ESMO Guidelines Discourage Delayed, Discontinued Treatment During the COVID-19 Pandemic

Giuseppe Curigliano, MD, PhD

Any type of anti-cancer therapy that could impact overall survival (OS) should not be discontinued or delayed, according to a European Society for Medical Oncology (ESMO) interdisciplinary expert consensus paper on how to manage patients with cancer during the coronavirus disease 2019 (COVID-19) pandemic.¹

The guidelines, which were recently published in the Annals of Oncology,² also discourage classifying all patients with cancer as especially vulnerable to COVID-19, regardless of age, gender, tumor subtype, and stage, as it could lead to inadequate care and potentially adverse outcomes. Collectively, the interdisciplinary panel, comprised of 64 experts and 1 voting patient advocate agreed on 28 statements.

“Although it was reasonable to adopt overprotective 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,” lead study author, Giuseppe Curigliano, MD, PhD, head of the Division of Early Drug Development at European Institute of Oncology, in Milan, Italy, stated in a press release.¹ “Based on current evidence, only patients who are elderly, with multiple comorbidities, and receiving chemotherapy are vulnerable to the infection.”

COVID-19 is a highly infectious disease caused by a new strain of the coronavirus (SARS-CoV-2) for which there is currently no approved therapy. Over 16 million cases have been reported worldwide, including more than 600,000 deaths since its outbreak in December 2019.³

In order to provide better guidance on the clinical and technical challenges related to diagnosis, risk assessment, response assessment, surgical planning, radiation therapy, and medical treatment during the COVID-19 pandemic, a steering committee consisting of 12 members with expertise in several malignancies created a comprehensive set of nuanced clinical statements.

“Of course, case-by-case discussions run by multidisciplinary teams remain pivotal to balance the risk of being infected against tumor control,” said Curigliano.

The steering committee (SC) compiled the questions that were voted on at the consensus meeting. The members of the multidisciplinary expert panel were nominated by the ESMO Guidelines Committee chair and co-chair. Collective insights led to the development of 10 working packages with detailed statements addressing the following areas:

1. Strategies for patient management and follow up
2. Prevention of SARS-CoV-2 infection in patients with cancer and prioritization of cancer care
3. Granulocyte colony–stimulating factor (G-CSF) use and thromboprophylaxis in cancer patients during the COVID-19 pandemic: benefits, risks, impact in COVID-19–negative and COVID-19–positive patients with cancer
4. COVID-19 testing: whom, when and how (polymerase chain reaction, serology)
5. Use of Immunotherapy
6. Use of targeted TKI therapies
7. Implementation of neoadjuvant and adjuvant chemotherapy
8. Radiation strategies during the COVID-19 pandemic
9. Prioritization of cancer care and intensive care unit triage in patients with cancer/rehabilitation after COVID-19 infection
10. Clinical trial activities in the COVID-19 era

A modified Delphi method was implemented for preparation, consensus, and reporting. Feedback from the steering committee was made available through email. Background information, including the working packages, were sent to panelists twice between May 29, 2020 and June 3, 2020. All comments and suggestions and any disagreements were raised and resolved prior to a second review from all panelists.

“The general advice is that whenever an anticancer treatment can impact overall survival of the patient, it should not be discontinued or delayed,” said Curigliano.

The treatment recommendations are based on the lack of data to suggest that using immune checkpoint inhibitors, non-cytotoxic targeted therapies, and some types of neoadjuvant or adjuvant systemic therapies, is harmful or associated with a higher risk of COVID-19–related complications or mortality.

For example, instead of withholding neoadjuvant immunotherapy in its approved indication, where there is significant survival benefit, the panel stated that checkpoint inhibitors should not be withheld or delayed. However, if a patient tests positive for COVID-19, neoadjuvant checkpoint inhibitors should be postponed until recovery.

“Ultimately, this set of statements will serve as a dynamic knowledge repository that will be better informed by accumulating data on SARS-CoV-2 biology, COVID-19 pandemic characteristics, on the risk of COVID-19 [in patients with cancer] and its modulating factors, and finally, on optimal cancer care in the presence of the virus,” concluded the study authors.

References

1. ESMO’s expert consensus: do not discontinue or delay cancer treatment that may impact on overall survival. News release. European Centre for Disease Prevention and Control. July 31, 2020. Accessed July 31, 2020. https://bit.ly/3gnewhu

2. Curigliano G, Banerjee S, Cervantes A, et al. Managing cancer patients during the COVID-19 pandemic: An ESMO Interdisciplinary Expert Consensus. Ann Oncol. Published July 31, 2020. doi:10.1016/j.annonc.2020.07.010

3. COVID-19 situation update worldwide, as of 31 July 2020. European Centre for Disease Prevention and Control. July 31, 2020. Accessed July 31, 2020. https://bit.ly/30fLNFt