Bowel cancer care is not elective and therefore must be maintained throughout the COVID-19 pandemic.

| What is coronavirus and how will the COVID-19 pandemic affect my bowel cancer care?
  
We know there is a lot of attention right now on the new coronavirus and the COVID-19 pandemic, and information is continually evolving.
 
Preparedness and awareness are paramount in these times, especially if you are newly diagnosed, living with, or living beyond bowel cancer, due to an increased risk for coronavirus infection.
 
Bowel Cancer Australia regularly updates this dedicated COVID-19 webpage to help you better understand the impact these changes will have on you and your loved ones.
 
It contains facts about COVID-19 and its symptoms; offers tips and tools from medical experts for taking care of yourself and others; and provides details about recent changes designed to keep you safe from infection that may impact colonoscopy access, specialist visits, and delivery of cancer treatments.
 
There is also information on how to manage anxiety for those who are feeling overwhelmed; things you can do to stay active even when indoors; tips for eating well; and questions you may want to ask your healthcare team.
 
This webpage is not intended as a replacement for your specialist’s advice.
 
Bowel Cancer Australia recommends that you speak with your specialist about any specific effects the pandemic will have on your treatment or care.
 
Click here for a list of questions you may want to discuss with your healthcare team.
Lived Experience during COVID-19 survey
 
How has COVID-19 impacted you?
 
Bowel cancer patients and their loved ones are facing new challenges because of COVID-19, such as delays or pauses in treatment, the emotional stress of coping with cancer during a pandemic, and financial hardships.
 
But the voices of Australians affected by bowel cancer, directly or through a loved one, are missing in much of the communication being shared regarding how COVID-19 is impacting people's lives.
 
Complete our 10-minute lived experience survey and let your voice be heard.

Isolated, but not alone
  
We want you to know that we are here for you. Providing practical information and emotional support, our Bowel Care Nurses and Nutritionist can help if you are feeling anxious, have questions or need support.
 
Click here to contact us or call the free Helpline Monday - Friday on 1800 555 494.
 COVID 19 and bowel cancer 
Am I at increased risk for COVID-19 if I have, or have had, bowel cancer? 
 
The lives of cancer patients and those living beyond cancer are not just being disrupted by COVID-19 – they are at risk.

People with cancer who develop COVID-19 are much more likely to die from the disease than those without cancer, according to a study involving 218 cancer patients who tested positive to COVID-19 in the United States between March 18 to April 8, 2020 at Montefiore Medical Center in the Bronx, New York City. Published in the online edition of Cancer Discovery, it is currently the largest study to assess outcomes for patients with cancer who have also been infected with COVID-19.

When compared to mortality rates in non-cancer patients at Montefiore Medical Center and across New York City during the same time, cancer patients in the study demonstrated a significantly higher risk of dying from COVID-19, according to the researchers.
 
A total of 61 cancer patients died from COVID-19, a case-fatality rate of 28%. (The mortality rate for COVID-19 in the United States is 5.8%, according to the World Health Organisation.)

The highest mortality rate occurred among COVID-19 patients with blood cancers: 37% (20 of 54 patients). In COVID-19 positive cancer patients with solid tumours, the mortality rate was 25% (41 of 164). However, the rates varied depending on the type of tumour. The mortality rate for patients with lung cancer was 55% and bowel cancer was 38%, compared with mortality rates of 14% for breast cancer and 20% for prostate cancer.

A detailed analysis of patients with cancer who died from COVID-19 shows that more than half of these individuals - 37 of 61- had been in places with a higher risk of exposure to COVID-19, such as nursing homes, hospitals, or emergency departments within the 30 days before being diagnosed with COVID-19. This was before widespread social distancing had been implemented. Furthermore, certain underlying conditions – older age, hypertension, heart disease, and chronic lung disease – were associated with the significantly increased mortality among cancer patients with COVID-19.

According to a study conducted in China published in The Lancet in February, cancer is one of 5 chronic medical conditions that can substantially increase the risk of death if you get a COVID-19 infection.
 
The risk of dying among people in China who had a confirmed COVID-19 diagnosis was approximately 1.4%.
 
For patients with a confirmed COVID-19 case who also had cancer, the risk increased 5-fold, to 7.6%.
 
It is important to note that the risk extends beyond the period of active treatment, because the after-effects of cancer and immunosuppressive effects of treatment can be long term and don’t end when people finish their last course of therapy or leave the hospital after surgery.

Unfortunately, there is no easy blood test to check someone’s level of immune suppression, but being in active chemotherapy, having low white-cell or low lymphocyte counts and/or taking immune-suppressive agents (such as prednisone) are all associated with immune suppression and increased risk of infection.

The risk also increased in people with chronic respiratory disease (8.0%), hypertension (8.4%), diabetes (9.2%), and cardiovascular disease (13.2%).

COVID-19 What can I do 
According to the American Society of Clinical Oncology (ASCO) the most important steps for avoiding infection with COVID-19 are the same for everyone, whether you have cancer or not.
 
The most important way to protect yourself is to avoid being exposed to coronavirus, whenever possible.
  • Stay away from anyone who feels sick or is displaying symptoms of infection, such as high temperature and/or a new and continuous cough.
  • Maintain a physical distance of 1.5 metres from anyone you do not live with, because some people may have the virus without knowing it and may have no visible symptoms.
  • Wash your hands frequently throughout the day with soap and water for at least 20 seconds, about the amount of time it would take to hum the “Happy Birthday” twice. If soap and water are not available, use a hand sanitizer that contains at least 70% alcohol.
  • Avoid touching your eyes, nose, and mouth with unwashed hands as this can transfer the virus from surfaces.
  • Regularly clean ‘high-touch’ objects and surfaces such as doorknobs, counters, toilets, keyboards, tablets, phones, and children’s toys, using household cleaning spray or wipes.

