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The European Society for Medical Oncology (ESMO) has issued guidelines that provide a practical road map for managing lung cancer patients during the COVID-19 pandemic, but the guidelines don’t address some issues that may affect U.S. physicians.
ESMO’s lung cancer guidelines provide specific details on when to prioritize and when to delay care. However, the guidelines don’t provide recommendations for managing patients who cannot participate in telemedicine or patients who have seen their clinical trial halted because of the pandemic, two situations that may be familiar to U.S. physicians.
Prioritization
As with ESMO’s other disease-focused COVID-19 guidelines, the lung cancer guidelines are organized into three priority levels – high, medium, and low – which are applied to several domains of diagnosis and treatment.
High-priority recommendations apply to patients whose condition is either clinically unstable or whose cancer burden is immediately life-threatening. Medium-priority recommendations apply to patients in noncritical situations for whom delaying care beyond 6 weeks would likely lower the chance of a significant benefit from the intervention. Low-priority recommendations apply to patients whose condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic.
ESMO applied the high-, medium-, and low-prioritization schema to clinically distinct domains of lung cancer management, including outpatient visits; imaging; surgical treatment and diagnostic intervention; radiation therapy; and medical oncology treatment of early, locally advanced, or metastatic lung cancer.
As an example, a high-priority outpatient visit would be a visit for a patient with a new diagnosis of lung cancer and disease-related symptoms, suspicion of advanced disease or small cell cancer, or a visit for treatment administration. Low-priority visits would be survivorship visits, follow-up for a patient with low or intermediate relapse risk, or a visit for psychological support alone. For each diagnostic and therapeutic domain, there are similarly explicit examples.
Strengths of the guidelines
Because of small cell lung cancer’s usually aggressive behavior, ESMO’s recommendations appropriately give high priority to the diagnosis and treatment of small cell lung cancer.
Regarding imaging of pulmonary nodules, ESMO’s guidelines are fairly faithful to the Fleischner Society’s 2017 recommendations (Radiographics. 2018 Sep-Oct;38[5]:1337-50).
Most importantly, ESMO urges oncologists to adjust their routines by amplifying telemedicine services, reducing clinic visits, delaying adjuvant radiation therapy, switching to oral therapies when possible, and taking minor liberties with the schedule and duration of immune-targeted therapy.
The guidelines contain advice on supportive therapies, particularly regarding more liberal use of myeloid growth factors for patients on cytotoxic chemotherapy and postponement of antiresorptive therapy when it is not needed urgently.
Unaddressed issues
ESMO’s guidelines do not suggest more liberal use of immune-targeted therapy alone for specific patient profiles, nor do the guidelines provide tips for enhancing mental and physical health of patients during this stressful time.
The guidelines put primacy on “patient safety.” However, Narjust Duma, MD, of the University of Wisconsin–Madison, noted that there may be other equally important considerations. The patient’s comfort level about management recommendations and the safety of family members are vital, especially those who are older or immunocompromised.
Dr. Duma also noted that access to care is an issue specific to the United States that is not specifically addressed in the ESMO guidelines.
Dr. Duma estimated that as many as 30%-40% of patients with lung cancer may have no access to the Internet, a smartphone, or the ability to set up a telemedicine encounter. A patient’s lack of health insurance, transportation, and shelter will also have a direct impact on a provider’s ability to implement the ESMO guidance.
In addition, ESMO’s lung cancer guidelines do not specifically address accrual of patients to research studies during the pandemic. In the United States, many institutions have decided to suspend recruitment of patients to clinical trials, and many developing studies have been put on hold.
Lung cancer management today
The COVID-19 pandemic poses unique challenges to cancer patient care, since cancer patients are at high risk of COVID-19-related mortality, but they also have a high risk of cancer progression and its associated morbidity and mortality. In an analysis of 355 Italian patients who died from COVID-19, 20% had active cancer (JAMA. 2020 Mar 23. doi: 10.1001/jama.2020.4683).
Patients with lung cancer may be particularly vulnerable to death from coronavirus infection caused by older age, comorbid conditions, and the frequent requirement for multiple modalities of treatment, including cytotoxic therapy. In China, among 18 patients with cancer and coronavirus infection, 28% had lung cancer, and those patients had a high risk of requiring ICU-level care (Lancet Oncol. 2020 Mar;21[3]:335-7).
Bearing these data in mind, even the most mundane aspects of lung cancer diagnosis, treatment, and follow-up require careful risk-benefit analysis before application to individual patients.
There are always gray areas, particularly in quantifying the risk of relapse or infection for individual patients. However, the articulation of the ESMO guidelines into the chosen domains should make them easy to apply in routine practice for many patients.
The holistic approach the ESMO guidelines promote has never been more critical than during the pandemic, nor more aptly applied than to patients with lung cancer.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest. Dr. Duma disclosed relationships with AstraZeneca and Inivata.
