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ESMO management and treatment adapted recommendations in the COVID-19 era: Urothelial cancer of the bladder

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 Urothelial bladder cancer

Outpatient visit priorities

High Priority

  • Patients with muscle-invasive disease should be evaluated for potentially curative therapy 
  • Patients with new presentation of advanced disease
  • Patients rapidly progressing on first-line immune therapy
  • Patients with suspected cancer-related emergency such as brain metastasis or spinal cord compression

Medium Priority 

  • Ongoing assessment for patients on treatment and assessment of response/progression to therapy
  • Follow-up visits while on surveillance post-chemotherapy
  • Further investigations (re-TURB) and initiation of treatment with BCG or discussion of cystectomy where feasible in high-/intermediate-grade or recurrent/BCG-refractory non-muscle-invasive disease

 Low Priority

  • Follow-up visits in clinically asymptomatic patients without evidence of metastatic disease (prefer teleconsulting if necessary)
  • Low-risk non-muscle-invasive disease

Priorities for imaging

High Priority

  • All imaging that is necessary to clarify disease stage (locally advanced or metastatic) to provide an exact treatment plan (surgery or systemic treatment)
  • Restaging during/after neoadjuvant chemotherapy
  • All imaging that needs to be done in clinically urgent situations (bleeding, fractures, high-grade toxicities of checkpoint inhibitors that need to be clarified)
  • Imaging in patients clinically suspicious for relapse or metastatic disease

Medium Priority 

  • On-treatment assessment of response to therapy

 Low Priority

  • Follow-up imaging in asymptomatic patients (postpone imaging at latest recommended timepoint)
  • Imaging for non-muscle-invasive disease

Priorities for surgical and radiation oncology

High Priority*

  • Bladder resection and upper tract biopsy to confirm diagnosis for advanced disease
  • Cystectomy should not be delayed unless neoadjuvant chemotherapy is given and be performed in preferably non-COVID-19 hospitals. Non urgent cystectomies, such as for NMIBC or non-cancer reasons, may be delayed until a more chronic phase of the pandemic has occurred. There may be scenarios where giving or extending neoadjuvant therapy may optimise the timing on cystectomy. Clearly every decision has to be made on a case-by-case discussion and tailored to locally available resources and the current pandemic status
  • Radiotherapy should not be seen as an attractive alternative to surgery as it is associated with its own challenges

High/Medium Priority

  • Cystoscopy for asymptomatic haematuria

 Low Priority

-

*See guidelines of the European Urology Association (EAU) on Considerations in the triage of urologic surgeries during the COVID-19 pandemic

 

Priorities for medical oncology - advanced disease

High Priority

  • Offer standard therapy in first-line metastatic disease. Immunotherapy might offer less risk than chemotherapy where indicated. If immunotherapy is considered, discuss case by case 4 or 6 weekly applications – according to the PD-L1/PD-1 inhibitor chosen – to minimise hospital visits
  • Palliative bladder radiation for severe haematuria or radiotherapy for spinal cord compression, if surgery is not feasible

Medium Priority 

  • First-line therapy in low-burden asymptomatic patients
  • Radiotherapy for bone pain or other palliative reasons

 Low Priority

  • Continuing palliative chemotherapy after 4 administered cycles after confirmed response (SD or PR)
  • Further chemotherapy (later lines) in platinum-refractory advanced disease

Priorities for medical oncology - muscle-invasive disease

High Priority

  • Offer neoadjuvant chemotherapy where it may provide downsizing or optimise the timing of cystectomy
  • Offer primary chemotherapy for symptom control or for node-positive disease
  • Radiotherapy, which is associated with multiple healthcare environment encounters, should not be considered as preferential to surgery during this time

High/Medium Priority 

  • Adjuvant chemotherapy in selected cases

 Low Priority

  • Adjuvant radiotherapy

   

List of abbreviations: BCG, Bacillus Calmette–Guérin; COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; NMIBC, non-muscle-invasive bladder cancer; PD-1, programmed cell death protein 1; PD-L1, programmed death-ligand 1; PR, partial response; SD, stable disease; TURB, transurethral resection of bladder.

 

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