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Table 1. Specialist outpatient clinic attendances for thoracic cancers in TTSH in 2019 and 2020, prior to and during the
COVID-19 pandemic
2019 (Jan-Dec) 2020 (Jan-Aug) Percentage change
No. of first visits Total 135 100
Monthly average 11.25 12.5 +10%
No. of review visits Total 2,048 1,256
Monthly average 170 157 -8%
TTSH: Tan Tock Seng Hospital; COVID-19:Coronavirus disease 2019; No.: number

pandemic also stated that high priority should be given for outpatient lung cancer patient with a new
diagnosis or suspicion of invasive lung cancer (clinical stage II/IIIA/IIIB or metastatic NSCLC or SCLC)
and patients with disease-related symptoms (dyspnoea, pain, haemoptysis, etc.) and the need for visits for
[24]
treatment administration . Recently, many guidelines and consensus statements have been published
related to cancer management during the COVID-19 pandemic to provide guidance to oncologists during
this difficult period [21,23,25] . The guidelines recommend that the clinical situation and quality of care for a
patient with lung cancer should not be changed, treatment plans should continue to be discussed with
a multidisciplinary team and implementation of the recommendations by the multidisciplinary team
[26]
should not be considered negotiable in light of the COVID-19 pandemic and its challenges . The ESMO
guidelines are defined by 3 levels of therapeutic intervention. Firstly, the high priority tier focuses on
immediately life-threatening cases, clinically unstable cases, and/or cases where the magnitude of benefit
appears to be substantial leading to a significant improvement in overall survival or quality of life (QOL).
Medium priority cases include non-critical situations where any more than a 6- to 8-week delay could
impact the patient’s overall outcome or magnitude of benefit. The lowest priority tier is defined as stable
conditions that allow services to be delayed for the duration of the pandemic with no survival benefit or a
change/reduction in QOL [25,26] . Lung cancer treatment at TTSH follows the guidelines as specified by ESMO
in a similar fashion and adapts a “business as usual” model for patients requiring high priority treatment
[Table 2].

For patients with stage III lung cancer who require definitive chemoradiation and small cell lung cancer
patients who require urgent systemic chemotherapy, the medical oncology department at TTSH continues
to prioritise timely interventions and strives to provide the same quality of care as in pre-pandemic
situations. Lung multidisciplinary meetings have continued to function on a regular basis discussing
complex cases with provisions for the setup of adequate social distancing and ensuring only attendance
of key personnel during this period of time to reduce exposure risk and to segregate teams as mentioned
previously.

For patients with small cell lung cancer where systemic chemotherapy is known to be effective and time-
sensitive, medical oncologists often still opt to institute chemotherapy urgently and the first cycle can
continue to be given as an inpatient. Patients who are diagnosed in the peripheral hospitals who require
urgent treatment and medical oncology management would be reviewed on a case-by-case basis and
transfer to TTSH can be arranged upon approval by the Head of Department, Division Head and the
Chairman of the Medical Board of both hospitals.

The medical oncology department at TTSH has instituted certain measures to review the outpatient
clinic list with aims to postpone appointments for patients deemed feasible for a longer interval review
(those with low/intermediate risks of relapse) or who are on mainly survivorship follow-ups. The primary
oncologist in charge of the clinic is asked to review the list of patients scheduled for outpatient clinics
during the height of the pandemic period and prescriptions may be topped up for patients on targeted
therapies if they are deemed to be stable and may be able to delay their follow up appointments. A