The coronavirus disease 2019 (COVID-19) pandemic has shifted the way health care is provided across the globe, and the United States is no exception. The oncology pharmacist plays a vital role in all aspects of the care for patients with cancer. However, most duties performed on a day-to-day basis are within inpatient rounding teams or in clinics with patients and other providers, a workflow that has changed drastically with the uprise of the COVID-19 pandemic.

In the outpatient setting, oncology pharmacists’ roles are usually centered on patient counseling, navigating treatment plans, drug procurement, and answering drug information questions. With COVID19, many of these responsibilities have shifted to remote operations. Each institution has responded differently depending on the state of the pandemic in their area. However, most pharmacists are now embracing telemedicine and facilitating patient visits, chemotherapy education counseling, and toxicity assessments via virtual platforms.

Oncology pharmacists have been given significant support and resources to facilitate working remotely and can perform order verification and insurance assistance from home. If an oncology pharmacist has not been shifted to remote work, the pharmacist will visit patients one-on-one to perform counseling activities while remaining socially distanced. The pharmacist, who was once accompanied by trainees or would accompany the physician, will now likely only be recruited into patient rooms for counseling or critical pharmacy needs because most institutions have limits on how many individuals may be present in patient care rooms.

In the inpatient setting, oncology pharmacists are key players during rounds when a majority of drug-related interventions are made. To facilitate safe work amid the pandemic, most rounding teams have developed a system over virtual platforms such as Zoom, Webex, and Microsoft Teams. Others may have limited team rounding activities to a maximum number of providers that may include the pharmacist. Medication reconciliation is a critical component of the oncology pharmacistʼs duties that has been performed safely over the phone with the patient, caregiver, and pharmacy with the assistance of electronic health records. To maintain the safety of patients and oncology pharmacists, direct patient interaction is often limited, given the risks of exposure to both parties and the ability to perform most tasks on virtual platforms.

Key to these changes is the pivotal role the oncology pharmacist plays in making decisions for patients at high risk of exposure to or with active COVID-19. Oncology pharmacists can share their expertise on the potential for drug-related issues (eg, immunosuppressants, drug interactions) with oncology and COVID-19-related therapeutics to assist providers in the complex treatment of these patients. Overall, the oncology pharmacist continues to be a vital member of the health care team, and in the short term, most positions have transitioned to performing duties remotely. For outpatient medicine, telemedicine will likely continue to flourish past the pandemic, given the convenience and safety for patients.

In the inpatient setting, oncology pharmacists will continue to provide exemplary care for their rounding teams, with many developing a hybrid or rotating model to have the pharmacist continue to serve as a member during in-person rounds.

Overcoming COVID-19 Barriers to Treatment
Several organizations have published guidance documents and recommendations focused on providing care to patients with cancer during the COVID-19 pandemic. These organizations include the American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), Society of Surgical Oncology, American Society for Radiation Oncology, American Society for Transplantation and Cellular Therapy and American Society of Hematology, in addition to several others.1-6 Many journals have also published articles providing additional guidance on this topic.

Several themes are consistent throughout these documents. The themes include the importance of COVID-19 screening and testing, infection control considerations, management of medical oncology, surgical oncology, radiation therapy, prioritization of care, inpatient and outpatient treatments, impact on clinical trials, and considerations for health care providers.1-6

According to ASCO, care teams and patients should work together to determine the management of oncology treatment plans during the pandemic. If a patient tests positive for COVID-19, treatment should be paused or delayed while the next steps are determined. Priority is based on weighing risk versus benefit and urgency of treatment, especially for patients with COVID-19. Certain patients with COVID-19 may still be considered appropriate for treatment, whereas, for many other patients with the virus, it may be appropriate to delay therapy for a minimum of 14 days or until symptoms resolve for 72 hours with 2 negative test results.1

According to NCCN, for patients with solid tumors, despite the threat of COVID-19 infection during treatment, adjuvant therapy with curative intent should likely proceed. For patients with metastatic disease, treatment delays may lead to worsening performance status and loss of the window to treat; thus, considerations should include how such delays may lead to hospital admission, further exhausting inpatient resources. Continual patient evaluation and involving the patient in the decision-making process is critical.2

