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).

Priorities for head and neck cancer patients

Outpatient visit priorities

High Priority
New diagnosis of head and neck cancer Patients experiencing acute toxicities during curative treatment with radiation/systemic therapies Post-operative patients with complications Head and neck cancer survivors experiencing signs/symptoms of recurrence

Medium Priority
Head and neck cancer survivors experiencing late toxicities Post-operative or post-(chemo)radiotherapy patients with no complications Psychological support visits (convert to telemedicine) Patients in early follow-up (first 2 years) after curative treatment

Low Priority
Patients in late follow-up (after 2 years) with neither signs/symptoms of recurrence nor toxicities: refer to telemedicine and postpone imaging Visits between two treatments for patients on systemic palliative treatment: refer to telemedicine

Prior to any in-person visit, patients should be screened for symptoms of COVID-19 by maximising telemedicine triage and establishing screening at intake by using checklists and monitoring tools
Telemedicine may play a role in primary assessment of signs and symptoms, reassuring anxious subjects, while prompting an urgent in-person visit in case of doubts (new lump in the neck, dysphagia, dyspnoea, minor bleeding…)
However, clinical examination of the head and neck via telemedicine for oncological reasons should be avoided except for a general inspection of the neck, face and anterior oral cavity (also in such circumstances, however, it should be noted that palpation and close inspection are the main resources for clinical judgement, especially in already treated patients)

Priorities for head and neck cancer patients: Primary surgery

High Priority
Larynx – Hypopharynx: cT3-cT4, every cTN+, rT3-rT4, every rTN+, every patient with instable airway (dyspnoea or pending dyspnoea, dysphagia, painful swallowing, risk of bleeding…) Oral cavity – Oropharynx: cT2-cT4, every cTN+, every patient with instable airway (dyspnoea or pending dyspnoea, dysphagia, painful swallowing, risk of bleeding…), pathological fracture of the mandible, trismus Paranasal sinuses: cT2-cT4, every cTN+, every patient with diplopia, facial deformity, skin ulceration, frequent and massive oral and/or nose bleeding Thyroid: cT4, every cT with bulky N+, aggressive histotypes (medullary, tall cell, undifferentiated…) Salivary glands: cT3-cT4, every cTN+, aggressive histotypes (salivary duct, adenoid cystic, high grade mucoepidermoid…) Skin of face and neck: squamous cell carcinomas cT3-cT4 and every cTN+ Every G2-G3 soft tissues or bone sarcomas Every paediatric tumour

High Priority

Larynx – Hypopharynx: cT3-cT4, every cTN+, rT3-rT4, every rTN+, every patient with instable airway (dyspnoea or pending dyspnoea, dysphagia, painful swallowing, risk of bleeding…)
Oral cavity – Oropharynx: cT2-cT4, every cTN+, every patient with instable airway (dyspnoea or pending dyspnoea, dysphagia, painful swallowing, risk of bleeding…), pathological fracture of the mandible, trismus
Paranasal sinuses: cT2-cT4, every cTN+, every patient with diplopia, facial deformity, skin ulceration, frequent and massive oral and/or nose bleeding
Thyroid: cT4, every cT with bulky N+, aggressive histotypes (medullary, tall cell, undifferentiated…)
Salivary glands: cT3-cT4, every cTN+, aggressive histotypes (salivary duct, adenoid cystic, high grade mucoepidermoid…)
Skin of face and neck: squamous cell carcinomas cT3-cT4 and every cTN+
Every G2-G3 soft tissues or bone sarcomas
Every paediatric tumour

High/Medium Priority
Larynx – Hypopharynx: cT1-cT2 Oral cavity – Oropharynx: cT1 Paranasal sinuses: cT1 Thyroid: cT2-cT3, non-bulky and non-critical N+ Salivary glands: cT1-cT2 Skin of face and neck: squamous cell carcinoma cT1-cT2, large basal cell carcinomas G1 soft tissues or bone sarcomas

Low Priority
Thyroid: cT1, TIR 3A, TIR 3B Skin of face and neck: small basal cell carcinomas

Multidisciplinary team meetings -physically or virtually- should remain the place where clinical choices about curative treatments are mainly defined
High-medium priority patients should not be delayed more than 2 months

Priorities for head and neck cancer patients: Primary non-surgical management and postoperative treatment

High Priority
Definitive (chemo)radiotherapy for oropharyngeal carcinoma regardless of HPV status and for advanced hypopharyngeal or laryngeal carcinoma Continuation of treatment in the context of a clinical trial, provided patient benefits outweigh risks, with possible adaptation of procedures without affecting patient safety and study conduct

High/Medium Priority
Postoperative (chemo)radiotherapy for non-in-sano resection/positive margins or extracapsular spread of squamous cell carcinomas, sarcomas, or salivary gland tumours of aggressive histology Definitive radiotherapy of early glottic cancer (cT1-cT2 N0) Symptomatic palliative treatment (e.g. bleeding, see also under “Priorities for symptomatic recurrent/metastatic patients)

Low Priority
Adjuvant radiotherapy for minor risk factors Basal cell carcinomas Asymptomatic palliative treatment

