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
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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]);
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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;
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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 lung cancer patients
Outpatient visit priorities
High Priority |
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- New diagnosis or suspicion of invasive lung cancer with either:
- Disease-related symptoms (dyspnoea, pain, haemoptysis, etc.)
- Suspicion of clinical stage II/IIIA/IIIB or metastatic NSCLC or SCLC
- Visits for treatment administration
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Medium Priority |
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- New diagnosis or suspicion of localised lung cancer of clinical stage I
- Post-operative patients with no complications
- Follow-up for patients at high risk of relapse
- Established patients with new problems or symptoms from treatment: convert as many visits as possible to telemedicine visits
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Low Priority |
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- Survivorship visits
- Follow-up for patients at low/intermediate risk of relapse
- Patients visits for psychological support (convert to telemedicine)
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Priorities for Lung Disease: Imaging
High Priority |
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- Patients with significant respiratory symptoms and/or other clinically relevant chest, cancer- or treatment-related symptoms. In patients with new respiratory symptoms such as dyspnoea, cough with or without fever, a CT-scan is recommended
- Standard staging work-up for suspected lung cancer of unknown stage or stage II/III/IV
- Biopsies for suspicious nodules or mass for suspected lung cancer of stage or stage III/IV
- Evaluation of active treatment response in the first 6 months of treatment or if suspicion of progression at any timepoint
- Pre-planned imaging evaluation per clinical trial protocol
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Medium Priority |
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- Follow-up imaging for high/intermediate risk of relapse within one year of completion of radical treatment
- Standard staging work-up for early lung cancer (stage I)
- Biopsies for suspicious nodules or mass for suspected invasive cancer of unknown stage or stage I/II
- Established patients with new problems or symptoms from treatment
- Evaluation of active treatment response beyond 6 months of treatment if stable/controlled situation
- Follow-up of nodules of incidental finding with either:
- Solid nodule 50-500 mm3
- Pleural-based solid nodule 5-10 mm
- Partially solid nodule with a non-solid component of ≥8 mm
- Known VDT (Volume Doubling Time) 400-600 days
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Low Priority |
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- Follow-up imaging for high/intermediate risk of relapse more than a year after completion of radical treatment
- Follow-up imaging after radical treatment in a low risk of relapse scenario
- Follow-up of nodules of incidental finding with either:
- Solid nodule <50 mm3
- Pleural-based solid nodule <5 mm
- Partially solid nodule with a non-solid component of <8 mm
- Non-solid nodule <8 mm
- Benign morphology
- Known VDT >600 days
- Lung cancer screening can be deferred until the COVID-19 pandemic resolves – It is reasonable for patients in the general population to defer screening low-dose CT, a deferral that is not likely to have an impact on overall survival
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Priorities for Lung Disease: Surgical Oncology
High Priority |
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- Drainage +/- pleurodesis of pleural effusion, pericardial effusion, tamponade risk
- Evacuation of empyema-abscess
- T2N0 tumours naïve from treatment or after induction chemotherapy
- Resectable T3/T4 tumours naïve from treatment or after induction chemotherapy
- Resectable N-1/N2 disease naïve from treatment or after induction chemotherapy
- Diagnostic procedure such as mediastinoscopy/thoracoscopy/pleural biopsy/endoscopy/transthoracic investigations for diagnostic/staging work-up
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Medium Priority |
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- Discordant biopsies likely to be malignant
- Resectable NSCLC with T1AN0 (alternative if no surgical capacity available, is stereotactic radiotherapy; surgery is preferred)
- Diagnostic work-up and/or resection of nodules of incidental finding with either:
- Solid nodule >500 mm3
- Pleural-based solid nodule >10 mm
- Solid component >50 0mm3 in partially solid nodule
- Known VDT <400 days
- New solid component in pre-existing non-solid nodule
(alternative if surgery indicated and no surgical capacity available is stereotactic radiotherapy)
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Low Priority |
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- Discordant biopsies likely to be benign
- Operable pure GGO nodule (T1a)
- Diagnostic work-up and/or resection of all other nodules of incidental finding including also:
- Solid nodule >500 mm3 and known VDT >600 days
(alternative if surgery indicated and no surgical capacity available is stereotactic radiotherapy)
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Priorities for Lung Cancer: Medical Oncology – Early Stage Lung cancer
High Priority |
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- Concomitant chemoradiotherapy for SCLC limited disease stage I/II
- Neoadjuvant chemotherapy (enabling deferral of surgery by 3 months) in clinical stage II