ESMO provides specific recommendations for using immune checkpoint inhibitors (ICIs), targeted tyrosine kinase inhibitors (TKIs), and implementation of adjuvant and neoadjuvant chemotherapies. ICIs should not be withheld or delayed in the absence of COVID-19 infection when there is an approved indication for adjuvant/neoadjuvant treatment and when there is a proven survival benefit. If a patient tested positive for COVID-19, the ICI should be postponed until recovery from the virus.3

For patients with certain cancers—such as metastatic melanoma, intermediate- or poor-risk metastatic renal cell carcinoma, PD-L1-positive non–small cell lung cancer (NSCLC), hepatocellular carcinoma where there is a clear survival benefit— ICI therapy should be interrupted in the setting of COVID-19. According to ESMO, restarting therapy should be considered after complete resolution of the virus following negative testing. High-dose steroids may incur a potential risk for mortality in patients with cancer and COVID-19. If grade 3/4 immune-related adverse events require management, switching to another immunosuppressant agent may be considered if possible.3

Decisions regarding withholding TKI therapy also depend upon risk versus benefit. In the decision-making process, the magnitude of the benefit from the TKI should be considered in a tumor-specific context. In the event a patient tests positive for COVID-19, it is reasonable to withhold TKI therapy in patients with stable disease until COVID-19 recovery. In the event of patients with less severe COVID-19 or patients with targetable, oncogene-addicted high-volume tumors at high risk of flare upon TKI discontinuation, TKI therapy may be continued.

The implementation of adjuvant or neoadjuvant chemotherapy is patient and disease specific as well. For example, for patients with breast cancer in the curative setting, following a discussion with the care team and patient and a risk versus benefit analysis, regimens and doses of systemic therapies should be followed. Priorities include avoiding significant delays and implementing protective and supportive measures, such as growth factor support and selection of a less immunosuppressive regimen. For patients with stage II-III NSCLC, following a discussion with the care team and patient, adjuvant chemotherapy is recommended for fit, young patients without significant comorbidities.3

There is an ongoing need to identify innovative strategies to minimize exposure of oncology patients to COVID-19.7 Despite the global pandemic, continuation of cancer treatments is needed to maintain disease control and improve patient outcomes. There is significant opportunity to streamline interventions in the infusion center setting.

Part 2 of this article will discuss those strategies for streamlining interventions and lessons learned by oncology pharmacists during the pandemic. 
 
KIROLLOS HANNA, PHARMD, BCPS, BCOP, is an oncology pharmacy manager at M Health Fairview pharmacy services at the University of Minnesota Medical Clinic in Maple Grove, and assistant professor of pharmacy at Mayo Clinic College of Medicine and Science in Rochester, Minnesota.

ASHLEY BARLOW, PHARMD, is a PGY-2 oncology resident at MD Anderson Cancer Center in Houston, Texas.

BROOKE BARLOW, PHARMD, is a PGY-2 critical care resident at the University of Kentucky HealthCare in Lexington.



REFERENCES
  1. ASCO special report: a guide to cancer care delivery during the COVID-19 pandemic. ASCO. Updated December 15, 2020. Accessed December 10, 2020. https:// www.asco.org/sites/new-www.asco.org/files/content-files/2020-ASCO-Guide-CancerCOVID19.pdf
  2. Ueda M, Martins R, Hendrie PC, et al. Managing cancer care during the COVID-19 pandemic: agility and collaboration toward a common goal. J Natl Compr Canc Netw. 2020;18(4):366-369. doi:10.6004/jnccn.2020.7560
  3. Curigliano G, Banerjee S, Cervantes A, et al. Managing cancer patients during the COVID-19 pandemic: an ESMO multidisciplinary expert consensus. Ann Oncol. 2020;31(10):1320-1335. doi:10.1016/j.annonc.2020.07.010
  4. COVID-19 resources. Society of Surgical Oncology. Updated October 5, 2020. Accessed December 10, 2020. https://www.surgonc. org/resources/covid-19-resources
  5. COVID-19 clinical guidance. American Society for Radiation Oncology. Updated May 20, 2020. Accessed December 10, 2020. https://www.astro.org/Daily-Practice/ COVID-19-Recommendations-and-Information/Clinical-Guidance
  6. COVID-19 resources. American Society of Hematology. Updated January 4, 2021. Accessed December 10, 2020. https://www. hematology.org:443/covid-19
  7. Hanna KS, Segal EM, Barlow A, Barlow B. Clinical strategies for optimizing infusion center care through a pandemic. J Oncol Pharm Pract. 2021;27(1):165-179. doi:10.1177/1078155220960211