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Cancer Care Chronicles
April 10, 2020

Caring for Patients With Cancer During the COVID-19 Outbreak in Italy

Author Affiliations
  • 1Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
JAMA Oncol. 2020;6(6):821-822. doi:10.1001/jamaoncol.2020.1426

At the time of this writing, the novel coronavirus 2019 (COVID-19) outbreak was detected in Italy only 5 weeks ago, and it has changed our lives and the lives of our families forever. After a 12-hour shift at our hospital, The National Cancer Institute of Milan, we decided to turn off the lights, put a candle near the screens of our laptops, and share our feelings with the oncology community.

We had come back from Australia and Peru on the previous Saturday morning to the news that the first case had already been discovered in the city of Codogno. We were expecting the first case; we knew that it could happen; we knew it would happen; but we did not know when or where. In the beginning, there was a bit of disbelief and, although the virus was close, it still seemed very far away. It did not help that scientists and politicians were divided into alarmists and nonalarmists. Even we, people of science, could not disentangle ourselves from what was true and what was blown out of proportion. In the second phase, we felt afraid for the elderly, for the most fragile people in the community, but we never thought that the virus would touch all of us so closely. As the time passed we felt more patriotic, and at 6:00 in the evening, when the numbers of the dead were published, people took to their balconies and began singing to life and the national anthem, as they had done in China in the months before. Children hung rainbows out with the words “everything will be fine.” We have all been afraid; we have been glued to the web for hours in a desperate search for comforting news or falling numbers. We tried doing math: if only they locked everything down, within 10 days we will start to see a decrease in the number of deaths. But no, the numbers went up. Today, we rejoice that there were only 600 deaths instead of 800. We felt outrage toward those who refused to stay at home while we were still working. We felt anger toward those who went out for long rides with the dog, those who jogged, and for those who did not understand that their lack of responsibility was putting our lives and the lives of our families at risk. The first great pain I felt was when a dear friend’s relative became sick in a community for the elderly. The fever went up; the first test results were negative; the fever stayed high; and then the second test results came in positive. And there, in isolation, without ever seeing family or friends again, the person died. The people who die from COVID-19 have no rights—no right to be visited, no right to a hug, no right to a funeral. They die alone.

Then our colleagues began to get sick. Unfortunately, many of us, physicians, sometimes feel immortal. We often think something can happen to others and not to us, but this time death touches us all. In the evening the city is dark and silent. The only noises you can hear are the ambulance sirens. Now we feel like the patients in these ambulances, mortal and frail.

Nevertheless, we are not overwhelmed by the heaviness of restrictive measures on social distancing: every day, for 5 to 6 days per week, we cannot follow the hashtag #stayhome because we go to work, and we have at least the chance to share thoughts, fears, and—sometimes—anger and disappointment. We meet colleagues and patients and even laugh about funny stories, but it is clear to all of us that the level of stress and the risk of burnout that health care professionals are facing is alarming. In a few days, we had to decide on the risk-benefit ratio of using intensified treatments and combinations, maintenance strategies, and later-line treatments for each individual patient. We set up multidisciplinary teams by video to discuss our experiences and hard-to-make decisions. We had to find the best strategies to communicate our management of care plans to our patients and their families. As physicians of a referral center facing the lockdown of the whole country, we had to decide what to do for some patients with cancer already enrolled in clinical trials, and the patients who faced travel disruptions and the lack of flights from the south of Italy to our hospital in the north, and the fear these patients with cancer had of being infected with COVID-19 while traveling.

We were terrified after reading the recent reports on undocumented infections as a crucial source of contagion.1 We were terrified when we thought about models of transmission when applied to our daily lives here at the hospital. Unfortunately, during the past few days, we have been facing the terrific and very real effects of the lack of prevention of intrahospital infections. In the Lombardy region, the epicenter of the outbreak in Italy, and in many other regions in Italy, asymptomatic or paucisymptomatic health care workers who had contact with patients confirmed to have COVID-19 are not routinely tested unless they develop severe symptoms. Individual protection devices are often lacking and cannot be used for intermediate-risk scenarios. Some of our colleagues have tested positive and are now at home or, even worse, hospitalized in intensive care units. Some of us have already infected entire families, children, grandparents.

At this moment, we feel unprotected. Although everyone in the newspapers is praising physicians as heroes, we feel alone, thrown into jeopardy, thrown into an abyss. Our region has left us to fight the cancer battle and the COVID-19 war without true protection, without knowing whether we are infected with the virus. We go to work every day because we love our jobs, and this is the life we have chosen. But we are people too; we are afraid of getting infected, of going home in the evening, of infecting our children, our parents. When entering our homes, we take the stairs and not the elevator, afraid of infecting the condominiums and buildings where we live. But above all, we live with the absurdity of trying to cure patients of a disease like cancer at the same time potentially being the vehicles for a virus that might kill these very patients.

To stand up and fight for maintaining high standards in cancer care, we have launched a social media campaign called #knowyourstatus to extend periodical and frequent testing for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), the virus that causes COVID-19, to health care workers involved in the treatment of patients with cancer. Our aim is to guarantee separate and “clean” pathways for patients with cancer. Even if this objective is failing in front of our very eyes, we will not give up on maintaining the involvement of institutions, patients’ advocacy organizations, and oncologist associations.

In this time of fear and anger, the most important thing is sharing. We have found ourselves united across borders. We have felt the love of so many people for us and for our country. How do we survive then? With love for our patients, for our professions, and thanks to the sharing that has been created between us.

We do not know if we will ever go back to how we were before this ordeal. We want to thank everyone who has been with us every step of the way, but we will never forget the loneliness we were left in while fighting this war. In a different way but similar to someone who has died of COVID-19.

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Article Information

Accepted for Publication: March 25, 2020.

Corresponding Author: Filippo Pietrantonio, MD; Marina Chiara Garassino, MD, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian, 1-20133 Milan, Italy (filippo.pietrantonio@istitutotumori.mi.it; marina.garassino@istitutotumori.mi.it)

Published Online: April 10, 2020. doi:10.1001/jamaoncol.2020.1426

Conflict of Interest Disclosures: Dr Pietrantonio reported personal fees from Amgen, Roche, Merck-Serono, Bayer, Servier, Sanofi, and Lilly, and grants from BMS outside the submitted work. Dr. Garassino reported personal fees from Merck, BMS, AstraZeneca, Roche, Takeda, Celgene, Pfizer, and GSK. No other disclosures were reported.

Li  R, Pei  S, Chen  B,  et al.  Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2).   Science. 2020;eabb3221. doi:10.1126/science.abb3221PubMedGoogle Scholar