Cancer Patient Management During the COVID-19 Pandemic

Cancer patient prioritisation

The tiered approach of ESMO in delivering a guidance for cancer patients during the COVID-19 pandemic is designed across three levels of priorities, namely: tier 1 (high priority intervention), 2 (medium priority) and 3 (low priority) – defined according to the criteria of the Cancer Care Ontario, Huntsman Cancer Institute and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS), incorporating the information on the value-based prioritisation and clinical cogency of the interventions

High priority: Patient's condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g. significant overall survival [OS] gain and/or substantial improvement in quality of life [QoL]);
Medium priority: Patient's situation is non-critical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority;
Low priority: Patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is non-priority based on the magnitude of benefit (e.g. no survival gain with no change nor reduced QoL).

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Priorities for ovarian cancer

Documented multidisciplinary tumour team (MDT) decision making, taking into account patient condition (vulnerable patients)* and available resources [Intensive Care Unit (ICU) support for surgery]. If not adequate, refer to or discuss with an Oncological Hub for gynaecological cancers.

Patients and family should be adequately informed about the risk/benefit ratio of each intervention with clinicians taking into account of national therapeutic or interventional guidelines or national specialty recommendations in relation to COVID-19.

*vulnerable patients: >65 years, pre-existing cardiovascular disease, pre-existing respiratory disease

Outpatient visit priorities

High Priority
Potentially unstable (acute abdominal pain, intestinal obstruction, complications during post- surgery recovery Symptomatic new patient (symptomatic ascites or pleural effusion, intestinal obstruction)

Medium Priority
Newly diagnosed asymptomatic patients, no prior surgery Post-operative patients with no complications Patients continuing on chemotherapy – telemedicine where possible Established patients with new problems or symptoms from treatment – convert as many visits as possible to telemedicine appointments

Low Priority
Follow-up visit on PARPi maintenance; most can be managed through telemedicine with scheduled blood tests and imaging done close to home. Explore postal drug delivery For maintenance bevacizumab, if facilities exist to continue, supervision can be performed by telemedicine, ensuring BP and urinalysis are monitored Survivorship visits off study

For patients on clinical trials, seek information about changes in management for individual studies from the co-ordinating trials unit – treatment frequency; blood investigations and imaging.

Priorities for ovarian cancer: Imaging (CT scan)

High Priority
Symptomatic patient (intestinal obstruction, abdominal perforation)

Medium Priority
Diagnostic imaging for clinical suspicion of ovarian cancer (clinical, US)

Low Priority
Follow-up visit out of study Follow-up visit on PARPi maintenance

Priorities for ovarian cancer: Surgical oncology

High Priority
Radiologically confirmed intestinal obstruction in newly diagnosed patient Bowel perforation, peritonitis Post-surgery complications (perforation, anastomotic leak) Pelvic mass with torsion or causing urinary or intestinal obstruction

Medium Priority
Establishment of cancer diagnosis when high suspicion exists (e.g. diagnostic laparoscopy) Primary cytoreductive surgery Possible interval debulking surgery following review by multidisciplinary team. Continuation of first-line therapy with postponement of surgery should be considered as an option Symptomatic patients with inoperable primary or recurrent cancer requiring palliative cancer procedures (e.g. diverting colostomy, venting PEG tubes)

Medium Priority

Establishment of cancer diagnosis when high suspicion exists (e.g. diagnostic laparoscopy)
Primary cytoreductive surgery
Possible interval debulking surgery following review by multidisciplinary team. Continuation of first-line therapy with postponement of surgery should be considered as an option
Symptomatic patients with inoperable primary or recurrent cancer requiring palliative cancer procedures (e.g. diverting colostomy, venting PEG tubes)

Low Priority
Risk-reducing surgery for genetic predisposition to gynaecological cancer Benign-appearing ovarian cysts/masses Recurrent cancer requiring palliative resection Oligometastatic first relapse where complete resection is feasible