 

Additional tips for you and those you love
  • Keep up healthy habits – eat well, sleep, exercise, and drink plenty of water.
  • If you need to cough or sneeze, use a tissue and then throw it away. If you don’t have a tissue, cough or sneeze into your elbow (not your hands).
  • Avoid non-essential use of public transport, varying your travel times to avoid rush hour, and work from home if possible.
  • Stay away from crowds and crowded areas.
  • Create a plan in case you get sick. Are there friends, family, or neighbours you can reach out to?
  • Ask your GP or specialist whether you should have a flu shot.

Extra precautions for patients receiving treatment

If you or a loved one is actively undergoing treatment, has had a transplant in the last 6 months, or is still taking immunosuppression drugs, there is an increased risk of serious infection requiring medical intervention. Avoiding exposure to the virus is essential.
  • Do not leave your house, except to attend essential medical appointments (please speak to your hospital team to determine which appointments are essential).
  • Do not attend any gatherings. This includes gatherings of friends and families in private spaces for example family homes, weddings, and religious services.
  • Do not go out for shopping, leisure, or travel and, when arranging food or medication deliveries, these should be left at the door to minimise contact.
  • Let family and friends know that you are at increased risk of infection and ask them to refrain from visiting if they are unwell or sick or have been exposed to the virus.
  • Ensure you have adequate groceries, medications, and other essential supplies if you’re planning to stay home to reduce risk of exposure. Woolworths and Coles are providing Priority Assistance home delivery to eligible customers include seniors, people with a disability and those with compromised immunity or who are required to self-isolate.
  • If you have a carer, make plans for a backup in case they get sick.
  • Discuss the option of teleconferencing with your treatment team. On 11 March 2020 the Australian Government announced funding for bulk-billed video-conference consultation services, which can be provided by GPs, specialists, , nurse practitioners and allied mental health workers for people isolating themselves at home on the advice of a medical practitioner, people with chronic health conditions or who are immunocompromised.
  • If you must attend appointments in clinic, arrive as close to your appointment time as possible to reduce waiting room congestion.
  • Keep in touch using remote technology such as phone, internet, and social media.

What should I do if I am diagnosed with COVID-19?
 
If you develop symptoms of COVID-19, the medical priority will be to isolate you and treat the COVID-19 infection rather than your cancer. Your cancer treatment will most likely need to be discontinued until symptoms of COVID-19 have resolved and there is some certainty that the virus is no longer present. This is because continuation of your cancer treatment could lead to further immunosuppression and increase your risk for serious complications related to COVID-19. Every case will be assessed individually based on the risks and benefits of all available options.

What should I do if my carer thinks they’ve been exposed to the coronavirus?
 
If you find out your carer has been exposed to coronavirus, notify your specialist and the cancer care team right away. They will help guide you and your carer in your next steps.

What should I do if my GP/specialist is diagnosed with coronavirus?

If your GP/specialist is diagnosed with coronavirus and you have not seen them recently, then you are unlikely to have been exposed to it. If you are concerned about the impact this will have on your treatment, contact your GP clinic, specialist or hospital for advice.
Covid Lived Experience survey

| Bowel cancer symptoms 
 
If you are experiencing symptoms suggestive of bowel cancer, it is important that you seek medical advice.
 
In the wake of COVID-19, GPs have reported a significant decline in patient visits due to concerns about attending clinics for medical issues other than COVID-19, as they fear contracting the virus or do not want to waste their GP's time.
 
Delays in visiting your GP could result in a cancer being undiagnosed, or being diagnosed at a later stage, leading to poorer cancer outcomes.
 
GP clinics now offer Medicare rebated online consultations, so you do not have to attend in person if you are concerned about being exposed to the virus.
 
When detected early, almost 99% of bowel cancer cases can be successfully treated, however less than half of bowel cancer cases are discovered before the cancer has become invasive.
 
Please contact your GP clinic immediately to discuss the best course of action for you to take at this time if you are worried about a symptom suggestive of bowel cancer. You can also contact our Bowel Care Nurses or call our free Helpline Monday - Friday on 1800 555 494.
 
Any of the below symptoms could be indicative of colon or rectal cancer and should be investigated by your GP if they persist for more than two weeks.
 
  • Blood in your poo or rectal bleeding

  • A recent, persistent change in bowel habit (e.g. diarrhoea, constipation or the feeling or incomplete emptying)

  • A change in the shape or appearance of your poo (e.g. narrower poos or mucus in poo)

  • Abdominal pain or swelling

  • Pain or a lump in the anus or rectum

  • Unexplained anaemia causing tiredness, weakness or weight loss
 

Screening and Surveillance
 
Bowel cancer screening 
 
Should I still participate in bowel screening during this time?
 
Yes. The National Bowel Cancer Screening Program (NBCSP) and Bowelscreen Australia continue to operate. For some, the additional time at home may provide the perfect opportunity to screen.
 
If you are ineligible for the NBCSP, but would like to screen, you can purchase a convenient and easy to use Bowelscreen Australia test online, in pharmacy or by calling 1800 555 494.
What if my bowel screen result comes back positive – will I still receive a follow-up colonoscopy?
 
