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ESMO management and treatment adapted recommendations in the COVID-19 era: Gastro-oesophageal tumours

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 gastro-oesophageal cancer patients

Outpatient visit priorities

High Priority

  • Potentially unstable (patients with severe dysphagia, weight loss, bleeding)
  • New diagnosis
  • Patients undergoing perioperative treatment (chemotherapy, chemoradiotherapy)
  • Patients diagnosed with metastatic disease currently with active treatment, receiving i.v. chemotherapy or immunotherapy

Medium Priority

  • Post-operative or post-definitive chemoradiotherapy patients with no complications
  • Patients in palliative care treatment with no active treatment, well controlled, with potential telemedicine follow-up
  • Patients receiving well-tolerated oral therapies (maintenance with capecitabine)
  • Patients in need of psycho-social support without any other acute medical need

 Low Priority

  • Established patients with no new issues
  • Survivorship visits
  • Follow-up for patients at low-to-moderate risk of relapse

Priorities for gastro-oesophageal cancer: Imaging (CT scan) 

High Priority

  • Symptomatic patient (severe dysphagia, intestinal occlusion or other acute symptoms)
  • Initial staging
  • Pre-operative evaluation including re-evaluation after pre-operative treatment
  • Evaluation of patients undergoing active treatment or patients in follow-up with clinical suspicion of symptomatic disease progression

Medium Priority

  • Follow-up in patients with ongoing active treatment for the metastatic setting with non-clinical suspicion of progression

 Low Priority

  • Follow-up visit

Priorities for gastro-oesophageal cancer: Surgery 

High Priority

  • Patients with ongoing peri-operative treatment (chemotherapy or chemoradiotherapy)
  • Radiologically confirmed intestinal occlusion in newly diagnosed patients
  • Bowel perforation, peritonitis
  • Post-surgery complications (perforation, anastomotic leak)
  • Patients with new diagnosis with active bleeding in localised disease and no comorbidities

Medium Priority

  • Staging laparoscopy
  • Symptomatic patients with inoperable primary or recurrent cancer requiring palliative cancer procedures (e.g. palliative bypass, feeding tubes)

 Low Priority

  • Radiologically confirmed intestinal occlusion in stage IV patients treated actively with current clinical suspicion of progression

 Priorities for gastro-oesophageal cancer: Endoscopic procedures

High Priority

  • Patients with clinical cT1N0: consider endoscopic resection according to ESMO guidelines
  • Patients with high suspicion of oesophageal/gastric cancer diagnosis unstable, such as bleeding, severe dysphagia and weight loss, symptomatic anaemia + other upper GI related symptoms
  • Patients with oesophago-gastric cancer and active bleeding
  • Patients susceptible to clear benefit from a stent or endoscopic gastrostomy for feeding tube

Medium Priority

  • EUS for staging

 Low Priority

  • Follow up

 Priorities for gastro-oesophageal cancer: Medical oncology: advanced disease 

High Priority

  • Patients receiving first-line treatment of chemotherapy or maintenance* and with clinical benefit**
  • Continuation of treatment in the context of a clinical trial
  • Patients with MSI tumour status treated with check-point inhibitors with clinical benefit***

Medium Priority

  • Second-line treatment or beyond

 Low Priority

  • Patients with intestinal occlusion due to peritoneal carcinomatosis treated with a conservative approach (best supportive care)

*For patients receiving oxaliplatin-based regimens, consider combination with capecitabine for the front-line and maintenance strategies according to patient characteristics

**Consider dose reduction to reduce risk of potential side effects in older/high-risk population.

***In patients receiving check-point inhibitors, consider delaying treatment scheduling, for example for 6 weeks and with telemedicine appointments if no complications are referred

 

 Priorities for gastro-oesophageal cancer: Medical oncology: early disease

High Priority

  • Continuation of treatment in the context of a clinical trial
  • Continuation of treatment of patients with ongoing pre-operative treatment (chemotherapy or chemoradiotherapy)

Medium Priority

  • Post-operative chemotherapy: consider each case individually according to the clinical benefit: downstaging in the pathological specimens of gastrectomy and risk

 Low Priority

-

Priorities for gastro-oesophageal cancer: Radiotherapy approach

High Priority

  • Continuation of treatment in the context of a clinical trial
  • Continuation of treatment of patients with ongoing neoadjuvant/definitive chemoradiotherapy approach without relevant toxicities and co-morbidities

Medium Priority

  • Palliative radiation for pain control or bleeding

 Low Priority

-

Consider avoiding starting any chemoradiotherapy approach for newly diagnosed oesophageal or gastric tumours in frail populations and especially in patients with cardiovascular comorbidities. If clinical dysphagia, consider a stent or percutaneous endoscopic gastrostomy

 

 

List of abbreviations: CT, computed tomography; EUS, endoscopic ultrasound; GI, gastrointestinal; i.v., intravenous; MSI, microsatellite instability.

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