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As we all struggle to provide optimal care for our patients during these unprecedented times, it is clear that the pandemic has affected us all in different ways: with differing timing, magnitude, resource constraints, and local policies.

Given these circumstances, it is difficult to develop broadly applicable guidelines. However, several fundamental principles are being followed by most institutions and have been discussed in other societies, as well as disease-specific guidelines. The overarching goals are to continue to provide optimal cancer care, minimize risk to patients, minimize risk to staff, and conserve PPE.

• Defining elective vs non-elective procedures: Essentially all healthcare facilities have put a moratorium on elective procedures during this crisis. Thankfully, our Cancer Service line and physician leadership determined very early on that the treating physician or physicians would determine which treatments and procedures were necessary. As a result, most IO treatments are continuing as normal with the exception of ablation of small tumors with favorable biology ( if known) such that a delay of 2-3 months would be unlikely to affect the outcome. We continue to place ports, do biopsies, Y90, TACE, and ablations for palliation of pain and larger tumors. All RCC ablations have been put on hold. We continue to provide other palliative procedures such as neurolysis, tunneled peritoneal and pleural catheters, etc.

• Minimize risk to patients: Our cancer patients all represent a vulnerable patient population during this pandemic. The risks, benefits, and comorbidities of each patient’s case are considered individually. Therefore, an 80 year old patient with diabetes, NASH cirrhosis and a new 3 cm HCC might not be treated presently vs a relatively healthy 60 year old HCV patient with the same presentation. We have made significant changes in our imaging workflows to keep outpatients and inpatients separated to minimize the risk of cross-contamination. We are not keeping patients overnight for observation unless medically necessary. Follow up imaging is being directed towards our outpatient imaging centers rather than our main campus. All clinic visits switched to virtual when possible.

• Minimize risk to staff: Understandably, our entire staff (Attendings, fellows, residents, technologists, nurses) have significant concerns and anxiety during this crisis. We have divided into teams, each covering a week at a time, to attempt to minimize exposure to everyone at once. Those with health concerns/pre-existing conditions are working from home or taking a leave of absence. All staff have undergone training for proper donning/doffing of PPE and we have done rehearsals as well as the real thing. We now have a backup call team to serve as the “clean team” for grabbing supplies and taking over after a procedure on a COVID positive or PUI. We have asked for clearance to test asymptomatic inpatients prior to AGPs but we do not have enough testing bandwidth for this presently.

• Conserving PPE: Our institution started mask conservation protocols the first week of March, which was quite early in the crisis. We all use one standard surgical mask per day, which is distributed centrally and tracked. We are minimizing the number of operators scrubbing into cases to help conserve. N95 masks used only for AGPs, COVID positive and PUI and are re-sterilized with UV for repeat use.

• What’s next?: As we see the curves flatten, we are beginning to take stock of the financial impact of the crisis and consider how and when to start opening up the practice to less urgent cases. The financial impact is huge, and we will be feeling the effects for many months, if not longer. That being said, there is great pressure to begin this process yet uncertainty as to whether or not we have reached our peak. The various models vary by as much as 5-6 weeks for the peak resource needs locally in Milwaukee.

While do not know how long the immediate effects of this pandemic will last, it is becoming increasingly clear institutions globally are preparing for months of impact. Ensuring your institution and staff are prepared for ongoing changes to usual operations will help to provide some clarity during these unprecedented circumstances.