- Delivery of adjuvant chemotherapy in T3/4 or N2 disease for young (<65 years old) and fit patients
- G-CSF use if febrile neutropaenia risk evaluated to be >10-15%
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Medium Priority |
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- Adjuvant chemotherapy in T2b-T3N0 or N1 disease should be discussed with patients, considering clinical features and prognosis
- Medical follow-up between 2 cycles should be performed only if necessary and by telephone
- Blood check between 2 cycles should be performed only if necessary and at home if possible
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Low Priority |
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- Adjuvant chemotherapy in stage T1A-T2bN0 with negative prognostic features (lymphovascular infiltration, histological subtype…). The risk versus potential benefit should be individually discussed with patients
- Adjuvant chemotherapy for patients with significant comorbidities, or elderly patients >70y, should be discussed and possibility omitted
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Priorities for Lung Cancer: Medical Oncology – Locally advanced Lung Cancer
High Priority |
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- Concomitant chemoradiotherapy for SCLC limited disease stage III
- Concomitant or sequential chemoradiotherapy for inoperable NSCLC Stage III
- Starting consolidation durvalumab (within 42 days)
- Neoadjuvant chemotherapy in clinical stage III
- G-CSF use if febrile neutropaenia risk evaluated to be >10-15%
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Medium Priority |
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- Medical follow-up between 2 cycles should be performed only if necessary and by telephone
- Blood check between 2 cycles should be performed only if necessary and at home if possible
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Priorities for Lung Cancer: Medical Oncology – Metastatic Lung Cancer
High Priority |
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- 1st-line treatment including chemotherapy, chemotherapy plus IO, IO alone or TKIs to improve prognosis, cancer-related symptoms and QoL
- Start 2nd-line chemotherapy or IO in symptomatic and progressive disease patients
- Start 2nd-line TKI in progressive disease patients
- G-CSF use has to be considered if despite optimal dose modification, risk of febrile neutropaenia is >10%
- Anti-PD-(L)1 scheduled cycles may be modified/delayed to reduce clinical visits (for instance, using 4-weekly or 6-weekly dosing instead of 2- or 3-weekly for selected agents when appropriate (where allowed from National Regulatory Agency)
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Medium Priority |
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- Start 2nd and beyond line chemotherapy or IO in asymptomatic patients, in absence of threatening disease (volume/location)
- Consider, when feasible, oral chemotherapy treatment instead of intravenous (etoposide, vinorelbine) to reduce hospital visits
- Medical follow-up between 2 cycles should be performed only if necessary and by telephone
- Blood check between 2 cycles should be performed only if necessary and at home if possible
- For patients ongoing with IO from more than 12/18 months, delaying the next cycle, omitting some scheduled cycle, or generally enlarging intervals should be considered
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Low Priority |
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- Discontinuation of IO after 2 years of treatment should be considered, keeping in mind the lack of prospective evidence
- For patients ongoing with IO having stopped due to toxicity, resuming might be delayed in absence of disease progression
- Postpone antiresorptive therapy (zoledronic acid, denosumab) that is not needed urgently
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Priorities for Lung Cancer: Radiation Oncology
High Priority |
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- Radiotherapy for inoperable stage II-III cancers, with contra-indications for chemotherapy
- Concomitant (preferred) or sequential chemoradiotherapy for inoperable NSCLC Stage II/III
- Concomitant (preferred) or sequential chemoradiotherapy for SCLC limited disease
- Superior vena cava obstruction, significant haemoptysis, spinal cord compression, significant bone pain or any life-threatening condition amenable to palliative radiotherapy
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Medium Priority |
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- SABR-SBRT for stage I cancers
- Adjuvant PORT for R1 resection, if indicated in NSCLC could be considered at the at the end of adjuvant chemotherapy or delayed up to 3 months from surgery
- PCI in limited stage SCLC after chemotherapy
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Low Priority |
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- Adjuvant PORT N2 R0, if indicated in NSCLC should be discussed and if retained considered at the at the end of adjuvant chemotherapy or delayed up to 3 months from surgery
- PCI in extensive stage SCLC after chemotherapy may be replaced by MRI active surveillance
- Non-life-threatening conditions such as mild bone or chest pain should be considered for more aggressive analgesics and use of palliative radiotherapy should be individualised depending on individual benefit/risk ratio
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List of abbreviations: CT, computed tomography; G-CSF, granulocyte colony-stimulating factor; GGO, ground-glass opacity; IO, immune-oncology; NSCLC, non-small cell lung cancer; QoL, quality of life; PD-1, programmed cell death protein 1; PD-L1, programmed death-ligand 1; SABR, stereotactic ablative radiotherapy; SBRT, stereotactic body radiotherapy SCLC, small cell lung cancer; TKI, tyrosine kinase inhibitor; VDT, volume doubling time.