Priorities for ovarian cancer: Medical oncology – advanced disease

High Priority
NACT in symptomatic patients Post-operative ChT or continuation of post-operative ChT for high-grade serous/endometrioid tumours. Importance of BRCA testing continues as these patients are eligible for PARP inhibitors and should be considered for shortened ChT cycles Continuation of treatment in the context of a clinical trial

Medium Priority
First-line post-operative ChT in advanced-stage clear cell or mucinous tumours ChT for high-grade serous/endometrioid symptomatic platinum-eligible recurrent patients)

Low Priority
ChT for high-grade serous/endometrioid platinum non-eligible symptomatic recurrent patients Symptomatic slowly growing recurrent disease ChT for recurrent low-grade serous tumours

Priorities for ovarian cancer: Medical oncology – early disease

High Priority
Adjuvant ChT for stages I-IIA high-grade serous/endometrioid Continuation of treatment in the context of a clinical trial

Medium Priority
Adjuvant ChT for stages IC-IIA infiltrative mucinous

Low Priority
ChT for IC IIA low-grade serous/endometrioid/clear cell/expansile invasion mucinous IC low-grade serous endometrioid/expansile/invasion mucinous, ChT possible option, considered less essential and to be discussed with the patient, taking into account the risk/benefit ratio

Chemotherapy in advanced disease:

Platinum-based therapy, in combination where feasible: carboplatin/paclitaxel every 3-4 weeks (to reduce visits and risk of myelotoxicity). Consider 4-6 cycles depending on response and prognostic factors. Consider reduced number of cycles (4-5) in responding patients before adding PARP inhibitor. Consider early discontinuation of paclitaxel for toxicity
GCS support to prevent leukopaenia
Limit dexamethasone to reduce immunosuppression
Caution with bevacizumab because of the associated hypertension which may worsen COVID-19 outcome, and use of resources with maintenance therapy
Maintenance with PARP [poly (ADP-ribose) polymerase] inhibitors in high-grade serous/endometriod cancers with a BRCA mutation responding to platinum-based therapy
In patients who have a BRCA mutation and are PARP naïve, consider rucaparib monotherapy in situations where platinum therapy cannot be given
Non platinum-based therapies are low priority (above) and should only be used after careful review of the risk/benefit

Chemotherapy in early disease:

3-6 cycles carboplatin/paclitaxel (6 cycles in high-grade serous/endometrioid/clear cell)
Carboplatin 6 cycles

Dose adaptation or single-agent carboplatin (AUC5 every 4 weeks) in vulnerable* patients.

*vulnerable patients: >65 years, pre-existing cardiovascular disease, pre-existing respiratory disease

List of abbreviations: BP, blood pressure; ChT, chemotherapy; CT, computed tomography; NACT, neoadjuvant chemotherapy; PARP, poly (ADP-ribose) polymerase; PARPi, poly (ADP-ribose) polymerase inhibitor; PEG, percutaneous endoscopic gastrostomy; US, ultrasound.

References

Huntsman Cancer Institute Patient Scheduling Recommendations During COVID 19 Crisis 17 March, 2020

NHS Clinical guide for the management of non-coronavirus patients requiring acute treatment: Cancer 23 March 2020, Version 2. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty-guide-acute-treatment-cancer-23-march-2020.pdf (31 March 2020, date last accessed)

BGCS framework for care of patients with gynaecological cancer during the COVID-19 Pandemic (Final. 22/03/2020). https://www.bgcs.org.uk/wp-content/uploads/2020/03/BGCS-covid-guidance-v1.-22.03.2020.pdf (31 March 2020, date last accessed)

SGO surgical considerations for gynecologic oncologists during the COVID-19 pandemic (March 27, 2020). https://www.sgo.org/clinical-practice/management/covid-19-resources-for-health-care-practitioners/surgical-considerations-for-gynecologic-oncologists-during-the-covid-19-pandemic/ (31 March 2020, date last accessed)

Colombo N, Sessa C, du Bois A, et al. ESMO–ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease. Ann Oncol 2019; 30: 672-705.