Many aspects of the Australian healthcare system are being impacted due to the COVID-19 pandemic, so bowel screen participants may experience delays before undergoing further investigation via a follow-up colonoscopy.

Your case will be assessed by a specialist to determine if urgent diagnostic colonoscopy is necessary based on your symptoms, co-morbidities, and COVID-19 risks.

Am I at risk of getting bowel cancer if my follow-up colonoscopy is delayed?

If you received a positive test result, it means that blood was detected in the sample you mailed in. You should contact your GP immediately to discuss the result and obtain a referral for further investigation via colonoscopy within 30 days.

Due to current circumstances related to COVID-19, colonoscopy within 30 days may not be possible. However, medical guidelines recommend waiting no more than 120 days for a follow-up colonoscopy following a positive test result, because health outcomes are worse.

If you experience any new symptoms or are waiting for a follow-up colonoscopy or any other follow-up investigation, contact your GP or specialist immediately to discuss your circumstances.
| Colonoscopy
 
On March 25, the Prime Minister restricted elective surgery to Category One and urgent Category 2 cases in public hospitals, with private hospitals to follow beginning 1 April.
 
In response, the Gastroenterological Society of Australia (GESA) advised specialists to defer routine 1, 3- or 5-year polyp or IBD surveillance colonoscopies and colonoscopies following a positive faecal immunochemical test (FIT) result if a previous high-quality colonoscopy had been performed in the past four years.
EMERGENCY / URGENT PROCEDURES
Reasonable to proceed
Colorectal bleeding, considered not to be due to haemorrhoids
Assessment and management of acute colonic obstruction
Investigation of probable new diagnosis or flare of Inflammatory Bowel Disease (IBD) where findings will direct management
ELECTIVE / SEMI-ELECTIVE PROCEDURES
Defer
Positive bowel screening test (patient 50 years or older) but with high quality colonoscopy within 4 years
Repeat procedure for early assessment of multiple colonic polyps detected at a recent prior colonoscopy
Routine 1, 3 year or 5 year polyp or Inflammatory Bowel Disease (IBD) surveillance
Bright red minor rectal bleeding likely of anal origin
CASE-BY-CASE ASSESSMENT
Talk to your specialist
Positive bowel screening test (patient 50 years or older) without high quality colonoscopy within 4 years
Iron deficiency with or without anaemia where no other cause likely on clinical assessment
Surveillance for confirmed or suspected inherited colorectal cancer syndrome inc. Serrated Polyposis
Repeat procedure for prior inadequate colonoscopy preparation
Large colonic polyps for endoscopic resection where occult submucosal invasive disease is possible

The National Cabinet agreed on 15 May 2020 to reopen elective surgery, by removing restrictions and restoring hospital activity involving 3 stages.
 
It is a decision of each State/Territory to determine which stage applies to its circumstances, the timeline for implementation and the level of normal surgical activity is safely restored. The stages are:
  • Stage 1 – up to 50 per cent of normal surgical activity levels;
  • Stage 2 – up to 75 per cent of normal surgical activity levels;
  • Stage 3 – up to 100 per cent of normal surgical activity levels or as close to normal activity levels as is safely possible.
Private hospitals should mirror their own State/Territory's approach to surgical activity unless agreed otherwise with the relevant State/Territory.
 
The level of elective surgery will be reviewed monthly from May 2020 by the Australian Health Ministers’ Advisory Council (AHMAC), to ensure that it remains safe and sustainable.
 
On 16 July 2020, the Victorian Government announced public hospital elective surgery capacity will be reduced by 50 per cent and private hospital elective surgery capacity limited to 75 per cent in Metropolitan Melbourne to free up bed space due to the increase in number of COVID-19 cases

If your surveillance colonoscopy has been postponed, rescheduling it should be a high priority. Each case will be handled individually. To find out how this change may impact your surveillance colonoscopy, contact your specialist.
 
If you are currently experiencing symptoms or received a positive screening test result, contact your GP/specialist immediately to let them know and they will determine the best course of action for you at this time.
 
The selection of patients to undergo elective surgery will ultimately be a clinical one, guided by the following principles, recommended by the Australian Health Protection Principal Committee (AHPPC) and endorsed by National Cabinet:
  • Procedures representing low risk, high value care as determined by specialist societies
  • Selection of patients who are at low risk of post-operative deterioration
  • Children whose procedures have exceeded clinical wait times
  • Assisted reproduction (IVF)
  • Endoscopic procedures
  • Screening programs
  • Critical dental procedures

The number of colonoscopies, sigmoidoscopies and polyp removal procedures performed in April 2020, was around half of those undertaken in March 2020.

  • Colonoscopies and sigmoidoscopies decreased 55% (from 56,048 in March to 25,454 in April); and
  • Procedures to remove polyps which are associated with colonoscopy/sigmoidoscopy procedures also decreased 57% (from 25,509 in March to 10.896.

The number of investigations then increased in May and June but were still lower than for March 2020.

  • Colonoscopies and sigmoidoscopies were 36% and 15% lower with 35,957 and 47,508 services in May and June respectively.
  • Polyp removal procedures were 34% lower and 11% lower with 16,726 and 22,683 services in May and June respectively. 

Colonoscopy and sigmoidoscopy procedures


Removal of polyp(s) during colonoscopy


COVID 19 Treatment and Care
 
| Treatment
 
How will the COVID-19 pandemic affect my bowel cancer care?
 
