Scagliotti Speaks to Italy's Response to COVID-19 Outbreak

Giorgio V. Scagliotti, MD

Despite significant restrictive measures being put in place, Italy remains the country hardest hit by the novel coronavirus 2019 (COVID-19) pandemic, with hundreds of individuals dying from the virus per day.

"I can easily say that when this pandemic started in Italy, there was some level of underestimation of the risks associated with COVID-19," said Giorgio Vittorio Scagliotti, MD, PhD, chief of the Medical Oncology Division at the S. Luigi Hospital in Orbassano (Torino), Italy. "In the beginning of March, it became clear that the contagiousness of the disease was extremely high."

As the number of confirmed cases continues to rise, data are beginning to emerge regarding the risks associated with COVID-19 and patients with cancer, said Scagliotti, who is also the head of the Department of Oncology and a professor of oncology at the University of Torino.

Measures including isolating potentially positive patients, social distancing, and moving patient consultations and follow-ups to a largely telemedicine-based platform have been implemented in attempt to combat the morbidity of COVID-19 in these patients.

"We are really in the middle of the storm," explained Scagliotti. "However, the diagnostic and therapeutic flow is still in place for our patients, of course with some restrictions. It is our moral obligation to deliver the information we have. In these days, we are sharing the same fears as our patients but there is no alternative."

In an interview with OncLive, Scagliotti spoke to the state of the healthcare system in Italy amongst the COVID-19 outbreak, techniques being implemented to "flatten the curve," and his outlook on the future after the pandemic.

OncLive: How has it been living in Italy during this pandemic? What is the state of the healthcare system?

Scagliotti: For the oldest of us, this is reminiscent of what happened with measles. Of course, the advent of the measles vaccine [nearly eradicated] that problem.

COVID-19 started with a few patients. In most cases, our patients with cancer live in the community, so there were some [situations where] the disease disseminated when the patients were admitted to the hospital.

Patients with cancer may have some degree of fever already. As a result, it was difficult to give the right attention to this moderate increase in fever [frequency] in the beginning. Of course, the situation completely changed over the last 3 weeks. It then became clear that some patients were COVID-19—positive and they should stay in quarantine. Many of these patients still maintain a relatively good social life, so [not isolating them] was a way to contaminate [others in the community].

The physicians and nurses who were exposed to those patients in the beginning may have also disseminated the disease.

What restrictive measures have been put in place at your institution?

It became a huge storm. We needed to reshape our activity in the oncology department. We quickly put a series of rules in place, such as social distancing and not allowing any caregivers to wait in the waiting room. We also decided to switch to telemedicine for regular follow-ups, as well as therapeutic discussions.

Of course, we still have patients with newly diagnosed cancer who we need to care for. We are implementing a second-level triage system to check for symptoms like fever, asking those patients to wear surgical masks, and to stay home unless they are getting blood tests or chest x-rays. [If they are negative for COVID-19], we move them into the consultation or chemotherapy administration rooms. We've completely reshaped the way in which we are running daily activities.

With that restructuring, what does daily life in the clinic look like for you?

Obviously, if we want to continue to keep a COVID-19—free environment, we have to implement strict rules. This is something that can I can transmit to my patients. All of the residents and physicians are wearing surgical masks and gloves. We are trying to avoid any contact with the patients and keep a distance if we need to.

Obviously, some patients need a physical examination. If there is a suspected patient—and we are catching ≥1 potentially positive patient daily—we have strict rules. We are isolating the patient in a room and performing the COVID-19 diagnostic test. If the patient is positive, we are moving them to our newly developed oncology ward for COVID-19—positive patients. If they are negative, they are moved to our internal medicine and hematology departments.

Have there been any data to read out regarding COVID-19?

We already have the published report in The Lancet of the Chinese experience. In general, patients with cancer have some degree of immunosuppression [and are thus at a higher risk of COVID-19].

In China, there also appears to be an increased risk for patients who received surgery in the month prior to the COVID-19 outbreak. I do not believe we can apply the same principle in Italy.

We know that being an active smoker puts patients at a higher risk, but that is not something that is completely new. It is difficult to isolate the effect because most of our patients with lung cancer, for example, are smokers. It is likely factual that smokers are in some ways at a higher risk compared with never-smokers, but we need more time to collect data.

Interesting, in Italy, it is clear that of the patients who are admitted to the intensive care unit, 7 or 8 out of 10 are men. We don't know if there is a protective factor in females. We need to keep our minds free because it is pretty easy when you are walking through the storm to end up coming to a wrong conclusion. It is a purely observational fact that COVID-19 is affecting mainly men, particularly regarding the more severe forms.

