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).
Priorities for Multiple Myeloma patients
Priorities for Multiple Myeloma: Medical Oncology*
Young, transplant-eligible patients
High Priority |
|---|
- Patients with newly diagnosed active/high-risk disease (SLiM-CRAB criteria present):
- Treatment should not be postponed
- Therapeutic decisions should be made on a case-by-case basis, considering disease stage, risk, age, cytogenetics/FISH, comorbidities
- Consider G-CSF support to minimise risk of neutropaenia
|
Medium Priority |
|---|
- Patients on continuous first-line treatment:
- Consider delaying ASCT and prolong induction regimen for up to 6-8 cycles
- Patients scheduled to undergo ASCT should be tested for COVID-19 before ASCT
- For standard-risk patients, consider delaying ASCT by additional induction cycles and/or lenalidomide maintenance (no proven OS benefit for early treatment in this setting compared with modern 3-drug induction followed by lenalidomide maintenance therapy without ASCT consolidation)
- Use interval phone and/or virtual visits whenever possible to monitor tolerability of treatment, to decrease clinic visits
- Consider extending access to lenalidomide for up to 2 months for patients receiving maintenance therapy (with telemedicine/remote lab tests in between)
- In patients in need of IVIg replacement, consider administration at reduced frequency
- Consider G-CSF support to minimise neutropaenia
|
Low Priority |
|---|
- Patients in stable remission (currently without active treatment):
- Delay follow-up visits and/or perform by telemedicine if possible
- Delay antiresorptive therapy (zoledronic acid, denosumab) and/ or reduce frequency (e.g. every 3 months)
|
Elderly, transplant non-eligible patients with newly diagnosed MM
High Priority |
|---|
- Patients with newly diagnosed active/high-risk disease (SLiM-CRAB criteria present):
- Treatment should not be postponed
- Therapeutic decisions should be made on a case-by-case basis, considering disease stage, risk, age, cytogenetics/FISH, comorbidities
- Consider G-CSF support to minimise risk of neutropaenia
|
Medium Priority |
|---|
- Patients on continuous treatment:
- Patients responding to lenalidomide/dexamethasone: consider discontinuation of dexamethasone and maintain response with lenalidomide alone
- Prefer prescription of orally available drugs
- If parenteral drug administration is necessary, consider using it at reduced frequency
- Use interval phone and/or virtual visits whenever possible to monitor tolerability and outcome
- Reduce dexamethasone dose to ≤20 mg weekly
- Consider G-CSF support to minimise risk of neutropaenia
|
Low Priority |
|---|
- Patients in stable remission on continuous treatment (or without active treatment):
- Delay follow-up visits and/or perform by telemedicine if possible
- Delay antiresorptive therapy (zoledronic acid, denosumab) and/or reduce frequency (e.g. every 3 months)
|
Patients with relapsed/refractory MM
High Priority |
|---|
- Patients with relapsed disease requiring therapy (development of new SLiM-CRAB criteria or significant paraprotein relapse) or refractory MM:
- Treatment should not be postponed
- Therapeutic decisions should be made on a case-by-case basis, considering disease stage, risk, cytogenetics/FISH, age, comorbidities
- Consider G-CSF support to minimise risk of neutropaenia
|
Medium Priority |
|---|
- Patients with relapsed/refractory disease on continuous treatment:
- In patients responding to lenalidomide/dexamethasone, consider modifying the treatment regimen to minimise need for clinic/hospital visits, e.g. by:
- using weekly instead of biweekly administration of drugs (e.g. carfilzomib, bortezomib)
- preference for oral agents (i.e. ixazomib, lenalidomide, pomalidomide)
- switching to monthly administration of daratumumab as soon as possible
|
Low Priority |
|---|
- Patients with relapsed/refractory disease in stable remission on continuous treatment:
- Delay antiresorptive therapy (zoledronic acid, denosumab) and/or reduce frequency (e.g. every 3 months)
|
Patients with SMM or MGUS
Medium Priority |
|---|
- Consider delaying scheduled visits or reducing clinic visits for surveillance of patients with high-risk SMM (individualised decision according to risk) and/or perform scheduled visits particularly for surveillance by telemedicine and local lab tests if possible
|
Low Priority |
|---|
- Delay scheduled visits for patients with low risk SMM or MGUS and/or perform by telemedicine and local lab tests if possible
|
*adapted from recommendations made by the International Myeloma Society
List of abbreviations: ASCT, autologous stem cell transplantation; FISH, fluorescent in situ hybridisation; G-CSF, granulocyte colony-stimulating factor; IVIg, intravenous immunoglobulin; MGUS, monoclonal gammopathy of undetermined significance; MM, multiple myeloma; OS, overall survival; SMM, smouldering multiple myeloma; Tx, treatment.