Cancer care is not elective and therefore must be maintained throughout the COVID-19 pandemic.
 
However, to keep you as safe as possible during the COVID-19 pandemic, your cancer care may be adapted. How it is adapted will depend on the goal of treatment.
 
Curative treatment is likely to continue as planned to ensure the best chance of remission; however, the risks associated with contracting COVID-19 in patients who are currently receiving palliative care may outweigh any potential benefits of continuing palliative treatment during the pandemic.
 
Your multidisciplinary team (MDT) should review each individual patient in order to decide if any changes to treatment are needed after considering
  • your condition
  • the urgency of the planned cancer treatment
  • the anticipated benefit of the treatment verses the potential risk of developing COVID-19 while undergoing treatment
  • the available resources to safely provide the treatment

If you are being offered a treatment that is not in accordance with the Optimal Care Pathway, you should clearly understand this and provide your consent.
 
You need to understand:
  • whether COVID-19 has impacted the delivery of the Optimal Care Pathway
  • how your treatment will be modified
  • why this modification is necessary
  • what the potential implications of these modifications are on your long-term outcomes
  • the agreement and documentation in the MDT meeting of the modified treatment plan, with clear communication to the GP.
It is therefore very important to keep in contact with your specialist or nurse via telephone or email to ensure you understand if, when, how and why your treatment plan might be modified.
 
If you have any concerns or questions about your situation, please speak with your specialist team. or call our Helpline on 1800 555 494 to speak with a Bowel Care Nurse.
COVID-19 is an emerging, rapidly evolving situation.
 
Although it is virtually impossible to detail every possible scenario that clinicians and patients could face over the coming months, the below table highlights strategic guidance to consider when making multidisciplinary recommendations for the management of bowel cancer during the COVID-19 pandemic.
 
It has been presented by the Colorectal Cancer Alliance (DC, USA) and the Otto J Ruesch Center for the cure of gastrointestinal cancers at the Georgetown University Lombardi Comprehensive Cancer Center (DC, USA).
 
Clinical variables such as MSI-High, right-versus left-sided disease, RAS/BRAF and HER 2 will also need to be incorporated into individual patient decisions.

Treatment that should be commenced
if possible
Rectal cancer, neo-adjuvant chemotherapy
5FU / Oxaliplatin stage III bowel cancer, 4-8 weeks post operative
First line metastatic bowel cancer
Primary resections
Surgery for obstructions, severe bleeding
Palliative radiotherapy
Treatment should not be commenced
without justification
Oxaliplatin for stage II bowel cancer
(Xeloda okay)
Elective liver or other metastatic resections
Rectal chemotherapy /
radiation therapy
Treatment should not be stopped
without justification
Adjuvant 5FU / Xeloda for stage III
bowel cancer (month 1-3)
Adjuvant chemotherapy
for metastatic resection
Rectal chemotherapy /
radiation therapy
Treatment can potentially be stopped or delayed after careful consideration
Oxaliplatin in adjuvant treatment setting
Adjuvant treatment after 3 months
Routine follow-up blood tests and scans
Surveillance colonoscopy
Maintenance therapy; Palliative chemotherapy; Follow-up scans if stable
(metastatic bowel cancer)
Elective liver or other metastatic resections
Rectal resections after
major neo-adjuvant response
Post operative radiotherapy
Palliative radiotherapy if pain controlled

Adaptations to appointments
 
Many specialists have started offering pre-treatment meetings and follow-up appointments via telephone and video conferencing services to reduce the risk of spreading the coronavirus. Ask your healthcare team if this is an option for you. Certain telehealth services are now covered by Medicare.
 
If your specialist wants to keep treatment appointments, only one loved one or carer should go with you and they should be prepared to be screened at the door or to wait outside. No one who is sick or has any COVID-19 symptoms should go to a cancer treatment clinic.
Adaptations to diagnostic and staging procedures
 
Tests to diagnose or stage bowel cancer may be delayed if the risk of infection with coronavirus outweighs the benefits of the tests. However, this will be discussed on a case-by-case basis. In the event of any disruption, hospitals will always make decisions to prioritise tests for those most in need.
Adaptations to treatment
 
You may be asked to reschedule or delay some types of treatments in order to reduce your risk of infection with COVID-19. In many cases a slight delay in treatment is completely safe; your specialist will only suggest this if it is in your best interest.
Adaptations to surgery plans

The temporary suspension of non-urgent elective surgeries does not affect most cancer surgeries, because cancer is classified as ‘category 1 – urgent’ in the healthcare system.
 
If you have an upcoming cancer surgery, your specialist will discuss all the options with you to ensure optimal outcomes while minimising your risk of coronavirus infection.
 
If the surgery requires post-operative intensive care, the current availability of intensive care units will also be considered as part of the decision-making process.
 
The dangers related to bowel cancer progressing following a surgery delay will be weighed against the risks associated with the patient being exposed to the new coronavirus.
 
Your specialist may offer neoadjuvant therapy (treatment given before surgery) in certain situations where it is available but not routinely used, to delay your surgery until the risk has lessened.
 
It is important to note however, neoadjuvant therapy that is immunosuppressive or that requires clinic visits also carries a risk of becoming infected with COVID-19.
 
Because bowel cancer patients are at increased risk of complications from infection if they develop COVID-19, it is essential that the benefit of surgery during the pandemic exceeds that risk.
For bowel cancer surgeries in May 2020 (883) were 16% lower than those recorded for March (1,056) and April (996). The number of bowel cancer surgeries increased in June 2020 (938), but were still 11% lower than for March 2020.  

