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ESMO management and treatment adapted recommendations in the COVID-19 era: Primary brain 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 primary brain tumour patients

Outpatient visit priorities

High Priority

  • Newly diagnosed brain tumour
  • New onset or worsening of symptoms indicative of tumour- or treatment-related complications (e.g. neurological symptoms, dyspnoea, chest pain)
  • Clinical or radiological evidence for tumour recurrence
  • Application of intravenous or intrathecal anticancer treatment
  • Wound-healing problems after neurosurgical intervention

Medium Priority

  • Evaluation of clinical status, laboratory or neuroradiological results in known brain tumour patients without new or worsening symptoms and with active therapy (convert to telemedicine visits whenever possible)
  • Prescription of oral anticancer treatment (convert to telemedicine visits whenever possible)
  • Post-operative patients without need for active therapy and no complications

 Low Priority

  • Evaluation of clinical status, laboratory or neuroradiological results in known brain tumour patients without new or worsening symptoms and without active therapy (convert to telemedicine visits whenever possible)
  • Visits of patients on a best supportive care regimen
  • Visits of psychological support (convert to telemedicine)
  • Survivorship visits
  • Second opinion visits (convert to telemedicine)

Priorities for primary brain tumour patients: Neuro-Imaging

High Priority

  • New onset or worsening of neurological symptoms

Medium Priority

  • Follow-up in patients without new or worsening neurological symptoms with ongoing anticancer treatment

 Low Priority

  • Follow-up in patients without new or worsening neurological symptoms without ongoing anticancer treatment

Priorities for primary brain tumour patients: Neurosurgery 

High Priority

  • Need for acute decompression
  • Maximal safe resection in suspected malignant glioma
  • Diagnostic biopsy in suspected primary central nervous system lymphoma (PCNSL)

Medium Priority

  • Resection/biopsy of non-contrast enhancing primary brain tumour with stable neurological symptoms
  • Re-resection of recurrent lower WHO grade glioma

 Low Priority

  • Partial resection of recurrent malignant glioma

Priorities for brain tumour patients: Radiotherapy

High Priority

  • Radiotherapy of newly diagnosed glioblastoma, IDH wild-type
  • Radiotherapy of lower WHO grade gliomas, IDH-mutant with relevant clinical manifestations
  • Radiotherapy of adult medulloblastoma

Medium Priority

  • Radiotherapy of lower WHO grade gliomas, IDH-mutant

 Low Priority

  • Re-irradiation of gliomas

Priorities for brain tumour patients: Systemic therapy 

High Priority

  • High-dose chemotherapy (with methotrexate) for newly diagnosed PCNSL
  • Temozolomide concurrent with and adjuvant to radiotherapy for newly diagnosed glioblastoma with MGMT promoter methylation
  • Temozolomide after radiotherapy for IDH-mutant 1p19q-intact anaplastic astrocytoma
  • Alkylating chemotherapy after radiotherapy in newly diagnosed 1p19q-codeleted anaplastic oligodendroglioma
  • Alkylating chemotherapy for recurrent glioma with MGMT promoter methylation
  • Strict control of steroid prescription (“as little as possible, as much as needed”)

Medium Priority

  • Temozolomide concurrent with and adjuvant to radiotherapy for newly diagnosed glioblastoma without MGMT promoter methylation
  • Systemic therapy for progressive brain tumours without evidence, e.g. meningioma or ependymoma in adults
  • Alkylating chemotherapy after radiotherapy in IDH-mutant WHO grade II astrocytoma
  • Adjuvant chemotherapy after radiotherapy for adult medulloblastoma

 Low Priority

  • Alkylating chemotherapy in patients with recurrent gliomas lacking MGMT promoter methylation, patients with second or higher recurrence of glioma, and patients with reduced performance status or in advanced age

 

List of abbreviations: COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; IDH, isocitrate dehydrogenase; MGMT, O-6-methylguanine-DNA methyltransferase; WHO, World Health Organization.

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