First of all, I wish to thank @Benjamin P. Levy from Johns Hopkins/Sibley for his advice addressing this critical topic.

We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic should impact our practices in the coming weeks/months, as to the best management of our cancer patients. We are all scrambling with many issues as to who does or does not need to be seen, treated, at what intensity, and under what conditions. Amongst the myriad questions one relevant one is how the ongoing pandemic should influence our care of the by now very large population of patients on checkpoint inhibitors—with a particular focus as to how COVID-19 might call for us to adjust our iAE management practices. We admit that we can provide certainly no firm guidance as we are just urgently rethinking our own oncology teams’ practices as anyone else but a few thoughts come to mind as to prudent adjustments without overpanicking—as at the end of the day none of us wants to throw out “the patient with the bathwater”, right?

What are easy pickings as to proper decisions with today’s scenario at hand with institutions setting priorities to defer elective patient management, however still having enough capacity to support ongoing cancer treatments (admittedly this might change rapidly)?

1. Elective patients MUST be currently deferred—not just to minimize their potential exposure but also to save resources as simple as PPE
2. Treatments that can be deferred or adjusted to be more convenient need to be deferred/modified. E.g. we see no reason to give a checkpoint inhibitor every 2 weeks with approved every 4-week dosing being available and patients who had been well on an IO for extended periods of time might safely take a short treatment break—in particular given long half-life of drugs as to target inhibition. Patients should be of course actively engaged in this process and comforted about these decisions being safe.
3. We should mention that we will all need to find ways to isolate any potential COVID patient early in our clinical settings (e.g. ensuring PPE use as soon as concern arises, dedicated space in our clinical areas etc.) and as much as that is clinically safe, avoid unnecessary ED visits for potentially exposed patients to minimize the spread of infection.
4. So what to do when patients on an IO develop an iAE? Here is where we believe the risk of undertreatment in light of the fear of COVID-19 might pose more risk than provide benefit. Certain things that we should definitely try to do are:
   1. If a patient can be managed as an outpatient safely, we should do our best to do that (and keep it that way—e.g. by more frequent phone checks to minimize visits/allow adjustment of steroid doses/limit chance of need for ED visits/admissions, use of telemedicine when appropriate).
   2. On the other hand, if treatment is needed then for the typical patient we should offer the best validated approach—e.g. based on the superbly put together ASCO guidelines. While cancer patients have a higher risk of COVID-19 complications, there is certainly no data one way or the other as to the impact of steroid use. In addition, the risk of any given patient to acquire COVID-19 is still generally quite low, especially if we take the best measures while the risk of severe complications of a serious iAE such as, for example, colitis/pneumonitis can be quite high with improper management. So withholding an immune suppressive agent in a patient with severe steroid-refractory colitis for a projected concern would appear to be a poor decision. Now concurrent use of chemotherapy/radiation will of course complicate decision-making further adding complexity to proper work-up and management of these patients.
   3. Pneumonitis as a notable iAE might call for special attention as of course the symptoms and imaging findings might overlap with COVID-19 and therefore as much as possible urgent COVID-19 testing, in addition to rapid clinical/laboratory and radiographic evaluation and close collaboration with our ID and Pulmonary champion colleagues is of pivotal importance to enable the best decisions and minimize delays in the introduction of proper treatments to ensure the best outcomes for our patients.

Below are a few links as to COVID/oncology/steroids and ASCO guidelines as to iAE management and we encourage everyone else to share their advice/help work towards mutually agreed upon guidelines/algorithms to address common/significant scenarios and applaud theMednet for their great effort to quickly help us crowdsource such information:

https://www.ncbi.nlm.nih.gov/pubmed/32142621

https://www.ncbi.nlm.nih.gov/pubmed/32043983

https://www.asco.org/asco-coronavirus-information

https://www.ncbi.nlm.nih.gov/pubmed/29442540

I appreciate the excellent response and community coming together to share knowledge. At the risk of overloading with resources and content, there is a podcast by the Uromigos group (group of Urologic Oncologists) that discuss this topic at the link below and a written section compiled by Dr. Doug Johnson from Vanderbilt on the hemonc.org webpage. 

(1) Uromigos: Episode 11: COVID-19 and Immune Checkpoint Inhibitors for the Treatment of Cancer

(2) hemonc.org COVID-19 page