Cancer in the time of COVID-19: expert opinion on how to adapt current practice

Standard care in most patients is chemoradiotherapy with four cycles of cisplatin/etoposide as the preferred chemotherapy regimen.

Replacing intravenous with oral etoposide to reduce the time in hospital should be weighed against its lower biological availability and variable pharmacodynamics in a curative setting [6].

In patients with stage I small-cell lung cancer surgical resection of the tumour, followed by adjuvant chemotherapy (four cycles of cisplatin/etoposide), is indicated.

In selected patients, accelerated hyperfractionation of radiotherapy (twice daily) remains an option to decrease the number of hospital visits.

Palliative chemotherapy with platinum/etoposide is recommended.

Replacing intravenous with oral etoposide to reduce time in hospital may be considered, providing attention is given to its lower biological availability and variable pharmacodynamics [6].

In patients with increased risk of febrile neutropenia (FN), dose reduction may be an alternative to primary prophylactic use of granulocyte colony-stimulating factor (G-CSF) in all patients, given the palliative setting [7].

Given the limited improvement in overall survival and the need for tri-weekly clinic visits during the maintenance phase, the addition of a checkpoint inhibitor (atezolizumab or durvalumab) can be omitted.

The indication for second-line systemic therapy should be reviewed with extra care. In platinum-sensitive relapse, rechallenge with first-line chemotherapy is recommended. In platinum-refractory relapse, oral topotecan is the preferred regimen. Cyclophosphamide/doxorubicin/vincristine is not recommended as an alternative to topotecan in view of the need to hospitalise the patient.

Any third-line chemotherapy should be considered only in fit patients with low risk of complications.

Consider delaying surgery for ≤3 months in small tumours that appear not to grow fast; follow-up of growth rate with chest CT is recommended [3].

Consider stereotactic radiotherapy as an alternative in patients who are marginally fit for surgery, due to comorbidity or limited pulmonary reserve [3].

Minimal invasive approaches are preferred over thoracotomy to limit time in hospital [3].

Adjuvant chemotherapy in stage II and III and in some patients with high-risk stage IB leads to 5% improvement in 5-year survival and is therefore recommended.

In elderly patients with significant comorbidity or decreased performance (Eastern Cooperative Oncology Group (ECOG) performance score (PS) ≥2), the possible benefits of adjuvant chemotherapy may be outweighed by the increased risk of complications. Consider omitting adjuvant chemotherapy or stopping early (e.g. after three cycles) [3].

Consider administering cisplatin/docetaxel to limit time in hospital, as it avoids day 8 administration of gemcitabine or vinorelbine, and has equivalent efficacy. In non-squamous nonsmall cell lung cancer (NSCLC), cisplatin/pemetrexed is an equally efficacious alternative [8].

In patients with an activating epidermal growth factor receptor (EGFR) mutation, consider a 1-year course of daily oral EGFR tyrosine kinase inhibitor (TKI) as an alternative to adjuvant chemotherapy (currently no phase 3 evidence of superiority available).

Consider delaying curative radiotherapy for small tumours that appear not to grow fast; follow-up of growth rate with chest computed tomography is recommended [3].

Consider administering cisplatin/pemetrexed instead of cisplatin/etoposide, or weekly carboplatin/paclitaxel in non-squamous NSCLC to limit time in hospital [9].

Consider administering adjuvant durvalumab at a dose of 20 mg·kg⁻¹ every 4 weeks instead of 10 mg·kg⁻¹ every 2 weeks to limit time in hospital. Phase 1b data have not shown an increase in adverse events [3, 10]

Evaluate the indication for palliative chemotherapy, immunotherapy or both with extra care in elderly patients or patients with significant comorbidity, decreased performance (ECOG PS ≥2), social isolation, decubitus, urinary catheters, etc., especially in second or further lines [3].

Consider delaying chemotherapy or immunotherapy in patients who are asymptomatic and have indolent disease [3].

The usual recommendations for chemotherapy, immunotherapy and targeted therapy apply.

In patients with an increased risk of FN, dose reduction might be an alternative to primary prophylactic use of G-CSF in all patients, given the palliative setting [7].

Keep in mind that pneumonitis may also be drug-induced (e.g. chemotherapy, TKIs) or immune-mediated (checkpoint inhibitors).

Tri-weekly chemotherapy is preferred over weekly regimens (e.g. docetaxel) to limit time in hospital [4].

Consider limiting palliative chemotherapy to four cycles and omitting pemetrexed maintenance therapy [3].

In patients who have >50% programmed death-ligand 1 (PD-L1) expression, first-line pembrolizumab monotherapy is preferred over pembrolizumab plus chemotherapy [3].

Consider administering nivolumab at a dose of 480 mg every 4 weeks instead of 240 mg every 2 weeks to limit time in hospital [3, 11].

Immunotherapy as second-line is preferred over chemotherapy in patients who did not receive immunotherapy as first-line.

Where there is a lack of response to immunotherapy or significant toxicity, early discontinuation should be considered.

Third-line chemotherapy is not advisable [3].

Consider evaluating the response to immunotherapy or TKI less often in clinically stable patients.

Advance care planning should be discussed with all patients in order to avoid admission to hospital [3].

Do not resuscitate status should be available for all stage IV patients.

Patients receiving denosumab or low-molecular weight heparin should be taught to self-administer [3].

Patients receiving denosumab should not routinely consult a dentist before starting.

Avoid transfusion of blood or platelets by using dose reduction or early discontinuation of chemotherapy in palliative patients.