The European Society for Medical Oncology (ESMO) has issued guidelines that provide a practical road map for managing lung cancer patients during the COVID-19 pandemic, but the guidelines don’t address some issues that may affect U.S. physicians.
ESMO’s lung cancer guidelines provide specific details on when to prioritize and when to delay care. However, the guidelines don’t provide recommendations for managing patients who cannot participate in telemedicine or patients who have seen their clinical trial halted because of the pandemic, two situations that may be familiar to U.S. physicians.
Prioritization
As with ESMO’s other disease-focused COVID-19 guidelines, the lung cancer guidelines are organized into three priority levels – high, medium, and low – which are applied to several domains of diagnosis and treatment.
High-priority recommendations apply to patients whose condition is either clinically unstable or whose cancer burden is immediately life-threatening. Medium-priority recommendations apply to patients in noncritical situations for whom delaying care beyond 6 weeks would likely lower the chance of a significant benefit from the intervention. Low-priority recommendations apply to patients whose condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic.
ESMO applied the high-, medium-, and low-prioritization schema to clinically distinct domains of lung cancer management, including outpatient visits; imaging; surgical treatment and diagnostic intervention; radiation therapy; and medical oncology treatment of early, locally advanced, or metastatic lung cancer.
As an example, a high-priority outpatient visit would be a visit for a patient with a new diagnosis of lung cancer and disease-related symptoms, suspicion of advanced disease or small cell cancer, or a visit for treatment administration. Low-priority visits would be survivorship visits, follow-up for a patient with low or intermediate relapse risk, or a visit for psychological support alone. For each diagnostic and therapeutic domain, there are similarly explicit examples.
Strengths of the guidelines
Because of small cell lung cancer’s usually aggressive behavior, ESMO’s recommendations appropriately give high priority to the diagnosis and treatment of small cell lung cancer.
Regarding imaging of pulmonary nodules, ESMO’s guidelines are fairly faithful to the Fleischner Society’s 2017 recommendations (Radiographics. 2018 Sep-Oct;38[5]:1337-50).
Most importantly, ESMO urges oncologists to adjust their routines by amplifying telemedicine services, reducing clinic visits, delaying adjuvant radiation therapy, switching to oral therapies when possible, and taking minor liberties with the schedule and duration of immune-targeted therapy.
The guidelines contain advice on supportive therapies, particularly regarding more liberal use of myeloid growth factors for patients on cytotoxic chemotherapy and postponement of antiresorptive therapy when it is not needed urgently.
Unaddressed issues
ESMO’s guidelines do not suggest more liberal use of immune-targeted therapy alone for specific patient profiles, nor do the guidelines provide tips for enhancing mental and physical health of patients during this stressful time.
The guidelines put primacy on “patient safety.” However, Narjust Duma, MD, of the University of Wisconsin–Madison, noted that there may be other equally important considerations. The patient’s comfort level about management recommendations and the safety of family members are vital, especially those who are older or immunocompromised.
Dr. Duma also noted that access to care is an issue specific to the United States that is not specifically addressed in the ESMO guidelines.
Dr. Duma estimated that as many as 30%-40% of patients with lung cancer may have no access to the Internet, a smartphone, or the ability to set up a telemedicine encounter. A patient’s lack of health insurance, transportation, and shelter will also have a direct impact on a provider’s ability to implement the ESMO guidance.
In addition, ESMO’s lung cancer guidelines do not specifically address accrual of patients to research studies during the pandemic. In the United States, many institutions have decided to suspend recruitment of patients to clinical trials, and many developing studies have been put on hold.
Lung cancer management today
The COVID-19 pandemic poses unique challenges to cancer patient care, since cancer patients are at high risk of COVID-19-related mortality, but they also have a high risk of cancer progression and its associated morbidity and mortality. In an analysis of 355 Italian patients who died from COVID-19, 20% had active cancer (JAMA. 2020 Mar 23. doi: 10.1001/jama.2020.4683).
Patients with lung cancer may be particularly vulnerable to death from coronavirus infection caused by older age, comorbid conditions, and the frequent requirement for multiple modalities of treatment, including cytotoxic therapy. In China, among 18 patients with cancer and coronavirus infection, 28% had lung cancer, and those patients had a high risk of requiring ICU-level care (Lancet Oncol. 2020 Mar;21[3]:335-7).
Bearing these data in mind, even the most mundane aspects of lung cancer diagnosis, treatment, and follow-up require careful risk-benefit analysis before application to individual patients.
There are always gray areas, particularly in quantifying the risk of relapse or infection for individual patients. However, the articulation of the ESMO guidelines into the chosen domains should make them easy to apply in routine practice for many patients.
The holistic approach the ESMO guidelines promote has never been more critical than during the pandemic, nor more aptly applied than to patients with lung cancer.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest. Dr. Duma disclosed relationships with AstraZeneca and Inivata.
