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

Priorities for Pancreatic Cancer patients

Outpatient visit priorities

High Priority

  • 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

Medium Priority

  • 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

 Low Priority

  • Post-operative patients with no complications
  • Established patients with no new issues
  • Survival follow-up visits out of clinical trials

Priorities for Pancreatic Cancer: Imaging

High Priority

  • 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

Medium Priority

  • Restaging after surgical treatment

 Low Priority

  • Routine follow-up assessments outside the context of clinical trials

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

  • 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

Medium Priority

  • 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

 Low Priority

-

 Priorities for Pancreatic Cancer: Medical oncology: “localised and locally advanced disease”

High Priority

  • 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

Medium Priority

  • 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

 Low Priority

  • Follow-up imaging and restaging studies in asymptomatic patients, taking into account pathological stage

Priorities for Pancreatic Cancer: Medical oncology: “advanced/metastatic disease”

High Priority

  • 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

Medium Priority

  • 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

 Low Priority

  • 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.

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