What are the benefits and challenges of telemedicine? How are your patients responding to this virtual platform of treatment?

In Italy, we were not prepared to move to a tele-consulting system, so it took some time to adjust. We decided to implement a series of rules [to try to protect] all patients. When you are dealing with individuals living alone or couples who are both elderly [that becomes very important].

We try to make phone calls to make a general assessment of a patient's condition. If they have a facility to do blood examination close to home, we advise them to do that. The same goes as well for all our therapies. As in any country, there are oral therapies that can only be prescribed by hospital physicians. We decided to send patients a couple of months’ worth of their treatments by mail.

Any follow-up with a patient is now done by telemedicine. We are spending a lot of time in the afternoon when we typically see less patients to do telemedicine.

In addition to that, we are obviously not starting any treatment for those patients who test positive for COVID-19. We are trying to defer any radiotherapy and chemotherapy because at least in our situation, it is dangerous to consider [additional treatment]. There are some acute oncologic situations that require some type of immediate treatment, such as severe paraneoplastic syndrome or symptomatic brain metastases. We are trying to deliver any treatment between the 2 university hospitals that are based in Italy.

What modifications are being made for patients regarding schedules and regimens?

In terms of treatment, we decided to continue current patients on their active treatment. We are also discussing the opportunity to stop any immunological treatment with each patient, particularly if they are on long-term maintenance therapy. We want to shorten the duration of induction chemotherapy as much as possible. We are preserving a relatively COVID-19 free environment in the outpatient facility. Consequently, any active treatment for those patients in which we are almost sure they are not COVID-19 positive is going on as scheduled.

We are trying to defer potentially adjuvant treatment because we are considering it a risky situation to start something that can be deferred 2 to 4 weeks. Of course, we don't know when this terrible situation will end, but that is our decision at least in the short-term. It is a decision that is also supported by the Ministry of Health because different advocacy groups made a specific request in the first week of March 2019 to get advice from the Ministry of Health.

How have your patients responded to these new measures?

The response we got from our patients was unbelievable. They accepted the situation.

We need to be clear with them, spend some time with them, and reassure them because the idea of stopping chemotherapy is a major fear for them. We need to tell them that their treatment is continuing on.

Looking to the future, how do you see these events impacting practice going forward?

We need to rely on epidemiological data to answer the question of what will happen in the future.

It is highly dependent on how quickly the contagious curve and number of deaths decreases. There are at least 2 different mathematical models predicting the decrease of events. We ought to be in a better situation now to see the effect that the hugely restrictive measures have been put in place in Italy.

The more restrictive measures were implemented about 10 days ago*, and we hope to see some effects in the next 10 days. If we see a quick decrease in the number of people who are positive and a decrease in the number of deaths—which by the way, we are still exceeding several hundred deaths per day—that will lead us to convert the hospital back to regular life.

My hospital has approximately 400 beds. We have 130 beds for COVID-19—positive patients. We just opened a COVID-positive oncology ward, in which we have almost 20 patients. We hope to be back to a normal life in the best-case scenario in the middle of June, the beginning of July when we start reducing the number of COVID-19–positive wards.

We closed down all the surgical wards, most of the operating rooms to give enough space to those patients who are artificially ventilated.

I believe that we will be back to normal life by the end of June, purely based of these epidemiological changes. It could be longer, but we need to think of a future with a normal life or it will be difficult to go on.

Prior to the outbreak, we had 2 psychologists who provided regular service to physicians, nurses, and patients. Those psychologists are working nearly 24 hours to provide support during this time. It is especially hard for the residents and younger physicians. They are enthusiastic, but it is difficult to step into this role at the start of their professional [lives]. It's challenging to leave it [at work] and then step out into daily life. Consequentially, it is important to have psychological support.

What is your advice to fellow physicians regarding COVID-19?

In this critical time, we need to be straightforward. Social distancing and wearing protective surgical masks and gloves as protective shields are critical for everyone. As a physician, it is important to identify potentially COVID-19—positive patients. Don't underestimate any symptom. Try to intercept potentially positive patients as soon as possible. Isolate them and put all the measures in place to protect yourself and protect your patients. This is how to avoid disease dissemination and it is critical. Ultimately, it is important for patients to stay home as much as possible.

Italy has its worst day of the coronavirus pandemic 2ith 919 deaths Friday. Forbes: March 27, 2020. https://bit.ly/3avHWqA. Accessed March 28, 2020.