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Table of Contents
MUSINGS
Year : 2020  |  Volume : 3  |  Issue : 5  |  Page : 110-114

Intelligent adaptation to the changing surroundings amidst the COVID-19 pandemic for sarcomas and melanomas


1 Department of Medical Oncology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission06-Apr-2020
Date of Decision07-Apr-2020
Date of Acceptance08-Apr-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Jyoti Bajpai
Department of Medical Oncology, Room 1115, 11th Floor, Homi Bhabha Block, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_132_20

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How to cite this article:
Mailankody S, Bajpai J. Intelligent adaptation to the changing surroundings amidst the COVID-19 pandemic for sarcomas and melanomas. Cancer Res Stat Treat 2020;3, Suppl S1:110-4

How to cite this URL:
Mailankody S, Bajpai J. Intelligent adaptation to the changing surroundings amidst the COVID-19 pandemic for sarcomas and melanomas. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jun 3];3, Suppl S1:110-4. Available from: http://www.crstonline.com/text.asp?2020/3/5/110/283299



The coronavirus disease 2019 (COVID-19) pandemic has reached India too, and we are now on the verge of community spread of the virus.[1] However, cancer in general is an aggressive disease where essential treatment needs to be executed fast. The treating oncologists have the tremendous responsibility to handle the situation with utmost care, balancing cancer and COVID simultaneously and keeping in the mind the host factors – essentially individualized care!


  Cancer and Coronavirus Disease 2019 Top


The association of cancer and COVID-19 is complex.[2] We only have limited data. Although there was an initial publication from China which reported increased morbidity and mortality for cancer patients with COVID-19 infection, this included only 18 patients; the exact cause for increased mortality was not clear.[3],[4] The experience from China suggests that while the case fatality rate for the overall population is 2%, that for cancer patients is 6%, which is concerning.[3]

Multiple guidelines have been published recently for streamlining cancer care during this pandemic, however one must adapt and use the information that is most appropriate for one's community.[5],[6],[7],[8],[9],[10],[11],[12],[13] The issues faced by patients and oncologists are numerous.

For patients: There are two key safety concerns – virus exposure during hospital visits and the risk of COVID complications due to therapy itself.[12] Also to be considered are the effects of the difficulties in accessing timely medical care, difficulties in procuring medications, and delay in treatment.

For oncologists: Lack of personal protective equipment (PPE) for those not directly involved with the care of COVID-19 patients and increased personal risk are the major concerns. In addition, an organized approach to this pandemic, aiming to deliver good care with limited resources, including judicious use of PPE without undue burden on the existing workforce, is highly required.[13]

Additionally, oncologists need to strive to provide continuity of care, reschedule their routines, and protect themselves and their patients.[10] Liaison with the psychiatry team for timely help is desirable as the psychological impact of this pandemic on the staff and patients is immense.[11],[12],[13],[14]

Factors affecting oncologic care during this pandemic

  1. Host factors: Age, other comorbidities, general health, place of stay and ease of access to medical care, education and economic status, and general ability to comply with instructions (social distancing/self-quarantine)
  2. Cancer-related factors: Pace of the disease, histological subtype, stage and grade, and sites of disease (vital organs affected)
  3. Treatment-related factors: Intent of treatment, doses and intensity of chemotherapy used, level of immunosuppression, expected rate of complications, and the ability to manage the specific complications through telemedicine or phone consultations at peripheral centers.


As an oncology team, we need to be prepared to evaluate the above factors on a case-by-case basis and take decisions [Figure 1].[11-13] The National Health Service (UK) recommendations stratify the patients into six groups based on the probability of survival and the expected benefit from chemotherapy. Treatment is stratified into curative and non-curative, while chance of success, life prolongation, and palliation are graded from >50%, 15%–50%, and <15%, respectively.[6] The French guidelines also take into account other factors such as age and duration of malignancy.[7] Objective measures such as the European Society of Medical Oncology Magnitude of benefit estimates should be used whenever possible. Whenever possible, prioritization of patients should be decided in a multidisciplinary tumor (MDT) discussion and documented. Patients and caregivers also need to have a clear understanding regarding the prioritization principles.[5] Guidelines from national oncological societies, oncology peer groups, and at hospital level may also assist in the decision-making.[12]
Figure 1: Continuum of decision-making for oncology care during the coronavirus disease 2019 pandemic

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It is mandatory to have a two-way dialog with the patients regarding the implications of delaying cancer treatment versus the risk of COVID-19 infection so that they take informed decisions. There is a dearth of voluntary blood donation due to general reluctance to visit hospitals; limitation and risk of using public transport are additional concerns. Patients may be advised to find blood donors and temporary quarters close to the hospital to avoid the use of public transport as well as to practice “social distancing” strictly to prevent infections.

