ESMO’s Expert Consensus: Do Not Discontinue or Delay Cancer Treatment That May Impact on Overall Survival

LUGANO, Switzerland - An ESMO interdisciplinary expert consensus paper on how to manage cancer patients during the COVID-19 pandemic has been published today in Annals of Oncology, encouraging medical oncologists worldwide not to discontinue or delay any type of anti-cancer treatment that may potentially impact on overall survival (1). The experts also urge to stop labelling all cancer patients as vulnerable to coronavirus infection since this may lead to inappropriate care and potential negative outcomes.

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus in humans (SARS-CoV-2) for which there is no proven therapy yet (2). Since its outbreak in December 2019, over 16 million cases have been reported worldwide, including more than 600,000 deaths (3).

The COVID-19 emergency is still challenging oncology experts to continue delivering quality cancer care while protecting patients from the risk of being exposed to the coronavirus. Earlier this year, ESMO developed adapted guidelines for prioritising the various aspects of cancer care across different tumour types, with the aim to mitigate the negative effects of the pandemic on the management of cancer patients (4).

An international consortium was established by ESMO to discuss current clinical evidence from cohort studies and to provide expert advice on significant clinical open questions, from diagnosis to surgery related to cancer management in the COVID-19 era. The interdisciplinary expert panel, consisting of 64 experts and one voting patient advocate, agreed on 28 statements.

“The general advice is that whenever an anti-cancer treatment can impact overall survival of the patient it should not be discontinued or delayed,” explains first author of the consensus paper Prof. Giuseppe Curigliano, European Institute of Oncology (IEO), Milan, Italy, commenting on the recommendations about safety and risks of delivering cancer care in the pandemic era. The recommendation relies on the lack of convincing evidence that using immune checkpoint inhibitors, non-cytotoxic targeted therapies and some types of adjuvant or neoadjuvant systemic therapies is detrimental or, in principle, associated to a higher risk of complications or mortality. “Of course, case-by-case discussions run by multidisciplinary teams remain pivotal to balance the risk of being infected against tumour control, as stated in our previous work,” says Curigliano.

In the consensus paper, the interdisciplinary expert panel also warns against labelling all cancer patients as vulnerable to COVID-19 irrespectively of age, gender, tumour (sub)-type and stage. In fact, despite the fact that during the early days of the pandemic (5-7) cancer patients were reported to be at increased risk of contracting the coronavirus infection and developing a more severe disease, evidences collected up to today suggest that many patients with solid tumours are not more vulnerable to COVID-19 severe outcomes than the general population. (8,9)

“Although it was reasonable to adopt over-protective measures for our patients at the outbreak of a novel infective disease which was not previously observed in humans, we now need to step away from the assumption that all cancer patients are vulnerable to COVID-19,” continues Curigliano. “The implications have been important, because for some patients treatment was delayed or interrupted over the last few months, and I believe that we will see the impact of this over-precautionary approach in the next future.”

Responding to the critical question about who are cancer patients really at high risk related to the COVID-19 virus and its consequences, Curigliano concludes: “Based on current evidence, only patients who are elderly, with multiple comorbidities and receiving chemotherapy are vulnerable to the infection. In this population, before starting any treatment, we recommend to test patients for COVID-19 with a real-time RT-PCR (reverse transcription polymerase chain reaction), the current gold standard for diagnosis, in order to exclude that the patient is infected by the coronavirus.”

The set of statements published in the ESMO’s flagship journal has been designed to serve as a dynamic knowledge repository that will be better informed by accumulating further data on the SARS CoV-2 biology, the pandemic characteristics, the risk of cancer patients for COVID-19 and its modulating factors and, finally, on optimal cancer care in the presence of the virus.

References

1. Curigliano G, Banerjee S, Cervantes A, Garassino M, Garrido P, Girard N, Haanen J, Jordan K, Lordick F, Machiels JP, Michielin O, Peters S, Tabernero J, Douillard JY, Pentheroudakis G. Managing cancer patients during the COVID-19 pandemic: An ESMO Interdisciplinary Expert Consensus. 
2. European Society for Medical Oncology (ESMO). What should oncologists know about COVID-19?
3. European Centre for Disease Prevention and Control. COVID-19 situation update worldwide, as of 23 July 2020.  
4. European Society for Medical Oncology (ESMO). Cancer patients management during the COVID-19 pandemic. 
5. Liang W, Guan W, Chen R, Wang W, Jianfu Li, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a 446 nationwide analysis in China. Lancet Oncol. 2020 Mar 1;21(3):335–7.
6. Yu J, Ouyang W, Chua MLK, Xie C. SARS-CoV-2 Transmission in Patients With Cancer at a Tertiary Care Hospital in Wuhan, China. JAMA Oncol [Internet]. 2020 Mar 25 [cited 2020 Apr 8]; 
7. Miyashita H, Mikami T, Chopra N, Yamada T, Chernyavsky S, Rizk D, et al. Do Patients with Cancer Have a Poorer Prognosis of COVID-19? An Experience in New York City. Ann Oncol [Internet]. 2020 Apr 21 [cited 452 2020 Apr 25];0(0).
8. Kuderer NM, Choueiri TK, Shah DP, et al. Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study [published online ahead of print, 2020 May 28]. Lancet. 2020;S0140-6736(20)31187-9. doi:10.1016/S0140-6736(20)31187-
9. Conference Proceedings, ASCO Virtual Scientific Program 2020 Leora Horn, Jennifer G. Whisenant, Valter Torri, Li-Ching Huang, Annalisa Trama, Luis G. Paz-Ares, Enriqueta Felip, Vera Pancaldi, Alessandro De Toma, Marcello Tiseo, Pilar Garrido, Carlo Genova, Jacques Cadranel, Olivier Michielin, Anne-Marie C. Dingemans, Jan P. Van Meerbeeck, Fabrice Barlesi, Heather A. Wakelee, Solange Peters, Marina Chiara Garassino. LBA111 Thoracic Cancers International COVID-19 Collaboration (TERAVOLT): Impact of type of cancer therapy and COVID therapy on survival.