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ESMO management and treatment adapted recommendations in the COVID-19 era: Lung 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 lung cancer patients

Outpatient visit priorities

High Priority

  • New diagnosis or suspicion of invasive lung cancer with either:
    • Disease-related symptoms (dyspnoea, pain, haemoptysis, etc.)
    • Suspicion of clinical stage II/IIIA/IIIB or metastatic NSCLC or SCLC
  • Visits for treatment administration

Medium Priority

  • New diagnosis or suspicion of localised lung cancer of clinical stage I
  • Post-operative patients with no complications
  • Follow-up for patients at high risk of relapse
  • Established patients with new problems or symptoms from treatment: convert as many visits as possible to telemedicine visits

 Low Priority

  • Survivorship visits
  • Follow-up for patients at low/intermediate risk of relapse
  • Patients visits for psychological support (convert to telemedicine)

Priorities for Lung Disease: Imaging

High Priority

  • Patients with significant respiratory symptoms and/or other clinically relevant chest, cancer- or treatment-related symptoms. In patients with new respiratory symptoms such as dyspnoea, cough with or without fever, a CT-scan is recommended
  • Standard staging work-up for suspected lung cancer of unknown stage or stage II/III/IV
  • Biopsies for suspicious nodules or mass for suspected lung cancer of stage or stage III/IV
  • Evaluation of active treatment response in the first 6 months of treatment or if suspicion of progression at any timepoint
  • Pre-planned imaging evaluation per clinical trial protocol

Medium Priority

  • Follow-up imaging for high/intermediate risk of relapse within one year of completion of radical treatment
  • Standard staging work-up for early lung cancer (stage I)
  • Biopsies for suspicious nodules or mass for suspected invasive cancer of unknown stage or stage I/II
  • Established patients with new problems or symptoms from treatment
  • Evaluation of active treatment response beyond 6 months of treatment if stable/controlled situation
  • Follow-up of nodules of incidental finding with either:
    • Solid nodule 50-500 mm3
    • Pleural-based solid nodule 5-10 mm
    • Partially solid nodule with a non-solid component of ≥8 mm
    • Known VDT (Volume Doubling Time) 400-600 days

 Low Priority

  • Follow-up imaging for high/intermediate risk of relapse more than a year after completion of radical treatment
  • Follow-up imaging after radical treatment in a low risk of relapse scenario
  • Follow-up of nodules of incidental finding with either:
    • Solid nodule <50 mm3
    • Pleural-based solid nodule <5 mm
    • Partially solid nodule with a non-solid component of <8 mm
    • Non-solid nodule <8 mm
    • Benign morphology
    • Known VDT >600 days
  • Lung cancer screening can be deferred until the COVID-19 pandemic resolves – It is reasonable for patients in the general population to defer screening low-dose CT, a deferral that is not likely to have an impact on overall survival

Priorities for Lung Disease: Surgical Oncology

High Priority

  • Drainage +/- pleurodesis of pleural effusion, pericardial effusion, tamponade risk
  • Evacuation of empyema-abscess
  • T2N0 tumours naïve from treatment or after induction chemotherapy
  • Resectable T3/T4 tumours naïve from treatment or after induction chemotherapy
  • Resectable N-1/N2 disease naïve from treatment or after induction chemotherapy
  • Diagnostic procedure such as mediastinoscopy/thoracoscopy/pleural biopsy/endoscopy/transthoracic investigations for diagnostic/staging work-up

Medium Priority

  • Discordant biopsies likely to be malignant
  • Resectable NSCLC with T1AN0 (alternative if no surgical capacity available, is stereotactic radiotherapy; surgery is preferred)
  • Diagnostic work-up and/or resection of nodules of incidental finding with either:
    • Solid nodule >500 mm3
    • Pleural-based solid nodule >10 mm
    • Solid component >50 0mm3 in partially solid nodule
    • Known VDT <400 days
    • New solid component in pre-existing non-solid nodule

(alternative if surgery indicated and no surgical capacity available is stereotactic radiotherapy)

 Low Priority

  • Discordant biopsies likely to be benign
  • Operable pure GGO nodule (T1a)
  • Diagnostic work-up and/or resection of all other nodules of incidental finding including also:
    • Solid nodule >500 mm3 and known VDT >600 days

(alternative if surgery indicated and no surgical capacity available is stereotactic radiotherapy)

Priorities for Lung Cancer: Medical Oncology – Early Stage Lung cancer

High Priority

  • Concomitant chemoradiotherapy for SCLC limited disease stage I/II
  • Neoadjuvant chemotherapy (enabling deferral of surgery by 3 months) in clinical stage II
  • Delivery of adjuvant chemotherapy in T3/4 or N2 disease for young (<65 years old) and fit patients
  • G-CSF use if febrile neutropaenia risk evaluated to be >10-15%

