Cancer patient prioritisation
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
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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]);
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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;
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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 Pancreatic Cancer patients
Outpatient visit priorities
High Priority |
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- Patients with newly diagnosed resectable cancer – convert as many visits as possible to telemedicine appointments and schedule a multidisciplinary assessment in order to plan surgery
- Potentially unstable patients (complications in the post-surgery recovery period: anastomotic leak, bleeding, acute pancreatitis, fistulae, pneumonitis; jaundice; acute abdominal pain consistent with upper or lower intestinal occlusion; symptomatic ascites)
- Patients newly diagnosed with non-resectable (locally advanced) or metastatic cancer and symptoms such as jaundice, pain, weight loss
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Medium Priority |
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- Established patients with new minor to moderate problems or symptoms – convert as many visits as possible to telemedicine appointments
- Follow-up visits considering patients at high risk of relapse
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Low Priority |
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- Post-operative patients with no complications
- Established patients with no new issues
- Survival follow-up visits out of clinical trials
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Priorities for Pancreatic Cancer: Imaging
High Priority |
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- Symptomatic patients (intestinal occlusion, jaundice)
- Diagnostic imaging for clinical suspicion of pancreatic cancer (CT scan, followed by EUS in case of non-metastatic disease)
- Established patients with new problems or symptoms from treatment
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Medium Priority |
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- Restaging after surgical treatment
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Low Priority |
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- Routine follow-up assessments outside the context of clinical trials
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If feasible, encourage patients to perform laboratory and imaging assessments near home
Priorities for Pancreatic Cancer: Surgical oncology or image-guided surgical procedures
High Priority |
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- Resectable cancers (primary or after neoadjuvant treatment) including resectable cystic lesions with suspicion of malignancy
- Borderline cancers in patients not fit for neoadjuvant treatment
- Endoscopic placement of biliary stent in case of biliary obstruction in non-resectable or metastatic cancers
- Endoscopic placement of biliary stent in case of biliary obstruction: in resectable cancers with active cholangitis and bilirubin >250 µmol, or non-resectable localised cancers assigned to neoadjuvant or palliative treatment
- Post-surgery complications (anastomotic leak, bleeding, acute pancreatitis, fistulae)
- Histological assessment: CT scan or EUS-guided in case of urgent therapeutic consequences such as curative resection or symptom relief
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Medium Priority |
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- Hepato-jejunostomy (or hepato-gastro-jejunostomy in case of gastric obstruction) in case of biliary obstruction and recurrent cholangitis in patients with non-resectable localised or metastatic disease, good PS and life expectancy >3 months
- Duodenal stent and/or PEG tubes in case of gastro-duodeno-biliary obstruction in symptomatic patients in BSC
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Priorities for Pancreatic Cancer: Medical oncology: “localised and locally advanced disease”
High Priority |
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- Initiation of neoadjuvant or adjuvant treatment not yet initiated
- Completion of neoadjuvant or adjuvant treatment that has already been initiated
- Continuation of treatment in the context of clinical trial
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Medium Priority |
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- Adjuvant treatment to be initiated, if patient condition after surgery has not been recovered (to be postponed only within 12 weeks from surgery)
- In case of elderly patients with cardiovascular or other comorbidities not fit for a triplet regimen, evaluate risk/benefit ratio of a mono-chemotherapy
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Low Priority |
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- Follow-up imaging and restaging studies in asymptomatic patients, taking into account pathological stage
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Priorities for Pancreatic Cancer: Medical oncology: “advanced/metastatic disease”
High Priority |
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- First-line chemotherapy in patients fit for a combined regimen likely to improve survival and quality of life outcomes in metastatic disease
- Continuation of treatment in the context of a clinical trial
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Medium Priority |
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- In case of asymptomatic or pauci-symptomatic elderly patients, consider with caution the risk/benefit ratio derived from a monotherapy treatment
- Consider with caution starting or proceeding with second-line treatment according to patient's condition
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Low Priority |
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- Follow-up imaging and restaging studies in asymptomatic patients
- Antiresorptive therapy (zoledronic acid, denosumab) that is not needed urgently for hypercalcaemia
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- Dexamethasone use should be limited, as appropriate, to reduce immunosuppression
- Consider secondary prophylactic support with G-CSF to minimise the risks associated with febrile neutropaenia
- Consider thromboprophylaxis to prevent venous thromboembolism, which may worsen patients’ conditions in case of COVID-19 symptomatic infection
List of abbreviations: BSC, best supportive care; COVID-19, SARS-cov-2-related disease; CT, computed tomography; EUS, endoscopic ultrasound; G-CSF, granulocyte colony-stimulating factor; PEG, percutaneous endoscopic gastrostomy; PS, performance status.
