"Our efforts in the cancer clinic have been driven by patient safety and also maintaining patient access to care. In the age of COVID-19, those 2 things are sometimes at odds with each other."
Because of the strain on the health care system brought on by the novel coronavirus disease 2019 (COVID-19) pandemic, the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) have laid out guidelines to help practicing oncologists delineate the best ways to allocate limited resources.
"Health care has basically been turned upside down,” said Arjun V. Balar, MD, director of the genitourinary medical oncology program at NYU Langone’s Perlmutter Cancer Center in New York, New York, and co–editor-in-chief of Targeted Therapies in Oncology during an interview. “Our efforts in the cancer clinic have been driven by patient safety and also maintaining patient access to care. [In the age of COVID-19], those 2 things are sometimes at odds with each other."
With patients’ safety and access in mind, the NCCN issued tumor type–specific updates for the treatment of breast cancer, non–small cell lung cancer (NSCLC), prostate cancer, colorectal cancer (CRC), melanoma, nonmelanoma skin cancers, and T-cell and primary cutaneous lymphoma during the COVID-19 pandemic.1-7 Most of the recommendations aim to limit the number of patients who need to leave their homes for care by emphasizing the use of telehealth visits and oral systemic therapy regimens as well as outlining surgical procedures that may be temporarily delayed.
A key aspect of the recommendations for treating patients with breast cancer involves assigning patients to 3 priority levels based on urgency of care. Patients in category A are those with a life-threatening prognosis who cannot delay therapy, category B includes patients whose disease is not life-threatening but for whom treatment should not be delayed until after the pandemic, and category C comprises patients whose therapy can be deferred until after the pandemic.1
In general, the guidelines recommend that all visits be conducted remotely when feasible and that most breast-focused imaging be delayed. Practitioners should defer surgical procedures in all possible scenarios for which an alternative therapy could serve as a stand-in. The TABLE includes a select list of surgical procedures by priority.1
Balar spoke to his concerns regarding these delays of therapy. “This has forced us in the cancer [community] to delay treatments for patients,” he said. “The definition of an elective surgery, it’s important to understand, is that it is not really elective—it just means patients are scheduled for surgery…all of these were thought to be considered elective because of the need for ventilators for patients with COVID-19."
The recommendations for breast cancer care further detail ways to reduce the number of clinic visits by delaying or dose-adjusting systemic therapy based on disease subtype. For example, the guidelines advise that patients with advanced-stage invasive breast cancer have their therapy dose and schedule adjusted to reduce the need for monitoring visits and their chances of developing treatment-related adverse effects. Notably, endocrine therapy agents are considered safe, and clinicians may continue to use them during the COVID-19 pandemic.1
Because of the virus’ effect on the lungs and vulnerable populations, patients with lung cancer are at heightened risk of complications of COVID-19. As such, the NCCN outlined strategies for treating patients with NSCLC during the pandemic with the goal of reducing exposure while maintaining optimal outcomes.2
Treatment interval prolongation or deferred systemic therapy doses are a reasonable option for certain patients with metastatic disease, but medical oncologists should gear efforts toward continuing therapy for most. The guidelines recommend use of oral regimens in place of intravenous agents—such as substituting oral for intravenous etoposide—when feasible to reduce clinic visits. Additionally, reliance on circulating tumor DNA testing over tissue testing may be reasonable in this setting to avoid the need for tissue harvesting.2
As with the breast cancer recommendations, practitioners should evaluate surgical procedures to assess the possibility of postponement. For example, patients with clinical stage IA1 solid tumors can be deferred for 2 to 3 months, whereas patients with clinical stage IIIA (T3N1 or T4N0) should be strongly considered for surgery within 1 month.2
According to the NCCN guidance on prostate cancer care, “the benefit of routine localized prostate cancer care should not be overestimated. In most instances, minimal harm is expected with delays in care or treatment of 3 to 6 months, especially when weighed against the risk of mortality of COVID-19.”3
Oncologists should conduct telehealth visits with rare exceptions. They can avoid or defer routine care for most patients with prostate cancer, including delaying initiation of androgen deprivation therapy (ADT) in patients with a prostate-specific antigen doubling time of more than 9 months. For patients who need to continue on ADT, clinicians should prioritize 3-, 4-, and 6-month formulations for use over 1-month injections.3
The NCCN has provided similar documents detailing recommendations for therapy in patients with various other solid tumors and hematologic malignancies.4-7
"For patients who are on routine follow-up, we are doing much more virtual medicine,” said Balar. “Bringing patients into the health care system means putting them at risk for exposure or contracting the virus. Trying to both [treat patients and prevent disease spread] has been challenging, [but] patients [who] absolutely have to be here to receive treatment are physically present."