The European Society for Medical Oncology (ESMO) has issued guidelines that provide a practical road map for managing lung cancer patients during the COVID-19 pandemic, but the guidelines don’t address some issues that may affect U.S. physicians.
ESMO’s lung cancer guidelines provide specific details on when to prioritize and when to delay care. However, the guidelines don’t provide recommendations for managing patients who cannot participate in telemedicine or patients who have seen their clinical trial halted because of the pandemic, two situations that may be familiar to U.S. physicians.
Prioritization
As with ESMO’s other disease-focused COVID-19 guidelines, the lung cancer guidelines are organized into three priority levels – high, medium, and low – which are applied to several domains of diagnosis and treatment.
High-priority recommendations apply to patients whose condition is either clinically unstable or whose cancer burden is immediately life-threatening. Medium-priority recommendations apply to patients in noncritical situations for whom delaying care beyond 6 weeks would likely lower the chance of a significant benefit from the intervention. Low-priority recommendations apply to patients whose condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic.
ESMO applied the high-, medium-, and low-prioritization schema to clinically distinct domains of lung cancer management, including outpatient visits; imaging; surgical treatment and diagnostic intervention; radiation therapy; and medical oncology treatment of early, locally advanced, or metastatic lung cancer.
As an example, a high-priority outpatient visit would be a visit for a patient with a new diagnosis of lung cancer and disease-related symptoms, suspicion of advanced disease or small cell cancer, or a visit for treatment administration. Low-priority visits would be survivorship visits, follow-up for a patient with low or intermediate relapse risk, or a visit for psychological support alone. For each diagnostic and therapeutic domain, there are similarly explicit examples.
Strengths of the guidelines
Because of small cell lung cancer’s usually aggressive behavior, ESMO’s recommendations appropriately give high priority to the diagnosis and treatment of small cell lung cancer.
Regarding imaging of pulmonary nodules, ESMO’s guidelines are fairly faithful to the Fleischner Society’s 2017 recommendations (Radiographics. 2018 Sep-Oct;38[5]:1337-50).
Most importantly, ESMO urges oncologists to adjust their routines by amplifying telemedicine services, reducing clinic visits, delaying adjuvant radiation therapy, switching to oral therapies when possible, and taking minor liberties with the schedule and duration of immune-targeted therapy.
The guidelines contain advice on supportive therapies, particularly regarding more liberal use of myeloid growth factors for patients on cytotoxic chemotherapy and postponement of antiresorptive therapy when it is not needed urgently.
Unaddressed issues
ESMO’s guidelines do not suggest more liberal use of immune-targeted therapy alone for specific patient profiles, nor do the guidelines provide tips for enhancing mental and physical health of patients during this stressful time.
The guidelines put primacy on “patient safety.” However, Narjust Duma, MD, of the University of Wisconsin–Madison, noted that there may be other equally important considerations. The patient’s comfort level about management recommendations and the safety of family members are vital, especially those who are older or immunocompromised.
Dr. Duma also noted that access to care is an issue specific to the United States that is not specifically addressed in the ESMO guidelines.
Dr. Duma estimated that as many as 30%-40% of patients with lung cancer may have no access to the Internet, a smartphone, or the ability to set up a telemedicine encounter. A patient’s lack of health insurance, transportation, and shelter will also have a direct impact on a provider’s ability to implement the ESMO guidance.
In addition, ESMO’s lung cancer guidelines do not specifically address accrual of patients to research studies during the pandemic. In the United States, many institutions have decided to suspend recruitment of patients to clinical trials, and many developing studies have been put on hold.
Lung cancer management today
The COVID-19 pandemic poses unique challenges to cancer patient care, since cancer patients are at high risk of COVID-19-related mortality, but they also have a high risk of cancer progression and its associated morbidity and mortality. In an analysis of 355 Italian patients who died from COVID-19, 20% had active cancer (JAMA. 2020 Mar 23. doi: 10.1001/jama.2020.4683).
Patients with lung cancer may be particularly vulnerable to death from coronavirus infection caused by older age, comorbid conditions, and the frequent requirement for multiple modalities of treatment, including cytotoxic therapy. In China, among 18 patients with cancer and coronavirus infection, 28% had lung cancer, and those patients had a high risk of requiring ICU-level care (Lancet Oncol. 2020 Mar;21[3]:335-7).
Bearing these data in mind, even the most mundane aspects of lung cancer diagnosis, treatment, and follow-up require careful risk-benefit analysis before application to individual patients.
There are always gray areas, particularly in quantifying the risk of relapse or infection for individual patients. However, the articulation of the ESMO guidelines into the chosen domains should make them easy to apply in routine practice for many patients.
The holistic approach the ESMO guidelines promote has never been more critical than during the pandemic, nor more aptly applied than to patients with lung cancer.
Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest. Dr. Duma disclosed relationships with AstraZeneca and Inivata.