Bowel cancer surgeries

Adaptations to chemotherapy

The clinical decision to delay, modify or interrupt chemotherapy will be made on a case-by-case basis, depending on:
  • the risk of cancer recurrence if chemotherapy is delayed or interrupted,
  • the number of cycles of chemotherapy that have already been completed, and
  • how well the treatment is being tolerated.
If you are undergoing adjuvant treatment (treatment given after surgery) for resected high-risk disease, then your chemotherapy is likely to continue as planned.
 
If it is decided you will continue with chemotherapy during this time, your specialist may recommend that you take prophylactic growth factors, to help boost your immune system, along with antibiotics, to fight off any infections that might increase your risk of serious complications from COVID-19.
 
If the benefit of adjuvant chemotherapy is small and non-immunosuppressive options are available, your specialist may suggest using an alternative treatment to reduce your risk of complications from COVID-19. For example, there may be an opportunity to switch to a chemotherapy regimen that requires less frequent infusions (e.g. every 2/3 weeks rather than weekly). In certain situations, depending on the infrastructure in your area, the chemotherapy infusion may even be possible at home.
 
Alternatively, you may be able to switch from an intravenous chemotherapy to an oral therapy, reducing the number of times you need to visit the hospital or clinic.
 
If you are on maintenance therapy and are in established remission, your specialist may recommend a chemotherapy ‘holiday’.
 
During COVID-19 there has been rapid uptake of in-home care, including home-based intravenous (IV) chemotherapy administration. Australian private health funds have reported a 50-80% increase in patients seeking chemotherapy at home during the pandemic. 
 

Adaptations to radiotherapy

Your radiotherapy is likely to go ahead if you have a rapidly growing, potentially curable tumour. That’s because the risks of delaying radiotherapy may outweigh the risks associated with COVID-19.
 
However, to minimise your risk of exposure to COVID-19, your specialist might consider accelerated or hypo-fractionated radiotherapy schedules. This allows the total dose of radiotherapy to be delivered over a shorter period or in fewer doses compared with standard radiotherapy.
 
If altering your radiotherapy schedule could put you at risk, or if you are receiving radiotherapy for symptom control, potentially delaying your radiotherapy visits, and considering alternative treatments may be an option.
 
Any decisions regarding alterations or changes to your radiotherapy will only be made when medically justified and appropriate.
 
Speak with your specialist to determine the most appropriate course of action for your treatment.
 
Radiotherapy can also be used to palliate cancer-related symptoms such as bleeding, pain, shortness of breath and cough. In this setting, your specialist would aim to continue, given the benefit to your quality or life. Your specialist can reduce the number of visits of your radiotherapy, if this is safe and as effective as a longer course.

Adaptations to immunotherapy
 
If you are receiving immunotherapy, your specialist might adjust your treatment schedule to reduce the frequency of hospital visits. It is important to note that immunotherapies can cause serious immune-related side effects, including treatment-related pneumonitis, which may increase the risk of serious complications following a COVID-19 diagnosis. Speak with your specialist to determine the most appropriate course of action for you.
Adaptations to the management of side effects of cancer treatment

To avoid exposing you to the possible risk of coronavirus that could result from travelling to or being in hospital or clinic, your GP, specialist, or nurse may choose to conduct appointments over the telephone or via video. Although the visits may not be face-to-face, it is important that you continue to use this valuable time to report any new or troubling side effects from your cancer treatment.
 
Some COVID-19 symptoms overlap with the side effects of cancer treatment, for example fatigue and fever, so it is essential that you monitor any changes carefully and alert your team right away if you notice something.
 
As a way of proactively managing any possible side effects of your cancer treatment that could result in the potential need for emergency care and thus exposure to coronavirus, your specialist may consider any of the following depending on your individual circumstances.
  • If you are clinically stable (as determined by phone or video consultation), but report symptoms of febrile neutropenia, your specialist might prescribe antibiotics without you having to attend an appointment.
  • If you are at a relatively low risk of febrile neutropenia and do not usually take growth factors, your specialist may prescribe a prophylactic growth factor.
  • If your specialist believes you are at risk of serious treatment-related anaemia, they may prescribe an erythropoietin-stimulating agent to lower your risk of a subsequent hospital-based transfusion.
Many medications prescribed to treat side effects can now be delivered directly to you either by the Australian Postal Service or your local pharmacy. Speak with your specialist or pharmacist for details.
Adaptations to follow-up appointments

Following treatment for bowel cancer, there may be changes to your schedule of follow-up appointments to reduce the number of hospital visits. Essential follow-up tests will still be done but the frequency may change, and they may be in a different location.
 
Routine blood tests may be carried out at local healthcare centres rather than in hospitals, and consultations with your specialist are likely to take place via telephone. As you may not see your specialist face-to-face during the pandemic, it is very important that you make full use of the telephone appointments to report any new symptoms, side effects or concerns that you may have.
 
Essential imaging assessments to check on the progress of cancer (such as computed tomography scans) will still go ahead, but these may be reduced in frequency, especially if you are in remission or have stable or slowly progressing cancer. In some areas, your imaging assessments may be relocated to a local cancer centre to avoid potential exposure to coronavirus in a general hospital.
Adaptations to end of life care
 
It is very likely that the COVID-19 pandemic will affect end of life care and treatment plans. Visitors are being restricted to hospitals and hospices, so the option to be cared for at home by family rather than in a healthcare setting may be preferable. However, it is important to be aware that even if you choose to be cared for at home, under the current social distancing rules, you will still be unable to see visitors from outside your household.
 
