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 primary brain tumour patients

Outpatient visit priorities

High Priority
Newly diagnosed brain tumour New onset or worsening of symptoms indicative of tumour- or treatment-related complications (e.g. neurological symptoms, dyspnoea, chest pain) Clinical or radiological evidence for tumour recurrence Application of intravenous or intrathecal anticancer treatment Wound-healing problems after neurosurgical intervention

Medium Priority
Evaluation of clinical status, laboratory or neuroradiological results in known brain tumour patients without new or worsening symptoms and with active therapy (convert to telemedicine visits whenever possible) Prescription of oral anticancer treatment (convert to telemedicine visits whenever possible) Post-operative patients without need for active therapy and no complications

Low Priority
Evaluation of clinical status, laboratory or neuroradiological results in known brain tumour patients without new or worsening symptoms and without active therapy (convert to telemedicine visits whenever possible) Visits of patients on a best supportive care regimen Visits of psychological support (convert to telemedicine) Survivorship visits Second opinion visits (convert to telemedicine)

Priorities for primary brain tumour patients: Neuro-Imaging

High Priority
New onset or worsening of neurological symptoms

Medium Priority
Follow-up in patients without new or worsening neurological symptoms with ongoing anticancer treatment

Low Priority
Follow-up in patients without new or worsening neurological symptoms without ongoing anticancer treatment

Priorities for primary brain tumour patients: Neurosurgery

High Priority
Need for acute decompression Maximal safe resection in suspected malignant glioma Diagnostic biopsy in suspected primary central nervous system lymphoma (PCNSL)

Medium Priority
Resection/biopsy of non-contrast enhancing primary brain tumour with stable neurological symptoms Re-resection of recurrent lower WHO grade glioma

Low Priority
Partial resection of recurrent malignant glioma

Priorities for brain tumour patients: Radiotherapy

High Priority
Radiotherapy of newly diagnosed glioblastoma, IDH wild-type Radiotherapy of lower WHO grade gliomas, IDH-mutant with relevant clinical manifestations Radiotherapy of adult medulloblastoma

Medium Priority
Radiotherapy of lower WHO grade gliomas, IDH-mutant

Low Priority
Re-irradiation of gliomas

Priorities for brain tumour patients: Systemic therapy

High Priority
High-dose chemotherapy (with methotrexate) for newly diagnosed PCNSL Temozolomide concurrent with and adjuvant to radiotherapy for newly diagnosed glioblastoma with MGMT promoter methylation Temozolomide after radiotherapy for IDH-mutant 1p19q-intact anaplastic astrocytoma Alkylating chemotherapy after radiotherapy in newly diagnosed 1p19q-codeleted anaplastic oligodendroglioma Alkylating chemotherapy for recurrent glioma with MGMT promoter methylation Strict control of steroid prescription (“as little as possible, as much as needed”)

High Priority

High-dose chemotherapy (with methotrexate) for newly diagnosed PCNSL
Temozolomide concurrent with and adjuvant to radiotherapy for newly diagnosed glioblastoma with MGMT promoter methylation
Temozolomide after radiotherapy for IDH-mutant 1p19q-intact anaplastic astrocytoma
Alkylating chemotherapy after radiotherapy in newly diagnosed 1p19q-codeleted anaplastic oligodendroglioma
Alkylating chemotherapy for recurrent glioma with MGMT promoter methylation
Strict control of steroid prescription (“as little as possible, as much as needed”)

Medium Priority
Temozolomide concurrent with and adjuvant to radiotherapy for newly diagnosed glioblastoma without MGMT promoter methylation Systemic therapy for progressive brain tumours without evidence, e.g. meningioma or ependymoma in adults Alkylating chemotherapy after radiotherapy in IDH-mutant WHO grade II astrocytoma Adjuvant chemotherapy after radiotherapy for adult medulloblastoma

Low Priority
Alkylating chemotherapy in patients with recurrent gliomas lacking MGMT promoter methylation, patients with second or higher recurrence of glioma, and patients with reduced performance status or in advanced age

List of abbreviations: COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; IDH, isocitrate dehydrogenase; MGMT, O-6-methylguanine-DNA methyltransferase; WHO, World Health Organization.