Multidisciplinary team meetings -physically or virtually- should remain the place where clinical choices about curative treatments are defined
Curative intended radiotherapy should not be postponed for an interval longer than 4-6 weeks
Do not necessarily change fractionation unless radiation-therapy resources are limited
Consider implementing moderately hypofractionated regimens, only in case of extreme shortness of resources (fractions of 2.2-3 Gy)
Concurrent chemoradiotherapy should be preferred to induction chemotherapy followed by (chemo)radiotherapy for organ preservation, to limit overall treatment time and chemotherapy-related immunosuppression
High-dose three-weekly cisplatin should be preferred to low-dose weekly cisplatin to reduce medical visits
Consider omitting concomitant chemotherapy only in case of extreme shortness of resources
If the patient tested positive for COVID-19 before treatment, postpone radiotherapy initiation until test becomes negative
Keep continuity in radiotherapy in case of COVID-19 positivity with mild/no symptoms; continue radiotherapy if at least 2 weeks of treatment have been performed, provided it is clinically practicable
Interrupt treatment in case of severe symptoms
Supportive care during radiotherapy with/without systemic therapy:
a) provide dental clearance before starting radiation adopting safety measures for both patients and healthcare professionals
b) keep a low threshold for suspicion of infection, due to the possible anergic state of head and neck cancer patients
c) implement the use of patient-reported outcome measures to periodically assess symptoms
Consider replacing weekly on-site patient reviews with video- or telephone-consultations

Priorities for head and neck cancer patients: Systemic therapies in recurrent and/or metastatic disease

High Priority
Continuation of treatment in the context of a clinical trial, provided patient benefits outweigh risks, with possible adaptation of procedures without affecting patient safety and study conduct Early initiation of systemic therapy in patients with fast disease pace, high tumour burden and/or symptomatic

Medium Priority
Initiation of systemic therapy in patients with less aggressive disease features

Low Priority
Monotherapy (e.g. with immune checkpoint inhibitors) in frail patients

Continuation of treatment in the context of a clinical trial, provided patient benefits outweigh risks, with possible adaptation of procedures without affecting patient safety and study conduct
In patients on treatment with immune checkpoint inhibitors and having achieved partial/complete response or with clinical benefit and without toxicities, consider switching from a q2-3w schedule to a q4-6w schedule to reduce medical visits (a telemedicine visit with or without laboratory testing between two treatment cycles is suggested to monitor these patients, who often are frail)
Patients on IO showing signs of pneumonitis on CT scans should be tested for COVID-19 before administering steroids
For patients in treatment with intravenous chemotherapy, shift to oral chemotherapy (e.g. capecitabine), when feasible, might be offered to avoid frequent access to hospital

Priorities for head and neck cancer patients: Symptomatic recurrent/metastatic disease and end-of-life care

High Priority
Tracheotomy in case of obstruction of the upper airways/stridor Threatening lesion, e.g. risk of fracture or bleeding Acute spinal cord compression

Medium Priority
Irradiation of symptomatic metastases (depending on symptoms and availability of radiotherapy resources): e.g. bleeding, superior cava syndrome

Low Priority
Irradiation of asymptomatic and non-threatening metastases Local ablative treatment (surgery/stereotactic radiotherapy) of metastases in oligometastatic setting

Steroids should be avoided as much as possible or administered as conservatively as possible
Consider implementing 1-4 fraction regimens for symptomatic palliative cases (e.g. 1x 8 Gy, “QUAD-SHOT”)

List of abbreviations: COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; CT, computed tomography; HPV, human papillomavirus; IO, immuno-oncology; qXw, every X weeks.

Specific bibliography:

Thomson DJ, Palma D, Guckenberger M et al. Practice recommendations for risk-adapted head and neck cancer radiation therapy during the COVID-19 pandemic: An ASTRO-ESTRO Consensus Statement. Int J Radiat Oncol Biol Phys 2020;107:618-627. Hanna TP, Evans GA, Booth CM. Cancer, COVID-19 and the precautionary principle: prioritizing treatment during a global pandemic. Nat Rev Clin Oncol 2020; 17:268–270.
Hanna TP, Evans GA, Booth CM. Cancer, COVID-19 and the precautionary principle: prioritizing treatment during a global pandemic. Nat Rev Clin Oncol 2020; 17:268–270.
Curigliano G, Banerjee S, Cervantes A et al; all Voting Panel members. Managing cancer patients during the COVID-19 pandemic: An ESMO Interdisciplinary Expert Consensus. Ann Oncol 2020; doi.org/10.1016/j.annonc.2020.07.010. In Press.

Essential bibliography:

World Health Organization. COVID-19: Operational guidance for maintaining essential health services during an outbreak. Available at: https://www.who.int/publications-detail/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreak (1st September 2020, date last accessed).

National Comprehensive Cancer Network. Coronavirus Disease 2019 (COVID-19) Resources for the Cancer Care Community. Available at: https://www.nccn.org/covid-19/ (26th August 2020, date last accessed).

National Comprehensive Cancer Network. NCCN Guidelines Head and Neck Cancers Version 2.2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf (26th August 2020, date last accessed).