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ESMO management and treatment adapted recommendations in the COVID-19 era: Epithelial ovarian 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).

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Priorities for ovarian cancer

Documented multidisciplinary tumour team (MDT) decision making, taking into account patient condition (vulnerable patients)* and available resources [Intensive Care Unit (ICU) support for surgery]. If not adequate, refer to or discuss with an Oncological Hub for gynaecological cancers.

Patients and family should be adequately informed about the risk/benefit ratio of each intervention with clinicians taking into account of national therapeutic or interventional guidelines or national specialty recommendations in relation to COVID-19.

*vulnerable patients: >65 years, pre-existing cardiovascular disease, pre-existing respiratory disease

Outpatient visit priorities

High Priority

  • Potentially unstable (acute abdominal pain, intestinal obstruction, complications during post- surgery recovery
  • Symptomatic new patient (symptomatic ascites or pleural effusion, intestinal obstruction)

Medium Priority

  • Newly diagnosed asymptomatic patients, no prior surgery
  • Post-operative patients with no complications
  • Patients continuing on chemotherapy – telemedicine where possible
  • Established patients with new problems or symptoms from treatment – convert as many visits as possible to telemedicine appointments

 Low Priority

  • Follow-up visit on PARPi maintenance; most can be managed through telemedicine with scheduled blood tests and imaging done close to home. Explore postal drug delivery
  • For maintenance bevacizumab, if facilities exist to continue, supervision can be performed by telemedicine, ensuring BP and urinalysis are monitored
  • Survivorship visits off study

For patients on clinical trials, seek information about changes in management for individual studies from the co-ordinating trials unit – treatment frequency; blood investigations and imaging.

Priorities for ovarian cancer: Imaging (CT scan)

High Priority

  • Symptomatic patient (intestinal obstruction, abdominal perforation)

Medium Priority

  • Diagnostic imaging for clinical suspicion of ovarian cancer (clinical, US)

Low Priority

  • Follow-up visit out of study
  • Follow-up visit on PARPi maintenance

 Priorities for ovarian cancer: Surgical oncology

High Priority

  • Radiologically confirmed intestinal obstruction in newly diagnosed patient
  • Bowel perforation, peritonitis
  • Post-surgery complications (perforation, anastomotic leak)
  • Pelvic mass with torsion or causing urinary or intestinal obstruction

Medium Priority

  • Establishment of cancer diagnosis when high suspicion exists (e.g. diagnostic laparoscopy)
  • Primary cytoreductive surgery
  • Possible interval debulking surgery following review by multidisciplinary team. Continuation of first-line therapy with postponement of surgery should be considered as an option
  • Symptomatic patients with inoperable primary or recurrent cancer requiring palliative cancer procedures (e.g. diverting colostomy, venting PEG tubes)

Low Priority

  • Risk-reducing surgery for genetic predisposition to gynaecological cancer
  • Benign-appearing ovarian cysts/masses
  • Recurrent cancer requiring palliative resection
  • Oligometastatic first relapse where complete resection is feasible

Priorities for ovarian cancer: Medical oncology  advanced disease

High Priority

  • NACT in symptomatic patients
  • Post-operative ChT or continuation of post-operative ChT for high-grade serous/endometrioid tumours. Importance of BRCA testing continues as these patients are eligible for PARP inhibitors and should be considered for shortened ChT cycles
  • Continuation of treatment in the context of a clinical trial

Medium Priority

  • First-line post-operative ChT in advanced-stage clear cell or mucinous tumours
  • ChT for high-grade serous/endometrioid symptomatic platinum-eligible recurrent patients)

Low Priority

  • ChT for high-grade serous/endometrioid platinum non-eligible symptomatic recurrent patients
  • Symptomatic slowly growing recurrent disease
  • ChT for recurrent low-grade serous tumours 

 Priorities for ovarian cancer: Medical oncology – early disease

High Priority

  • Adjuvant ChT for stages I-IIA high-grade serous/endometrioid
  • Continuation of treatment in the context of a clinical trial

Medium Priority

  • Adjuvant ChT for stages IC-IIA infiltrative mucinous

Low Priority

  • ChT for IC IIA low-grade serous/endometrioid/clear cell/expansile invasion mucinous
  • IC low-grade serous endometrioid/expansile/invasion mucinous, ChT possible option, considered less essential and to be discussed with the patient, taking into account the risk/benefit ratio

 

Chemotherapy in advanced disease:

  • Platinum-based therapy, in combination where feasible: carboplatin/paclitaxel every 3-4 weeks (to reduce visits and risk of myelotoxicity). Consider 4-6 cycles depending on response and prognostic factors. Consider reduced number of  cycles (4-5) in responding patients before adding PARP inhibitor. Consider early discontinuation of paclitaxel for toxicity
  • GCS support to prevent leukopaenia
  • Limit dexamethasone to reduce immunosuppression
  • Caution with bevacizumab because of the associated hypertension which may worsen COVID-19 outcome, and use of resources with maintenance therapy
  • Maintenance with PARP [poly (ADP-ribose) polymerase] inhibitors in high-grade serous/endometriod cancers with a BRCA mutation responding to platinum-based therapy
  • In patients who have a BRCA mutation and are PARP naïve, consider rucaparib monotherapy in situations where platinum therapy cannot be given
  • Non platinum-based therapies are low priority (above) and should only be used after careful review of the risk/benefit

Chemotherapy in early disease:

  • 3-6 cycles carboplatin/paclitaxel (6 cycles in high-grade serous/endometrioid/clear cell)
  • Carboplatin 6 cycles

Dose adaptation or single-agent carboplatin (AUC5 every 4 weeks) in vulnerable* patients.

*vulnerable  patients: >65 years, pre-existing cardiovascular disease, pre-existing respiratory disease 

List of abbreviations: BP, blood pressure; ChT, chemotherapy; CT, computed tomography; NACT, neoadjuvant chemotherapy; PARP, poly (ADP-ribose) polymerase; PARPi, poly (ADP-ribose) polymerase inhibitor; PEG, percutaneous endoscopic gastrostomy; US, ultrasound.

References

Huntsman Cancer Institute Patient Scheduling Recommendations During COVID 19 Crisis 17 March, 2020

NHS Clinical guide for the management of non-coronavirus patients requiring acute treatment: Cancer 23 March 2020, Version 2. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty-guide-acute-treatment-cancer-23-march-2020.pdf (31 March 2020, date last accessed)

BGCS framework for care of patients with gynaecological cancer during the COVID-19 Pandemic (Final. 22/03/2020). https://www.bgcs.org.uk/wp-content/uploads/2020/03/BGCS-covid-guidance-v1.-22.03.2020.pdf (31 March 2020, date last accessed)

SGO surgical considerations for gynecologic oncologists during the COVID-19 pandemic (March 27, 2020). https://www.sgo.org/clinical-practice/management/covid-19-resources-for-health-care-practitioners/surgical-considerations-for-gynecologic-oncologists-during-the-covid-19-pandemic/ (31 March 2020, date last accessed)

Colombo N, Sessa C, du Bois A, et al. ESMO–ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease. Ann Oncol 2019; 30: 672-705.

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