Management of cancer cases with active disease

In view of the emergency situation that the country is experiencing with the Coronavirus pandemic and in an effort to implement measures to protect citizens, including the measure of reducing the attendance of patients at Health Care Centers, the Oncological Society of Cyprus (O.E.K.) has adopted and communicated to its members on 18/3/20 recommendations for the management of cancer cases with active disease issued by the Society of Medical Oncologists of Greece. The recommendations are based on the corresponding ones of ASCO (American Society of Clinical Oncology) and on a review of the relatively small bibliography.

The Board of Directors of OEK called on Oncologists to follow the following in their daily practice:

• Patients requiring adjuvant/neoadjuvant chemotherapy.

If the goal is cure, then every effort should be made to ensure that treatment is not postponed or omitted due to the possibility of coronavirus infection. If the benefit is considered marginal (e.g. hormone-dependent breast cancer), the potential coronavirus infection should be weighed against the benefit.

• Patients requiring adjuvant radiotherapy.

Since the goal is healing, it should not be postponed or skipped in view of the possibility of coronavirus infection.

• Patients requiring adjuvant/neoadjuvant immunotherapy.

Since the goal is cure, it should not be postponed or skipped in view of the possibility of coronavirus infection. It could be administered every 4-6 weeks depending on the agent and with an accelerated SIP process to modify the timing of their administration (e.g. if it had approval every 2 weeks, it would not need re-approval if it is to be administered in 4 weeks).

• Patients requiring adjuvant/neoadjuvant hormone therapy.

There is no problem administering these medications because they most likely do not increase the risk of coronavirus infection.

• Patients requiring diagnostic invasive biopsy.

It should be individualized depending on the possible diagnosis, the benefits of potential treatment, and the patient’s comorbidities.

• Patients who require surgery to remove a primary tumor. If the goal is cure, then it should not be postponed or omitted in view of the possibility of coronavirus infection. As for metastasectomies or oncomeiotic procedures, a thorough assessment of the patient’s overall condition and the goal of treatment should be made and potential benefits should be evaluated.
• Patients who have metastatic cancer and require intravenous chemotherapy

with or without immunotherapy.

Treatment is not modified, always depending on the overall condition of the patient. Maintenance therapy could potentially be discontinued. Any conversion from intravenous to oral therapy should be considered on a case-by-case basis.

• Patients who have metastatic cancer and require oral

chemotherapy.

It is administered and all other personal protection measures are taken at the same time.

• Patients who have metastatic cancer and require monotherapy with

 immunotherapy.

Its administration continues. It could be administered every 4-6 weeks depending on the drug and with an accelerated SIP procedure to modify the timing of their administration.

• Patients who have metastatic cancer and require hormone therapy. There is no problem administering these drugs.
• Patients who have metastatic cancer and require hormone therapy and

 simultaneous targeted therapy.

Treatment is not modified, but there is increased vigilance for any symptoms indicative of respiratory infection.

• Patients who have metastatic cancer and require targeted therapy.

Treatment is not modified, but there is increased vigilance for any symptoms indicative of respiratory infection.

• Patients who have metastatic cancer, are receiving treatment and need

 additional radiotherapy.

Weigh the benefit of adding radiotherapy.

• End-stage patients who are not receiving specific anticancer treatment.

All preventive measures that apply to the rest of the population should be taken and, in addition, unnecessary tests that do not further contribute to their palliative care should be avoided.

At the same time, the O.E.K. adopts the following recommendations for cancer cases requiring surgical care, which determine the priorities as follows:

https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty- guide-acute-treatment-cancer-23-march-2020.pdf,

 Categorization of cancer patients requiring surgery

 A. Priority level 1a:

Risk of loss of life: Emergency surgery within 24 hours .

B. Priority level 1b

Emergency surgery within 72 hours .

 Clarification:

Emergency/urgent surgery concerns the rescue of a patient from conditions such as obstruction, bleeding and local and/or local infection, permanent damage/clinical harm in the event of worsening of the condition such as spinal cord compression.

C. Level 2 Priority

Elective surgeries for the purpose of cure are categorized as follows:

The decision to perform surgery within 4 weeks to save the patient/deteriorate the disease without performing surgery, based on:

• Urgent symptomatology
• Complications such as compressive symptoms
• Biological priorities of each type of cancer (expected rate of tumor growth)

Local complications can be temporarily controlled, e.g. by stent placement, previously postponed surgery and/or interventional radiology.

Minor surgical procedures in day surgery, for the placement of equipment required to provide beneficial oncological treatment for the patient, e.g. port a cath, should not be postponed if possible.

 D. Level 3 Priority

Elective surgeries can be delayed for 10-12 weeks, where it is documented based on literature data that survival is not negatively affected.

 Decisions are made after consultation between the Oncologist and Surgeon.

The Multi-Thematic Team (MDT) can study and propose non-

 surgical options including extension/continuation of neoadjuvant therapy and non-surgical treatments if the prognosis is the same.

The Cyprus Oncology Society recommends the implementation of the above guidelines for the period of the state of emergency.

From the Board of Directors of OEK

27/3/2020