We are happy to share a letter to the editor entitled: Covid19: breaking bad news with social distancing in pediatric oncology, authored by Nicolas ANDRE from MGHI, that has been accepted for publication in Pediatric Blood and Cancer, although not related to metronomics, we wanted to share it given the ongoing pandemic.

The full text is copied bellow.

The Covid-19 pandemic has forced citizens worldwide to rely on social distancing measures as the main tools to prevent the rapid spreading of the virus (1). In pediatric oncology, there were important initial concerns for immunocompromised patients who were considered to be at higher risk of developing severe form of the disease (2,3). Consequently, potential challenges (2) have been identified and advice given by the principal child cancer organizations (3). Although more experience from countries that have been facing the pandemic are being published, results are inconsistent so far ranging from reassuring in Milano (4), Madrid (5) or New York (6) to worrying in France where 4 out of 33 Covid-19 positive patients required intensive care and 1 death at last follow up (7). Over the last weeks, despite the pandemic we were able to maintain “normal“ care for pediatric cancer patients in our institution, including high-dose chemotherapy followed by peripheral stem cells transplantations, or recruitment in early phase clinical trials. Only follow-up visits have been re-scheduled or switched to remote consultations. After almost 2 months of lock-down and still ongoing social distancing measures, an unexpected challenge has emerged. Inddeed, during that period, as usual we had to break bad news: for diagnosis, for relapse or palliative care. Initially, when breaking bad news, I had the feeling something was going wrong, or at least was not going as usual. Was I doing something wrong? Was stress induced by a high level of anxiety due to the lack of specific information on the real risk for adolescents/children with cancer both among the medical team and or parents affecting the “breaking bad news” process?

Why didn’t I take that teenagers in my arms after disclosing her a metastatic relapse and she looked in such a distress?

Social distancing!

Masks to start with. They are of course a barrier to saliva droplets potentially containing covid-19, but most importantly they are also a barrier to adequately transmit and discriminate emotions just relying on eyes expression, looks…beyond tears. Silent communication with long looks without words can sometimes be enough and better that long talks but do parents and children feel the same when half of the face is covered. I asked about it to one of my patients and he answered “I think can read your eyes”. By increasing the physical space between people to avoid virus spreading, but here again, for physicians and some parents/patients, holding hands, holding shoulders, hugging are important non-verbal elements of communications and help showing compassion. We might break social distancing to break bad news, but if not pre-agreed by the patient or its parents, is it acceptable? Couldn’t it be perceived as an additional threat, contribute to alter intuitive communication which is characterized by broad, shared goals and mutual respect?   Breaking bad news while trying to maintain social distancing is an unexpected new challenge associated with Covid-19. We will very likely learn to better communicate, read & share our respective emotions even with masks and physical distancing and sometimes allow ourselves exceptions to social distancing. Meanwhile, this impact shall be further evaluated among all stakeholders: patients, their parents, and physicians and adapted strategies to better cope with it developed.

References:

1)     Pan A, Liu L, Wang C, Guo H, Hao X, Wang Q, Huang J, He N, Yu H, Lin X, Wei S, Wu T. Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak in Wuhan, China. JAMA. 2020; 323:1-9.

2)     Kotecha RS. Challenges posed by COVID-19 to children with cancer. Lancet Oncol. 2020 May;21(5):e235.

3)     Sullivan M, Bouffet E, Rodriguez-Galindo C, Luna-Fineman S, Khan MS, Kearns P, Hawkins DS, Challinor J, Morrissey L, Fuchs J, Marcus K, Balduzzi A, Basset-Salom L, Caniza M, Baker JN, Kebudi R, Hessissen L, Sullivan R, Pritchard-Jones K. The COVID-19 pandemic: A rapid global response for children with cancer from SIOP, COG, SIOP-E, SIOP-PODC, IPSO, PROS, CCI, and St Jude Global. Pediatr Blood Cancer. 2020 May 13:e28409.

4)     de Rojas T, Pérez-Martínez A, Cela E, Baragaño M, Galán V, Mata C, Peretó A, Madero L COVID-19 infection in children and adolescents with cancer in Madrid. Pediatr Blood Cancer. 2020 May 8:e28397.

5)    Terenziani M, Massimino M, Biassoni V, Casanova M, Chiaravalli S, Ferrari A, Luksch R, Meazza C, Podda M, Schiavello E, Spreafico F.SARS-CoV-2 disease and children under treatment for cancer.Pediatr Blood Cancer. 2020 May 6:e28346.

6)     Boulad F, Kamboj M, Bouvier N, Mauguen A, Kung AL.  COVID19 in Children With Cancer in New York City. JAMA Oncol. 2020 May 13:e202028.

7)     André N, Rouger-Gaudichon J, Brethon B, Phulpin A, Thébault É, Pertuisel S, Gandemer V. COVID-19 in pediatric oncology from French pediatric oncology and hematology centers: High risk of severe forms? Pediatr Blood Cancer. 2020 May 8:e28392