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Development of a SARS-COV-2 Testing Algorithm at a Cancer Center

 

May 20, 2020

Development of a SARS-COV-2 Testing Algorithm at a Cancer Center

By Leah Hampson Yoke, MCHS, PA-C, Fred Hutchinson Cancer Research Center and University of Washington School of Medicine

The first cases of SARS-COV-2 in the United States occurred early this year on the West Coast. While this appeared to be an abrupt beginning in the United States, community transmission in the area had been simmering for weeks (Bedford et al., 2020). Little was known about this virus on a community level, and even less was known about the pathogenesis in cancer patients. When SARS-COV-2 PCR testing at Fred Hutchinson Cancer Research Center/University of Washington became available on March 2, many new questions arose. How does this novel virus present in cancer patients? Who should we test in our institution? Which symptoms should we target? Rigorous testing guidelines needed to be developed quickly to protect both patients and health-care workers caring for this vulnerable population.

Presentation in Cancer Patients

Currently, little is known about the presentation of COVID-19 in cancer patients. Initial reports from China described a cohort of 18 solid tumor patients, the majority of whom had lung cancer, who were admitted to local hospitals in Wuhan with laboratory-confirmed SARS-COV-2 and respiratory symptoms (Liang et al., 2020). In this group, patients with active cancer had a higher risk of severe events, including ICU transfer, intubation, and death when compared to patients with no cancer or cancer survivors. However, this study was underpowered to assess the impact of immune status and provided a very limited description of initial symptomatology of these patients.

Symptoms at presentation were described in two later papers, including one with a cohort of 28 cancer patients, also primarily with solid tumors, and a group of adult patients with hematologic disease (Malard et al., 2020Zhang et al., 2020). The most common presenting symptoms at diagnosis in both cohorts included fever, dry cough, and dyspnea.

Initial Testing Guidelines

With this limited data, our initial guidelines recommended testing patients with any respiratory symptom, including fever, based on the experience in other countries. Because the University of Washington Virology Laboratory had developed a certified SARS-COV-2 PCR assay, immediate testing was available once our guidelines were in place.

Patients with symptoms warranting testing were considered SARS-COV-2 rule-out patients and were placed immediately in droplet precaution, with observed donning and doffing instructions for providers and staff when entering and leaving the room. Concurrently, an extended spectrum respiratory viral panel was also run to both determine if there was an alternative viral etiology of their symptoms and to evaluate for coinfection.

Adjusting the Guidelines

However, soon after implementation, reports of atypical symptoms of COVID-19 surfaced, including a case report of a patient with diarrhea as their primary presenting symptom (Li et al., 2020). Larger studies also described cohorts of patients with gastrointestinal (GI)-related symptoms and relatively mild respiratory disease (Han et al., 2020). While the exact pathogenesis is not well understood, several similar cases were identified in our own center and guidelines were adjusted to include GI symptoms. This allowed for both close clinical monitoring, a lessened likelihood of missing any positive patients, and greater protection of health-care workers.

Current Screening and Testing Algorithms

As testing capacity increased, the ability to test asymptomatic immunocompromised patients became available. Currently, testing criteria is much broader and includes asymptomatic patients in varying stages of their cancer treatment at admission to the hospital and before any invasive procedure. However, infection control measures including droplet isolation are only initiated for symptomatic patients. At the same time, we have also identified an infectious disease provider (MD or AP) on call at all hours to answer COVID-related testing and infection control questions. This added level of response helps provide consistent guidance to primary oncology teams in decisions about testing and management.

To help other systems also faced with creating and implementing similar guidelines, the University of Washington and Seattle Cancer Care Alliance infection control groups created a public website to allow other institutions and clinics to view and modify from the work already created (UW Medicine, 2020). Although modification of these guidelines continues as more information on SARS-CoV-2 becomes available, this has proved to be an excellent resource to guide both infection control and testing of oncology patients. Thus far, this early work has provided a safer work environment and quick, efficient care for the most vulnerable patients.


References

Bedford, T., Greninger, A. L., Roychoudhury, P., Starita, L. M., Famulare, M., Huang, M.-L.,…Jerome, K. R. (2020). Cryptic transmission of SARS-COV-2 in Washington State. https://doi.org/10.1101/2020.04.02.20051417

Han, C., Duan, C., Zhang, S., Spiegel, B., Shi, H., Wang, W.,…Hou, X. (2020). Digestive symptoms in COVID-19 patients with mild disease severity: Clinical presentation, stool viral RNA testing, and outcomes. American Journal of Gastroenterology. https://doi.org/10.14309/ajg.0000000000000664

Li, R. L., Chu, S. G., Luo, Y., Huang, Z. H., Hao, Y., & Fan, C. H. (2020). Atypical presentation of SARS-CoV-2 infection: A case report. World Journal of Clinical Cases, 8(7), 1265–1270. https://doi.org/10.12998/wjcc.v8.i7.1265

Liang, W., Guan, W., Chen, R., Wang, W., Li, J., Xu, K.,…He, J. (2020). Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncology, 21(3), 335–337. https://doi.org/10.1016/S1470-2045(20)30096-6

Malard, F., Genthon, A., Brissot, E., van de Wyngaert, Z., Marjanovic, Z., Marjanovic, Z.,…Mohty, M. (2020). COVID-19 outcomes in patients with hematologic disease. Bone Marrow Transplant. https://doi.org/10.1038/s41409-020-0931-4

UW Medicine. (2020). UW Medicine COVID-19 Resource Site. Retrieved from https://covid-19.uwmedicine.org

Zhang, L., Zhu, F., Xie, L., Wang, C., Wang, J., Chen, R.,…Zhou, M. (2020). Clinical characteristics of COVID-19-infected cancer patients: A retrospective case study in three hospitals within Wuhan, China. Annals of Oncology. https://doi.org/10.1016/j.annonc.2020.03.296

 

Read more from the APSHO Advance: Special COVID-19 Series

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