By Jii Bum Lee, MD, and Sun Young Rha, MD, PhD

Proper treatment of patients with cancer during the COVID-19 pandemic is our foremost priority, especially for immunocompromised patients. The most important way to protect patients with cancer is to help them avoid exposure to COVID-19. In response to the COVID-19 pandemic, Severance Hospital, Yonsei University Health System in South Korea developed precautionary protocols that apply to all facilities within its premises, including Yonsei Cancer Center. We are following standard safety measures that apply to everyone, screening high-risk patients, and developing protocols for both outpatients and inpatients.

We believe that sharing our experience of COVID-19 screening may shed light on cancer management during this particular time.

Safety Measures

Since February 2020, hospital staff, patients, and caregivers have taken safety measures to avoid COVID-19 infection.

• Most of the entrance doors are sealed. Only designated doors with screening systems are used. Everyone must complete a COVID-19 screening form which is available in both paper and QR code. They must provide information about their travel history within 14 days, history of admission or visit to other hospitals at risk within 14 days, and whether they have experienced recently developed fever or respiratory symptoms related to COVID-19 infection.
• At walk-through screening areas, everyone who comes to the hospital has their temperature checked before entrance. This includes all health care workers as well as patients and caregivers. People who are afebrile are given stickers which they must wear at all times. The stickers are different every day.
• At drive-through screening areas, all drivers and passengers entering via the parking lot are checked in the same manner.
• Patients with cancer are requested to wear the highest level of mask protection to prevent both exposure and spread of coronavirus.
• Doctors, physician’s assistants, nurses, and all hospital staff including medical students must wear masks.
• Hand sanitizer is available at the entrance, elevators, and facilities within the cancer center.
• Elevator buttons are covered with antiviral films to prevent infection via contact (see photo below).

COVID-19 Screening

1. High-risk patients: High-risk patients are defined as the following: patients with cancer who have traveled overseas within 14 days (Group A), patients with cancer with a history of admission to emergency department or hospitals with recent outbreak of COVID-19 (Group B), and patients with cancer who have had contact with someone who has or is suspected of having COVID-19 infection (Group C).

• For asymptomatic patients:
  • Group A: We recommend they postpone their visit to cancer center for 14 days unless there is an emergent condition.
  • Group B: Patients must bring COVID-19 screening results done within 72 hours. If they do not have COVID-19 results, they are sent to the COVID-19 screening center located in Severance Hospital. 
  • Group C: Patients are sent to the COVID-19 screening center.
• For symptomatic patients:
  • Patients are immediately sent to the COVID-19 screening center. They are to self-isolate for 6 hours until they receive negative results for coronavirus. If tested positive, they are admitted to the COVID-19 ward.

2. Outpatient clinic in cancer center: Patients scheduled for outpatient clinic must comply with the following protocols.

• Day before cancer center appointment
  • Prior to appointments, patients receive text messages from the cancer center regarding safety protocols and the high-risk patient criteria as defined above. Outpatients in group A, B, and C must alert administration workers or nurses and follow protocols for high-risk patients.
  • If the patient has a fever (>37.5°C) and any respiratory symptoms (cough, sputum, rhinorrhea, headache, dyspnea) that recently developed, they must call the Korea Centers for Disease Control and Prevention (KCDC). Then, the patient is treated in the designated hospital by KCDC.
• Day of appointment
  • All patients who enter the outpatient clinic have their temperatures checked by nurses.
  • Only one family member or caregiver is allowed to accompany the patient, and must follow the same screening protocols.

3. General admission process for patients with cancer: Where the patient will be tested for COVID-19 depends on whether the patient is symptomatic or asymptomatic. Symptomatic patients must first go to the COVID-19 screening center within the Severance Hospital system. However, asymptomatic patients in Groups A, B, and C can be screened for COVID-19 after being admitted to the cancer center. Patients in these groups are isolated as follows:

• Group A: Patients are admitted to a single-bed isolation room only. They are isolated for a maximum of 14 days.
• Groups B and C: Patients are admitted to a single-bed isolation room. They are isolated for 7 days from the date of previous discharge or previous exposure. They are allowed to use multiple-bed rooms after testing negative for coronavirus on the seventh day.

4. Intensive care unit (ICU) for patients with cancer who are COVID-19-negative: Patients with cancer from the emergency department or general ward who need medical ICU (MICU) care are all initially screened for COVID-19 within 72 hours of ICU admission. They must wait for results in the area where they are being treated. If patients are COVID-19-negative, then they are admitted to MICU. Patients with cancer and pneumonia, however, must be screened once more, and the tests must be done 24 hours apart. Only COVID-19-negative patients are allowed in MICU. Patients who are positive for COVID-19 are sent to the COVID-19 ICU.
5. Admission for patients with cancer who are COVID-19-positive: COVID-19-infected patients are admitted to a separately designated area that includes a general ward and an ICU. Infection and pulmonology specialists primarily take care of severely ill patients. All patients must test negative for COVID-19 two times before moving to general wards.

Take-Home Message

At Yonsei Cancer Center, we have two strategies against the COVID-19 pandemic. First, we protect our patients with cancer from symptomatic COVID-19 patients or asymptomatic carriers. Second, we take proactive measures, which include early and repetitive COVD-19 tests, to screen for candidates requiring intensive supportive care. To do so, collaborative efforts between health care workers, patients, caregivers, and centers in the medical campus are critical. We hope that our experiences will help other cancer centers to take precautionary measures.

Dr. Lee and Dr. Rha are physicians in the Division of Medical Oncology at Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea.