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Page 8 of 11 Vong et al. J Cancer Metastasis Treat 2020;6:54 I http://dx.doi.org/10.20517/2394-4722.2020.116

Table 2. Priorities of treatment for lung cancer patients at TTSH (Adapted from ESMO guidelines of management of lung
cancer patients during the COVID-19 pandemic)
Prioritised without Lower priority/
delay Medium priority Delay appointment
Small cell lung cancer treatment *
Neoadjuvant chemotherapy in clinical stage III NSCLC *
Concomitant or sequential chemoradiotherapy for inoperable stage III *
NSCLC
Starting consolidation durvalumab (within 42 days) *
Delivery of adjuvant chemotherapy in stage II/III as recommended by *
lung tumour board
Newly diagnosed lung cancer patients with targetable mutations *
Newly diagnosed lung cancer patients who are candidates for 1st-line *
treatment including chemotherapy, chemotherapy plus IO, IO alone or
TKIs to improve prognosis, cancer-related symptoms and QOL
Start 2nd-line chemotherapy or IO in symptomatic and progressive *
disease patients
Start 2nd-line TKI in progressive disease patients *
Oncological emergencies (management of hypercalcaemia, cord *
compression, SVC obstruction, serious immune mediated adverse
effects etc.)
Start 2nd and beyond line chemotherapy or IO in asymptomatic *
patients, in absence of threatening disease (volume/location)
Discussion of adjuvant chemotherapy for Stage IB *
Anti-PD-(L)1 scheduled cycles may be modified/delayed to reduce *
clinical visits (for instance, using 4-weekly or 6-weekly dosing instead
of 2- or 3-weekly for selected agents when appropriate)
Postpone antiresorptive therapy (zoledronic acid, denosumab) that is *
not needed urgently
Follow-up for patients at low/intermediate risk of relapse *
Survivorship visits *

TTSH: Tan Tock Seng Hospital; ESMO: European Society for Medical Oncology; COVID-19: Coronavirus disease 2019; NSCLC: non-
small cell lung cancer; TKIs: tyrosine kinase inhibitors; IO: ImmunoOncology drug; QOL: quality of life; SVC: superior vena cava; PD-(L)1:
Programmed death-(ligand)1

medication delivery service has been set up by the hospital pharmacy which provided convenience to
patients and carers during the pandemic period in avoiding hospital visits and reducing long wait times at
the outpatient pharmacies. Without compromising patient safety and efficacy, systemic treatment regimens
should be adjusted to reduce hospital visits. Immunotherapy treatments may be given with a longer interval
via dose adjustments such as Nivolumab at 480 mg 4-weekly instead of 240 mg fortnightly; and 400 mg
Pembrolizumab 6-weekly instead of 200 mg 3-weekly. Efforts are also currently underway for pilot and
subsequent larger scale implementation of telemedicine consults.

Important clinical trials that are deemed to impact the patient’s overall outcome and have a significant
magnitude of benefit were able to continue treatment throughout the entire DORSCON Orange period.
Trials that may not have a significant impact on patient’s outcomes, in particular, qualitative research and
survey studies were placed on hold for recruitment during the height of the pandemic period as well.

EDUCATION AND TRAINING OF RESIDENTS AND JUNIORS DURING COVID-19 PANDEMIC
The COVID-19 pandemic has led to a significant impact on post-graduate education in Singapore and
educators now need to consider alternative novel methods of providing education to minimise disruption
[27]
to training of the junior medical staff . Almost universally across all academic centres, there has been
a transition to teaching via videoconferencing technologies which has been recognized as an effective
teaching modality in situations where distant learning is required [28,29] . However, online videoconferencing
teaching had posed several issues including the need for additional information technology resources and
funding for extra laptops, projectors and speakerphones. There is also a need to ensure that the students
have access to a stable internet connection throughout the different sites during the online teaching