overload on the healthcare system
and resources have to be reprioritised and distributed between patients with COVID-19 infections as well
as to continue ongoing medical care to the rest of the patient population. Healthcare workers are also under
the pump as clinic staff, nurses and doctors get out-posted to the COVID-19 frontline, leaving less team
members available to continue with the routine clinical workload. During the pandemic, many elective
surgeries and non-urgent procedures are deferred; however, disciplines such as the medical oncology and
radiation oncology departments often could not do the same. It is crucial for patients with lung cancer
to continue treatments in a timely fashion despite the pandemic. The number of patients seen at the
oncology outpatient clinic at TTSH in Singapore has also remained relatively stable during the DORSCON
Orange pandemic period despite a likely reduction in the number of patients undergoing investigations
for new cancer diagnoses and less elective surgeries. The average monthly number of specialist outpatient
clinic attendances in our hospital for patients with newly diagnosed thoracic malignancies increased
slightly by 10% from 2019 to 2020, suggesting the absence of treatment delays despite the pandemic for
patients with newly diagnosed thoracic malignancies requiring systemic therapy. The number of follow-
up visits decreased slightly by approximately 8%, likely due to the planned postponement of non-urgent
appointments such as for patients on survivorship follow-up [Table 1].

There were a total of 1,356 outpatient visits for patients with thoracic malignancies in TTSH from January
to August 2020. There were only 2 cases of COVID-19 diagnosed amongst these patients, both community
acquired without evidence of nosocomial transmission, and zero cases in medical and nursing staff within
the medical oncology department.

Despite the potential increased risk of inadvertent COVID-19 exposure, it is important to weigh the
competing risks of disease progression and treat the patients urgently especially in the cases where there
is an opportunity for cure. The ESMO guidelines regarding treatment of cancer patients during the