You will not be alone at this time, even if you are not able to receive end of life care at home. You will be fully supported by specialists and nurses in a hospital or hospice. Although visitors will probably not be allowed, you can stay in touch with loved ones via telephone and video calls.
 
Whether you receive care at home or in a hospital/hospice, your specialist or nurse will ensure that treatment for pain and discomfort is continued. It is very important that you report any new pain or other symptoms so that your specialist can help you to manage them.
 
This will be a distressing time for patients and families. However, you and your loved ones will still receive support from your healthcare providers via telephone, video calls and email. This may include support from your specialist and nurse as well as other healthcare providers such as a dietician, psychotherapist, counsellor, or social worker, depending on your individual needs. Your specialist will discuss the options available in your area and you will be fully involved in the decision-making process.
Modifiable Risk Factors
 
| Staying well whilst at home
 
Maintaining your emotional health
 
Discussions and concerns around the coronavirus outbreak and practising self-isolation can be stressful and impact our mental health and wellbeing. It’s natural to feel a range of emotions, such as stress, worry, anxiety, boredom, or low mood. Many people feel distressed by the constant news and overwhelming amount of information about the situation.
 
Provided by the Australian Department of Health, Head to Health brings together apps, online programs, online forums, and phone services, as well as a range of digital information resources.
 
Head to Health is committed to providing Australians with trusted information and digital supports to help support everyone's mental health and wellbeing during this pandemic.
 
If you are feeling anxious, have questions or need support, our Bowel Care Nurses and Nutritionist are here to help, providing emotional support as well as practical tips for minimising the risk of infection during this time. Email us or call our free Helpline Monday - Friday on 1800 555 494.
Things you can do to stay active while staying inside
 
Increasingly, evidence suggests getting enough physical activity and eating healthy foods can improve the quality of life and better treatment outcomes for people living with or beyond cancer.

However, medical experts are encouraging people to stay at home as much as they can to avoid exposure to the coronavirus and slow its spread and we know this is especially important for those at higher risk, including people with cancer.

With a bit of creativity, you can find new ways to get plenty of physical activity and eat healthy food even while you’re staying home more.

If you’re working or taking online classes from home:
  • Stand up or walk around while you read and answer emails and other messages on your laptop or phone.
  • During conference calls, stand up and pace, or stay seated and do leg lifts, knee lifts, and toe curls. Keep a weight under your desk for bicep curls. Do standing push-ups against a wall.
  • Take a short walk during lunch, or in place of a coffee break.
  • Set an alarm on your computer or phone to remind you to take an activity break. For example, take a one or two-minute standing or walking break every hour.

Other ideas to get moving:
  • Take a walk outside if it’s a nice day or walk inside around the house if it isn’t. Walk fast enough to speed up your heart rate and break a sweat.
  • Walk up and down your stairs. Take every other step to give your legs a good workout.
  • Turn on the radio and dance in the house, alone or with your partner.
  • If you don’t have stairs or much open space, you can do jumping jacks, or walk or jog in place. Try to keep moving for at least 10 minutes.
  • Use hand weights or grab an object like a soup can if you’re just starting to exercise, or a jug of water if you’re stronger. Bend at your elbows to curl your hand to shoulder level. Repeat 10 to 12 times, or until you can’t do it anymore.
  • Do squats when cleaning out closets or playing with your children. Be sure to bend with your knees and keep your back straight.
  • If you’re on social media or can search the internet, check for live-streaming exercise sessions or activity challenges that you can participate in.
 
Make TV time active time:
  • Stand up and fold laundry while you watch.
  • Do a few simple exercises like jumping jacks or walking in place, or by doing stretches in front of the screen.
  • Make a new rule: No sitting during TV commercials.
 
Make household chores count:
  • Mop or vacuum fast enough to get your heart pumping. A 68 kg person can burn about 150 calories an hour this way.
  • Have young children or pets at home? Playing with them can burn more than 200 calories per hour.
  • Yard work and gardening are also ways to burn calories and strengthen your arm, leg, and back muscles.
  • Pushing a lawn mower, raking leaves, shovelling, and other outdoor chores can be an effective workout.
  • Use stay-at-home time for projects you may have been putting off. Cleaning out the garage or attic is another way to be productive and active at the same time. 

Eating well while staying at home
 
The World Cancer Research Fund (WCRF) recommends eating a variety of vegetables and fruits, choosing breads, pastas, and cereals made from whole grains instead of refined grains, and brown rice instead of white. Eat less processed meat, less red meat, and fewer sweets, and drink less alcohol.

Eating healthy meals at home helps you cut down on fat, salt, and sugar – and saves money too. If you’re home from work or eating out less these days, consider it an opportunity to try new, healthier ways of cooking and eating.

