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ESMO management and treatment adapted recommendations in the COVID-19 era: Renal cell cancer

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).

 

Renal cell cancer management in challenging environments and health care systems

Outpatient visit priorities

High Priority

  • First visits for patients with advanced disease
  • Patients with suspected significant irAEs or other clinically significant AEs
  • Patients with large or critically located renal masses that cause local symptoms (haematuria, pain)
  • Patients with a suspected cancer-related emergency such as de novo or clinically symptomatic/progressing brain metastasis or spinal cord compression

Medium Priority 

  • Patients with IMDC good-risk disease in need for evaluation of systemic treatment start
  • Patients established on VEGF-targeted therapy after response has been assessed and treatment tolerance ensured. In selected patients, administration of two cycles (12 weeks) at each consultation may be considered
  • Patients on follow-up post-surgery (<6 months follow-up) or high-risk for relapse according to Leibovich score
  • Assessment of surgery for metastatic disease

 Low Priority

  • Patients under VEGF-targeted treatment with excellent tolerance and who have been on treatment >1 year (use telemedicine)
  • Patients on follow-up post-surgery (>6 months follow-up) or low/intermediate risk for relapse according to Leibovich score
  • Patients on long-term follow-up for metastatic disease in response

Priorities for imaging

High Priority

  • Any acute symptom (neurological, bleeding, fracture) that needs urgent imaging (MRI, CT, ultrasound)
  • Imaging for metastatic disease prior to starting treatment or surgery
  • Imaging to rule out or diagnose immune-mediated high-grade toxicities (pneumonitis, encephalitis, GI toxicities) 

Medium Priority 

  • Any imaging that serves to make changes to treatment

 Low Priority

  • Imaging for re-staging purposes in clinically stable patients
  • Imaging for long-term follow-up for advanced disease and post-surgery 

Priorities for surgical oncology

For guidance on management of localised disease see guidelines of the European Urology Association (EAU) on Considerations in the triage of urologic Surgeries during the Covid-19 pandemic

  • General comment: All cytoreductive nephrectomies should be postponed whenever feasible. Avoid surgery for metastatic disease

Priorities for radiation oncology/interventional radiology

High Priority

  • Stereotactic radiation for symptomatic brain metastasis

Medium Priority 

  • Radiofrequency ablations

 Low Priority

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Priorities for medical oncology – advanced disease (systemic treatment)

High Priority

  • Front-line treatment for metastatic intermediate-/poor-risk IMDC patients. ICI combinations or ICI/VEGF combinations remain standard in all but the most challenging healthcare environments. For poor-risk patients with poor performance status where the benefit of treatment is likely limited, best supportive care alone could be considered
  • Second-line therapy for symptomatic progressive disease. Switching to oral VEGF-targeted therapy may be more attractive than ICI therapy

Medium Priority 

  • Systemic treatment changes for asymptomatic progression of disease while on therapy
  • Front-line therapy for IMDC good-risk disease: oral VEGF-targeted therapy will suffice if ICIs are considered to be of too high risk. Delay start of systemic therapy when possible and prefer TKIs to TKI/PD-L1 combination in acute phase of pandemic
  • Continuing therapy beyond two years. Breaks/delays may be possible

 Low Priority

  • Treatment for systemic therapy-refractory disease (third-line therapy and beyond) where little response is expected

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General considerations: 

  • Immunotherapy regimes with a longer interval (4-weekly nivolumab or 6-weekly pembrolizumab) should be used where possible
  • Consider the elevated risk of potential pulmonary toxicities of immune checkpoint inhibition (especially of CTLA-4/PD-L1 combination)    

List of abbreviations: AE, adverse event; COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; CT, computed tomography; CTLA-4, cytotoxic T-lymphocyte-associated protein 4; GI, gastrointestinal; ICI, immune checkpoint inhibitor; IMDC, International Metastatic Renal Database Consortium; irAE, immune-related adverse event; MRI, magnetic resonance imaging; PD-L1, programmed death-ligand 1; TKI, tyrosine kinase inhibitor; VEGF, vascular endothelial growth factor.

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