For example, oncologists can manage care for patients with CRC who are receiving treatment that includes capecitabine without routine laboratory assessment in the absence of symptoms and provide an alternative dosing strategy that includes the oral agent. Oncologists could consider bridging capecitabine with or without oxaliplatin in patients with stage II or III disease whose surgeries are delayed because of the pandemic.4
With the exception of Merkel cell carcinoma, most nonmelanoma skin cancer excisions can be safely delayed during the pandemic, according to the NCCN.5 For patients with melanoma, systemic therapy substitution options are offered in cases of drug shortages.6
Rationing of medical supplies, ventilators, and critical and intensive care space in the hospital as well as medications will likely continue to affect health systems in the United States. This shift in resources will be a persistent encumbrance on the treatment of patients with cancer.
As such, ASCO has released recommendations for best strategies for resource allocation and encourages that oncologists play an active role in ensuring the needs of their patients are well represented in individual health-system policies and prioritization.8
According to the authors of the guidelines, scarce-resource allocation should depend on maximizing health benefits with fair, consistent, and transparent prioritization. The authors further strongly encourage that individual institutional guidance be developed before limited allocation strategies become necessary.8
Two resources that ASCO recommends for developing an institutional framework are “Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic: Managing Uncertainty, Safeguarding Communities, Guiding Practice,” from The Hastings Center,9 and the University of Pittsburgh’s “Allocation of Scarce Critical Care Resources During a Public Health Emergency,” which clarifies multiprinciple scoring systems that consider patients with preexisting life-limiting disease and individual cancer diagnoses and prognoses.10
Within institutional plans, ASCO said, maximizing health care outcomes—with benefits measured by either lives or life-years saved—is the core principle guiding resource allocation, which will give priority to the patients with the greatest likelihood of recovery from their current illness.
Institutions may need multidisciplinary teams to determine rationing of critical care resources, as the treating oncologist should not be in charge of determining use of scarce resources on their own patients. This approach is a divergence from the joint decision-making strategies that clinicians typically employ when deciding on best treatments; however, it is necessary to allow oncologists to maintain their f idelity to their patients.8
ASCO urges oncologists to engage with their patients in discussions about advance care planning that are properly documented in medical records “early and often.” In addition, oncologists should inform patients about plans and decisions surrounding resource allocation with honesty, to foster accountability within the health system.8
1. Dietz JR, Moran MS, Isakoff SJ, et al. Recommendations for prioritization, treatment and triage of breast cancer patients during the COVID-19 pandemic. NCCN. Accessed April 24, 2020. bit.ly/2Y20Xxy
2. Short-term recommendations for non-small cell lung cancer management during the COVID-19 pandemic. NCCN. Updated April 13, 2020. Accessed April 24, 2020. bit.ly/2VQLZaS
3. Management of prostate cancer during the COVID-19 pandemic. NCCN. Accessed April 24, 2020. bit.ly/2x4KY6E
4. Principles for management of colorectal cancer patients during the COVID-19 pandemic. NCCN. Published April 10, 2020. Accessed April 24, 2020. bit.ly/3byNMrS
5. Advisory statement for non-melanoma skin cancer care during the COVID-19 pandemic. NCCN. Updated April 22, 2020. Accessed April 24, 2020. bit.ly/3bMLVzT
6. Short-term recommendations for cutaneous melanoma management during COVID-19 pandemic. NCCN. Updated March 25, 2020. Accessed April 24, 2020. bit.ly/3bwvl70
7. Short-term recommendations for the management of T-cell and primary cutaneous lymphomas during COVID-19. NCCN. Accessed April 24, 2020. bit.ly/2S5RktL
8. Marron JM, Joffe S, Jagsi R, Spence RA, Hlubocky FJ. Ethics and resource scarcity: ASCO recommendations for the oncology community during the COVID-19 pandemic [Approved April 7, 2020]. J Clin Oncol. doi: 10.1200/JCO.20.00960
9. Berlinger N, Wynia M, Powell T, et al. Ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: managing uncertainty, safeguarding communities, guiding practice. The Hastings Center. Published March 16, 2020. Accessed April 23, 2020. bit.ly/3cEvDsH
10. White DB, Katz M, Luce J, et al. Allocation of scarce critical care resources during a public health emergency. University of Pittsburgh. Published April 15, 2020. Accessed April 23, 2020. bit.ly/2XY5ctS