These ideas may help:
  • When you do shop, stock your kitchen with ingredients for easy-to-prepare meals.
  • Search for healthy recipes that use ingredients you already have or choose an easy and delicious high and low-fibre recipe our Bowel Care Nutritionist has prepared.
  • Resist the urge to snack during the day. If you’re working from home, work in a room that’s far from the kitchen.
  • If you do snack during the day, choose something from our list of quick, healthy snacks, such as fresh fruit or mixed nuts.
  • If you have children home from school, get them to help with meals. Pre-schoolers can get items from the cupboard or refrigerator and help stir, while older children can use their math skills to measure ingredients, and tweens and teens can take the lead in finding and preparing the recipe.
  • If you’re thinking about getting takeout from local restaurants, call and ask for their menu or look it up online so you can make healthy choices.
If, during this time, you are finding it especially difficult to manage your dietary needs, remember we are here to help. You can download our comprehensive patient information booklet Eating Well - Living With Bowel Cancer for additional tips, or contact our Bowel Care Nutritionist for advice. 

Coronavirus and COVID 19
 
What is coronavirus and COVID-19? 
 
A coronavirus is a specific type of virus that commonly infects animals and people. The coronavirus that originated in Wuhan, China in 2019 is a new strain of coronavirus (SARS-CoV-2) that has not been detected in people before.

COVID-19 is a severe acute respiratory disease caused by the new coronavirus. Because it is unfamiliar to the human immune system, our bodies have not yet developed the ability to fight it off which is what makes it so dangerous.
 
Based on statistics from other countries, 80% of people infected with the virus will develop a very mild form of the disease, while the other 20% will require hospitalisation.

Among the 20% of people requiring hospitalisation, 5% will need intensive care, often involving artificial ventilation.

How does COVID-19 spread?
 
The coronavirus that causes COVID-19 spreads easily from an infected person, even if they do not have any obvious symptoms, to others they come into direct contact with.
 
Therefore, maintaining a physical distance between people you are not regularly in contact with is essential.

Even if you do not come into direct contact with someone who has been infected, you can still pick up the virus following contact with respiratory droplets from a person with the virus after they have sneezed or coughed.

If you touch your face or mouth after having contact with objects or surfaces that have the virus on it, you can become infected, so wash your hands with soap frequently or use an alcohol-based hand sanitiser when hand washing with soap is not possible.
 
Based on the information currently available and medical expertise, the Australian Government Department of Health is advising people at risk to self-isolate in their homes for 14 days, even if they have no symptoms.
How is COVID-19 different from the common cold or the flu?
 
It's easy to confuse the symptoms of the common cold and flu with the symptoms of a COVID-19 infection.
 
COVID-19 is a severe acute respiratory disease that has not been detected in people before. Because it is unfamiliar to the human immune system, our bodies have not yet developed the ability to fight it off which is what makes it so dangerous.
 
COVID cold flu

Incubation/duration
 
In most cases, it takes up to 14 days for COVID-19 symptoms to appear after a person has been infected with the new coronavirus; however, not all people who have been infected with the coronavirus will experience symptoms. The duration of a COVID-19 infection varies from person to person. If you are otherwise healthy, mild symptoms may go away after just a few days. If you have other health problems, such as a lung or heart condition, recovery may take weeks. In very severe cases, COVID-19 can be fatal.
Treatment

As with influenza, treatment for mild to moderate cases of COVID-19 includes rest, fluids, paracetamol, and respiratory support if symptoms become severe. There is no specific treatment for people who have COVID-19 and there are no vaccines that protect against COVID-19.
 
Early diagnosis and general supportive care are important. Most of the time, symptoms will resolve on their own. People who have serious disease with complications can be cared for in hospital.
What are the symptoms of COVID-19?
 
COVID-19 symptoms can range from very mild to severe, may appear 2-14 days after exposure to the virus and can include:
  • fever (37.3oC or higher)
  • cough (usually dry)
  • shortness of breath or difficulty breathing
  • chills
  • repeated shaking with chills
  • muscle or body aches 
  • headache
  • sore throat
  • new loss of taste or smell 
  • fatigue
  • congestion or runny nose
  • nausea or vomiting
  • diarrhoea

When to seek medical attention
 
If you notice any of the following symptoms for COVID-19 in either yourself or the person you’re caring for seek medical attention immediately
  • Trouble breathing 
  • Constant pain or pressure in the chest
  • New confusion or being hard to wake
  • Lips or face appearing slightly blue
Please consult your GP or specialist for any other symptoms that are severe of concerning to you. Call triple zero (000) if you have a medical emergency. Notify the operator that you have, or think you might have COVID-19. If possible, put on a facemask until medical help arrives.

How is coronavirus diagnosed?
Infection with COVID-19 is diagnosed by finding evidence of the virus in respiratory samples such as swabs from the back of the nose and throat or fluid from the lungs. Samples for testing can be taken directly by GPs or at a range of private pathology sites that are suitable for collection of COVID-19, or at public hospitals.

What if someone in my household gets sick with mild symptoms and the doctor tells them to stay at home?
  • If facemasks are available, have the person wear a facemask when they are around others.
  • Have the person wash their hands often or use hand sanitiser with at least 70% alcohol if they cannot get up to use soap and water.
  • Wash your hands often, especially after you’ve been with the sick person, and avoid touching your eyes, nose, and mouth.
  • Regularly clean all surfaces that are touched often, such as counters, tabletops, phones, and doorknobs.
  • Wash laundry thoroughly. Wear disposable gloves while doing laundry if you have them.
  • After you take the gloves off, wash your hands.
  • Have the person stay in one room, away from other people, as much as possible.
  • Have the person use a separate bathroom and bedroom if possible, and avoid sharing personal household items including dishes, utensils, towels, and bedding.

Support for You
 
| Where can I go for help?
 
