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 head and neck cancer patients
Outpatient visit priorities
- Prior to any in-person visit, patients should be screened for symptoms of COVID-19 by maximising telemedicine triage and establishing screening at intake by using checklists and monitoring tools
- Telemedicine may play a role in primary assessment of signs and symptoms, reassuring anxious subjects, while prompting an urgent in-person visit in case of doubts (new lump in the neck, dysphagia, dyspnoea, minor bleeding…)
- However, clinical examination of the head and neck via telemedicine for oncological reasons should be avoided except for a general inspection of the neck, face and anterior oral cavity (also in such circumstances, however, it should be noted that palpation and close inspection are the main resources for clinical judgement, especially in already treated patients)
Priorities for head and neck cancer patients: Primary surgery
- Multidisciplinary team meetings -physically or virtually- should remain the place where clinical choices about curative treatments are mainly defined
- High-medium priority patients should not be delayed more than 2 months
Priorities for head and neck cancer patients: Primary non-surgical management and postoperative treatment
- Multidisciplinary team meetings -physically or virtually- should remain the place where clinical choices about curative treatments are defined
- Curative intended radiotherapy should not be postponed for an interval longer than 4-6 weeks
- Do not necessarily change fractionation unless radiation-therapy resources are limited
- Consider implementing moderately hypofractionated regimens, only in case of extreme shortness of resources (fractions of 2.2-3 Gy)
- Concurrent chemoradiotherapy should be preferred to induction chemotherapy followed by (chemo)radiotherapy for organ preservation, to limit overall treatment time and chemotherapy-related immunosuppression
- High-dose three-weekly cisplatin should be preferred to low-dose weekly cisplatin to reduce medical visits
- Consider omitting concomitant chemotherapy only in case of extreme shortness of resources
- If the patient tested positive for COVID-19 before treatment, postpone radiotherapy initiation until test becomes negative
- Keep continuity in radiotherapy in case of COVID-19 positivity with mild/no symptoms; continue radiotherapy if at least 2 weeks of treatment have been performed, provided it is clinically practicable
- Interrupt treatment in case of severe symptoms
- Supportive care during radiotherapy with/without systemic therapy:
a) provide dental clearance before starting radiation adopting safety measures for both patients and healthcare professionals
b) keep a low threshold for suspicion of infection, due to the possible anergic state of head and neck cancer patients
c) implement the use of patient-reported outcome measures to periodically assess symptoms
- Consider replacing weekly on-site patient reviews with video- or telephone-consultations
Priorities for head and neck cancer patients: Systemic therapies in recurrent and/or metastatic disease
- Continuation of treatment in the context of a clinical trial, provided patient benefits outweigh risks, with possible adaptation of procedures without affecting patient safety and study conduct
- In patients on treatment with immune checkpoint inhibitors and having achieved partial/complete response or with clinical benefit and without toxicities, consider switching from a q2-3w schedule to a q4-6w schedule to reduce medical visits (a telemedicine visit with or without laboratory testing between two treatment cycles is suggested to monitor these patients, who often are frail)
- Patients on IO showing signs of pneumonitis on CT scans should be tested for COVID-19 before administering steroids
- For patients in treatment with intravenous chemotherapy, shift to oral chemotherapy (e.g. capecitabine), when feasible, might be offered to avoid frequent access to hospital
Priorities for head and neck cancer patients: Symptomatic recurrent/metastatic disease and end-of-life care
- Steroids should be avoided as much as possible or administered as conservatively as possible
- Consider implementing 1-4 fraction regimens for symptomatic palliative cases (e.g. 1x 8 Gy, “QUAD-SHOT”)
List of abbreviations: COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; CT, computed tomography; HPV, human papillomavirus; IO, immuno-oncology; qXw, every X weeks.
- Thomson DJ, Palma D, Guckenberger M et al. Practice recommendations for risk-adapted head and neck cancer radiation therapy during the COVID-19 pandemic: An ASTRO-ESTRO Consensus Statement. Int J Radiat Oncol Biol Phys 2020;107:618-627. Hanna TP, Evans GA, Booth CM. Cancer, COVID-19 and the precautionary principle: prioritizing treatment during a global pandemic. Nat Rev Clin Oncol 2020; 17:268–270.
- Hanna TP, Evans GA, Booth CM. Cancer, COVID-19 and the precautionary principle: prioritizing treatment during a global pandemic. Nat Rev Clin Oncol 2020; 17:268–270.
- Curigliano G, Banerjee S, Cervantes A et al; all Voting Panel members. Managing cancer patients during the COVID-19 pandemic: An ESMO Interdisciplinary Expert Consensus. Ann Oncol 2020; doi.org/10.1016/j.annonc.2020.07.010. In Press.
World Health Organization. COVID-19: Operational guidance for maintaining essential health services during an outbreak. Available at: https://www.who.int/publications-detail/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreak (1st September 2020, date last accessed).
National Comprehensive Cancer Network. Coronavirus Disease 2019 (COVID-19) Resources for the Cancer Care Community. Available at: https://www.nccn.org/covid-19/ (26th August 2020, date last accessed).
National Comprehensive Cancer Network. NCCN Guidelines Head and Neck Cancers Version 2.2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf (26th August 2020, date last accessed).