Cancer therapy may need to be scaled back or stopped altogether except for people with the highest need and likely benefit during the COVID-19 pandemic, new guidelines suggest.
To manage limited resources when oncology services are disrupted by shutdowns and staff shortages, prioritisation by treatment intent should favour curative therapy before adjuvant and non-curative therapy, according to the COVID-19 guidelines released by the Cancer Clinical Network of Queensland.
Prioritisation meetings with other healthcare staff may also need to consider the degree of potential benefit of therapy, they suggest. For curative therapy this may be the estimated percentage for chance of cure whereas for adjuvant therapy it would be absolute survival benefit.
However, non-curative therapy may still be associated with significant prolongation of survival in many cancer types, the guidelines note.
Oncologists will also need to reconsider the balance of risk and benefit of systemic therapy against additional COVID-19 risk, such as by considering performance status, age co-morbidities and degree of immunosuppression before starting new treatments, the guidelines say.
And if access to hospital clinics is restricted by factors such as transport or social distancing, oncologists may need to consider offering oral therapies to patients in the community as an alternative to intravenous therapies, with telehealth follow up.
The guidelines provide suggestions on other modifications that may be considered, such as longer cycle lengths or treatment breaks for patients currently on intravenous / subcutaneous therapy.
If staff and resources are more severely limited it may be necessary to consider stopping non-curative therapies with minimal survival benefit, especially those with high risk of complications, and perhaps the stopping of neoadjuvant therapy.
For example, for patients with breast cancer, the guidelines suggest considering oral options and subcutaneous traztuzumab.
For curative treatment they suggest limiting adjuvant therapy in elderly patients, based on the additional risk of COVID-19.
Non-curative treatment may be likewise limited in elderly patients, based on additional risk of COVID versus benefit of treatment, or limited to patients with PS 0/1 only. The duration of maintenance IV systemic therapy may also be reconsidered, the guidelines suggest.
The guidelines also provide advice on prioritisation of radiation therapy and stepping down of clinical trials.