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 Melanoma patients
Outpatient visit priorities
High Priority |
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High/Medium Priority |
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Medium Priority |
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Low Priority |
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- For patients on PD-1 blockade, we recommend double dosing with double interval to reduce visits: pembrolizumab 400 mg q6w and nivolumab 480 mg q4w with one inter-cure visit in telemedicine with blood exams performed in a laboratory close to the patient if a suitable COVID-19-protected facility is available, otherwise at the centre under current precautions
- For patients on TKIs, refer follow-up visits (e.g. monthly or q2m) to telemedicine with blood exams performed in a laboratory close to the patient if a suitable COVID-19-protected facility is available, otherwise at the centre under current precautions
Priorities for Surgery in Primary Melanoma
High Priority |
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High/Medium Priority |
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Low Priority |
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- Inclusions in adjuvant and neo-adjuvant trials should be discouraged as these will result in additional visits to the centre and expose the patient
Priorities for Adjuvant Systemic Therapies for Stage III Melanoma
High Priority |
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High/Medium Priority |
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Low Priority |
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- Depending on the local hospital situation, adjuvant treatments can be delayed up to the 12 weeks allowed in the adjuvant clinical trials
- Depending on the local hospital situation, adjuvant BRAFi/MEKi (as this oral strategy is more amenable to telemedicine) could be initiated and a later switch to adjuvant IO could be discussed
- Inclusions in adjuvant and neo-adjuvant trials should be discouraged as these will result in additional visits to the centre and expose the patient
- For patients on PD-1 blockade, we recommend double dosing with double interval to reduce visits: pembrolizumab 400 mg q6w and nivolumab 480 mg q4w with one inter-cure visit in telemedicine with blood exams performed in a laboratory close to the patient if a suitable COVID-19-protected facility is available, otherwise at the centre under current precautions
Priorities for Systemic Therapies for Non-Operable Stage III/IV Melanoma
High Priority |
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Medium Priority |
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- |
Low Priority |
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- For IO, the small numerical benefit of IPI/NIVO compared with PD-1 single agent has to be weighed against increased grade III/IV irAEs and the risk associated with steroid usage. The CheckMate 511 regimen (IPI 1 mg/kg and NIVO 3 mg/kg) can be discussed on a case-by-case basis
- For patients on PD-1 blockade, prefer double dosing with double interval to reduce visits: pembrolizumab 400 mg q6w and nivolumab 480 mg q4w with one inter-cure visit in telemedicine with blood exams performed in a laboratory close to the patient if a suitable COVID-19-protected facility is available, otherwise at the centre under current precautions
- Patients on IO showing signs of pneumonitis on CT scans should be tested for COVID-19 before administrating steroids
- For patients on TKIs, refer follow-up visits to telemedicine with blood exams performed in a laboratory close to the patient if a suitable COVID-19-protected facility is available, otherwise at the centre under current precautions
Priorities for Radiotherapy for Non-Operable Stage III/IV Melanoma
High Priority |
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High/Medium Priority |
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Low Priority |
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- Steroids should be avoided as much as possible or administrated as conservatively as possible
List of abbreviations: AJCC, American Joint Committee on Cancer; BRAFi, BRAF inhibitor; CT, computed tomography; IO, immuno-oncology; IPI, ipilimumab; irAE, immune-related adverse event; MEKi, MEK inhibitor; NIVO, nivolumab; PD-1, programmed cell death protein 1; qXm, every X months; qXw, every X weeks; TKI, tyrosine kinase inhibitor.
Specific bibliography
- Oude Ophuis CM, Verhoef C, Rutkowski P, et al. The interval between primary melanoma excision and sentinel node biopsy is not associated with survival in sentinel node positive patients - An EORTC Melanoma Group study. Eur J Surg Oncol 2016;42(12):1906-1913.
- Oude Ophuis CM, van Akkooi AC, Rutkowski P, et al. Effects of time interval between primary melanoma excision and sentinel node biopsy on positivity rate and survival. Eur J Cancer 2016;67:164-173.
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 April 2020, date last accessed).
ESMO Clinical Practice Guidelines: Melanoma. Available at: https://www.esmo.org/guidelines/melanoma (20 April 2020, date last accessed).
American College of Surgeons. COVID-19 Guidelines for Triage Cancer Patients. Available at: https://www.facs.org/covid-19/clinical-guidance/elective-case/cancer-surgery (1st April 2020, date last accessed).
American Society for Radiation Oncology (ASTRO). COVID-19 Recommendations to Radiation Oncology Practices. Available at: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information (1st April 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/ (1st April 2020, date last accessed).