Gastrointestinal Cancers

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

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 gastro-oesophageal cancer patients

Outpatient visit priorities

High Priority
Potentially unstable (patients with severe dysphagia, weight loss, bleeding) New diagnosis Patients undergoing perioperative treatment (chemotherapy, chemoradiotherapy) Patients diagnosed with metastatic disease currently with active treatment, receiving i.v. chemotherapy or immunotherapy

Medium Priority
Post-operative or post-definitive chemoradiotherapy patients with no complications Patients in palliative care treatment with no active treatment, well controlled, with potential telemedicine follow-up Patients receiving well-tolerated oral therapies (maintenance with capecitabine) Patients in need of psycho-social support without any other acute medical need

Low Priority
Established patients with no new issues Survivorship visits Follow-up for patients at low-to-moderate risk of relapse

Priorities for gastro-oesophageal cancer: Imaging (CT scan)

High Priority
Symptomatic patient (severe dysphagia, intestinal occlusion or other acute symptoms) Initial staging Pre-operative evaluation including re-evaluation after pre-operative treatment Evaluation of patients undergoing active treatment or patients in follow-up with clinical suspicion of symptomatic disease progression

Medium Priority
Follow-up in patients with ongoing active treatment for the metastatic setting with non-clinical suspicion of progression

Low Priority
Follow-up visit

Priorities for gastro-oesophageal cancer: Surgery

High Priority
Patients with ongoing peri-operative treatment (chemotherapy or chemoradiotherapy) Radiologically confirmed intestinal occlusion in newly diagnosed patients Bowel perforation, peritonitis Post-surgery complications (perforation, anastomotic leak) Patients with new diagnosis with active bleeding in localised disease and no comorbidities

Medium Priority
Staging laparoscopy Symptomatic patients with inoperable primary or recurrent cancer requiring palliative cancer procedures (e.g. palliative bypass, feeding tubes)

Low Priority
Radiologically confirmed intestinal occlusion in stage IV patients treated actively with current clinical suspicion of progression

Priorities for gastro-oesophageal cancer: Endoscopic procedures

High Priority
Patients with clinical cT1N0: consider endoscopic resection according to ESMO guidelines Patients with high suspicion of oesophageal/gastric cancer diagnosis unstable, such as bleeding, severe dysphagia and weight loss, symptomatic anaemia + other upper GI related symptoms Patients with oesophago-gastric cancer and active bleeding Patients susceptible to clear benefit from a stent or endoscopic gastrostomy for feeding tube

High Priority

Patients with clinical cT1N0: consider endoscopic resection according to ESMO guidelines
Patients with high suspicion of oesophageal/gastric cancer diagnosis unstable, such as bleeding, severe dysphagia and weight loss, symptomatic anaemia + other upper GI related symptoms
Patients with oesophago-gastric cancer and active bleeding
Patients susceptible to clear benefit from a stent or endoscopic gastrostomy for feeding tube

Medium Priority
EUS for staging

Low Priority
Follow-up

Priorities for gastro-oesophageal cancer: Medical oncology: advanced disease

High Priority
Patients receiving first-line treatment of chemotherapy, immunotherapy or maintenance* and with clinical benefit Continuation of treatment in the context of a clinical trial Patients with MSI tumour status treated with check-point inhibitors with clinical benefit*

Medium Priority
Second-line treatment or beyond

Low Priority
Patients with intestinal occlusion due to peritoneal carcinomatosis treated with a conservative approach (best supportive care)

*For patients receiving oxaliplatin-based regimens, consider combination with capecitabine for the front-line and maintenance strategies according to patient characteristics

**Consider dose reduction to reduce risk of potential side effects in older/high-risk population

***In patients receiving check-point inhibitors, consider delaying treatment scheduling, for example for 6 weeks and with telemedicine appointments if no complications are referred

Priorities for gastro-oesophageal cancer: Medical oncology: early disease

High Priority
Continuation of treatment in the context of a clinical trial Continuation of treatment of patients with ongoing pre-operative treatment (chemotherapy or chemoradiotherapy)

Medium Priority
Post-operative chemotherapy: consider each case individually according to the clinical benefit: downstaging in the pathological specimens of gastrectomy and risk

Low Priority
-

Priorities for gastro-oesophageal cancer: Radiotherapy approach

High Priority
Continuation of treatment in the context of a clinical trial Continuation of treatment of patients with ongoing neoadjuvant/definitive chemoradiotherapy approach without relevant toxicities and co-morbidities

Medium Priority
Palliative radiation for pain control or bleeding

Low Priority
-

Consider avoiding starting any chemoradiotherapy approach for newly diagnosed oesophageal or gastric tumours in frail populations and especially in patients with cardiovascular comorbidities. If clinical dysphagia, consider a stent or percutaneous endoscopic gastrostomy

Consider maintaining a regular telematic follow-up in patients from the groups of median and low priorities, and evaluate the mental health status of patients to consider psychological support due to COVID-19 confinement and the pandemic impact on the mental health of patients.

Consider COVID-19 vaccination according to the ESMO statement based on a four-step process:

Step 1: Consider the phase of malignant disease and therapy: active cancer on treatment, chronic disease after treatment or survivorship.
Step 2: Consider age, fitness/ performance status and medical comorbidities as general risk factors; specifically, obesity, diabetes mellitus, hypertension, respiratory, cardiac and renal disorders.
Step 3: Consider vaccine-related interactions on the tumour and on the treatment efficacy.
Step 4: Secure informed consent and improve shared decision making.

List of abbreviations: CT, computed tomography; EUS, endoscopic ultrasound; GI, gastrointestinal; i.v., intravenous; MSI, microsatellite instability.