Providing emotional support as well as practical tips for minimising the risk of infection during this time, our Bowel Care Nurses and Nutritionist are here to help if you are feeling anxious, have questions or need support.
 
Email our Bowel Care Nurses or Nutritionist or call our free Helpline Monday - Friday on 1800 555 494.
 
If you are having chemotherapy and develop a fever, you may be neutropenic, and should follow the process that your treating team has put in place for you.
 
Contact your GP/specialist immediately if you are concerned about your treatment or if you think you may have been exposed to COVID-19 or begin experiencing symptoms.
 
If you have serious symptoms it is important you seek urgent medical attention straight away. Call triple zero (000) for an ambulance.
 
To find out more about COVID-19 visit the Australian Government Department of Health website or Australian Government website.
 
You can also contact the Coronavirus Health Information Line on 1800 020 080.
What I Need to Ask 
Questions to ask your healthcare team 
 
There are many questions you might need to ask your healthcare team about how coronavirus could affect you or someone you are caring for.
 
The following questions have been adapted for use by bowel cancer patients and their loved ones, from a list originally created by the American Cancer Society.
 
Each person’s bowel cancer, treatment, and situation will be different, so the answers will not be the same for everyone.
 
If you or someone you’re caring for has bowel cancer or a history of bowel cancer, or are facing a possible bowel cancer diagnosis:
  • In my situation, how can I prevent getting coronavirus?
  • Am I at higher risk of getting coronavirus or COVID-19? Why or why not?
  • What symptoms of COVID-19 should I watch out for?
  • What should I do if I have symptoms of COVID-19?
  • If I get tested and I am positive for coronavirus, what will happen?
  • If I get tested and I am negative for coronavirus, what should I do if I still don’t feel well?
  • If I get tested and I am negative for coronavirus, can I still get infected later?
  • Will this outbreak, or my coronavirus test result, delay or affect my care in any way?
  • Is telehealth available so I get care virtually or be seen by a GP/specialist over the internet?
 
If you or a loved one is getting ready to have tests and investigations for bowel cancer:
  • Will having this procedure put me at a higher risk of getting coronavirus or COVID-19? Why or why not?
  • Is it necessary for me to have the procedure now or is it safe to wait?
  • Do you think I should delay this procedure? If so, for how long?
  • Is there a chance the hospital or facility will cancel my procedure? What are my options if it's cancelled?
  • Can I have the procedure somewhere else?
  • Can I bring a family member or friend with me? Can people visit me? Can I visit other people?
  • Is telehealth available so I get care virtually or be seen by a doctor over the internet?
  • Will this outbreak delay any results from the procedure?
 
If you or a loved one is getting ready to start bowel cancer treatment:
  • Will treatment put me at a higher risk of getting coronavirus or COVID-19? Why or why not?
  • Is there a chance I can be exposed to coronavirus when I come in for treatment?
  • Is it necessary to start treatment now or is it safe to wait? How long is OK to wait?
  • Do you think I should delay starting treatment?
  • Is there a chance the treatment centre will cancel my scheduled treatment? What are my options if it’s cancelled? Is there another treatment centre where I can get treatment?
  • Can I bring a family member or friend with me to treatment?
  • Can I go to work? Should my caregiver go to work?
  • Can I visit friends? Can friends and relatives visit me?
  • Are there special precautions I should take after treatment begins?
  • Is telehealth available so I get care virtually or be seen by a specialist over the internet?
  • Can I get care, treatment, or bloodwork at home?
 
If you or a loved one is currently undergoing treatment for bowel cancer:
  • Does my treatment put me at higher risk of getting coronavirus or COVID-19? Why or why not?
  • Is there a chance I will be exposed to coronavirus when I come in for treatment?
  • Do I need to wear a mask or gloves at home when I’m around my family and other people?
  • How much do I need to stay at home? Can I run errands like going to the supermarket?
  • Can I go to work? Should my caregiver go to work?
  • Can I visit friends? Can friends and relatives visit me?
  • Should I start my treatment now? Will it put me more at risk?
  • Are there medicines I can take during treatment to lessen my risk?
  • Do you think I should delay my treatment? If so, for how long?
  • What precautions do I need to take when I come in for treatment or check-ups?
  • Can I bring a family member or friend with me to treatment or check-ups?
  • Should I continue treatment or keep my appointments if I have symptoms of COVID-19?
  • Will I need to be seen more frequently now?
  • Will I need to have more frequent tests now?
  • Is there a chance the treatment clinic will cancel my scheduled treatment? What are my options if it’s cancelled? Is there another treatment clinic where I can get treatment?
 
If you or a loved one are not currently undergoing treatment or have finished treatment:
  • Am I still at higher risk of getting coronavirus or COVID-19? Why or why not?
  • Are there special precautions I should be taking? If so, for how long?
  • How much do I need to stay at home? Can I run errands like going to the store?
  • Can I go to work? Should my caregiver go to work?
  • Can I wait to come for follow-up tests or appointments until a later time?
  • Is there a chance I can be exposed to coronavirus if I come for follow-up tests or appointments?
  • Do you think I should I delay my upcoming check-up, follow-up test, or cancer screening?
  • Is there a chance my upcoming check-up, follow-up test, or cancer screening will be cancelled? What will happen if it’s cancelled? Can I get it somewhere else?
  • Can I reschedule a check-up, follow-up test, or cancer screening? If so, when should I reschedule it?
  • Is telehealth available so I get care virtually or be seen by a GP/specialist over the internet?
  • Will this outbreak delay any test results?

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