Medium Priority

  • Adjuvant chemotherapy in T2b-T3N0 or N1 disease should be discussed with patients, considering clinical features and prognosis
  • Medical follow-up between 2 cycles should be performed only if necessary and by telephone
  • Blood check between 2 cycles should be performed only if necessary and at home if possible

 Low Priority

  • Adjuvant chemotherapy in stage T1A-T2bN0 with negative prognostic features (lymphovascular infiltration, histological subtype…). The risk versus potential benefit should be individually discussed with patients
  • Adjuvant chemotherapy for patients with significant comorbidities, or elderly patients >70y, should be discussed and possibility omitted

Priorities for Lung Cancer: Medical Oncology – Locally advanced Lung Cancer

High Priority

  • Concomitant chemoradiotherapy for SCLC limited disease stage III
  • Concomitant or sequential chemoradiotherapy for inoperable NSCLC Stage III
  • Starting consolidation durvalumab (within 42 days)
  • Neoadjuvant chemotherapy in clinical stage III
  • G-CSF use if febrile neutropaenia risk evaluated to be >10-15%

Medium Priority

  • Medical follow-up between 2 cycles should be performed only if necessary and by telephone
  • Blood check between 2 cycles should be performed only if necessary and at home if possible

 Low Priority

-

Priorities for Lung Cancer: Medical Oncology – Metastatic Lung Cancer

High Priority

  • 1st-line treatment including chemotherapy, chemotherapy plus IO, IO alone or TKIs to improve prognosis, cancer-related symptoms and QoL
  • Start 2nd-line chemotherapy or IO in symptomatic and progressive disease patients
  • Start 2nd-line TKI in progressive disease patients
  • G-CSF use has to be considered if despite optimal dose modification, risk of febrile neutropaenia is >10%
  • Anti-PD-(L)1 scheduled cycles may be modified/delayed to reduce clinical visits (for instance, using 4-weekly or 6-weekly dosing instead of 2- or 3-weekly for selected agents when appropriate (where allowed from National Regulatory Agency)

Medium Priority

  • Start 2nd and beyond line chemotherapy or IO in asymptomatic patients, in absence of threatening disease (volume/location)
  • Consider, when feasible, oral chemotherapy treatment instead of intravenous (etoposide, vinorelbine) to reduce hospital visits
  • Medical follow-up between 2 cycles should be performed only if necessary and by telephone
  • Blood check between 2 cycles should be performed only if necessary and at home if possible
  • For patients ongoing with IO from more than 12/18 months, delaying the next cycle, omitting some scheduled cycle, or generally enlarging intervals should be considered

 Low Priority

  • Discontinuation of IO after 2 years of treatment should be considered, keeping in mind the lack of prospective evidence
  • For patients ongoing with IO having stopped due to toxicity, resuming might be delayed in absence of disease progression
  • Postpone antiresorptive therapy (zoledronic acid, denosumab) that is not needed urgently

Priorities for Lung Cancer: Radiation Oncology

High Priority

  • Radiotherapy for inoperable stage II-III cancers, with contra-indications for chemotherapy
  • Concomitant (preferred) or sequential chemoradiotherapy for inoperable NSCLC Stage II/III
  • Concomitant (preferred) or sequential chemoradiotherapy for SCLC limited disease
  • Superior vena cava obstruction, significant haemoptysis, spinal cord compression, significant bone pain or any life-threatening condition amenable to palliative radiotherapy

Medium Priority

  • SABR-SBRT for stage I cancers
  • Adjuvant PORT for R1 resection, if indicated in NSCLC could be considered at the at the end of adjuvant chemotherapy or delayed up to 3 months from surgery
  • PCI in limited stage SCLC after chemotherapy

 Low Priority

  • Adjuvant PORT N2 R0, if indicated in NSCLC should be discussed and if retained considered at the at the end of adjuvant chemotherapy or delayed up to 3 months from surgery
  • PCI in extensive stage SCLC after chemotherapy may be replaced by MRI active surveillance
  • Non-life-threatening conditions such as mild bone or chest pain should be considered for more aggressive analgesics and use of palliative radiotherapy should be individualised depending on individual benefit/risk ratio

 

List of abbreviations: CT, computed tomography; G-CSF, granulocyte colony-stimulating factor; GGO, ground-glass opacity; IO, immune-oncology; NSCLC, non-small cell lung cancer; QoL, quality of life; PD-1, programmed cell death protein 1; PD-L1, programmed death-ligand 1; SABR, stereotactic ablative radiotherapy; SBRT, stereotactic body radiotherapy SCLC, small cell lung cancer; TKI, tyrosine kinase inhibitor; VDT, volume doubling time.

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