In all patients, the following general measures can be followed:[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]

To minimize hospital contact and travel:

Pretreatment workup

  1. The use of telemedicine units and video/conference calls
  2. Patients can complete all necessary tests and workup and counseled regarding treatment options before the hospital visit. They can come to the hospital only for the start of chemotherapy.


Active treatment

De-escalation of treatment

  1. Use of oral or subcutaneous treatment instead of intravenous, which needs fewer resources such as oral metronomic chemotherapy (OMCT)
  2. Use of 3-weekly or 4-weekly regimens instead of dose-dense 2-weekly regimens
  3. Patients with metastatic disease and good disease control can be given treatment breaks appropriately
  4. Prescription of oral therapy for 3 months instead of monthly.


Supportive care

  1. Blood transfusions should be minimized, to reallocate blood for the emergencies
  2. Use of oral rather than intravenous antibiotics/antifungals where feasible
  3. Social media/WhatsApp support groups for patients for sharing their reports and voicing their concerns
  4. “Fever cards” can be given to patients, for easier management of uncomplicated low-risk febrile neutropenia at local clinics on an outpatient department basis.


Investigations

Minimize response assessment imaging (preferably consider shorter procedures such as ultrasonogram); perform imaging only if symptomatic progression or clinically inaccessible disease sites. The results of the investigations done at local laboratories can be communicated to doctors for further decision-making.

Follow-up

  1. Patients who are scheduled for routine follow-up or surveillance visits may postpone their visits. If they have concerns, they may contact their local physician
  2. When possible, we could confirm that the patients with scheduled appointments the next day, have no COVID-19-associated symptoms.


At the hospital

Every hospital should have a written policy on suspected/confirmed COVID-19-positive patients. Preferably, entry should be allowed only at one point so that a screening zone can be organized.[13] All patients should fill self-declaration forms regarding symptoms/travel history and screened by a health worker. This will help the oncology team to take the necessary precautions. The manifestations of COVID-19 in neutropenic patients may not be typical, hence utmost care is to be taken to prevent the inadvertent spread of the infection.

  1. Patients can be advised to come on their own whenever possible
  2. Electronic patient management system should be implemented to reduce waiting time; online payment billing services should be available
  3. Hospital infrastructure including day-care chemotherapy units and waiting rooms, should be modified to ensure adequate spacing and ventilation, hand hygiene facilities, and cleaning and disinfection of the surroundings
  4. Before entry into day-care units, confirmation should again be obtained that patients have no symptoms suspicious of COVID-19[8]
  5. Minimization of subsidiary services such as canteen facilities, welfare-scheme counters, and billing facilities within the hospital should be should be considered.[13]


From the oncology team, MDT discussions can be done through videoconferencing options or meeting applications, allowing sharing and discussion of radiology images also. Any oncology team member with contact or symptoms should avail testing and self-quarantine himself/herself. The hospital should ensure adequate care for its workers.


  Bone and Soft-Tissue Sarcoma Patients and Melanoma Patients Top


Ewing sarcoma

  1. Patients who are recently diagnosed with Ewing sarcoma (ES) Patients can complete pretreatment consults/counseling and workup prior to face-to-face contact. The results of the MDT meeting also can be conveyed electronically to the patient
  2. Curative intent treatment in localized disease – Chemotherapy can be started after a detailed discussion with the patient; they should be willing to stay close to the hospital as the treatment is intensive and needs good supportive care. Starting treatment with 3-weekly regimens, the use of growth factors (preferably pegylated granulocyte colony-stimulating factors [GCSFs] rather than regular GCSF to avoid daily pricks and visits), and optimization of nutritional status before the start of treatment may help to reduce the need for supportive care. As is used in palliative care, anticipatory prescriptions/instructions for the common post-chemotherapy problems such as nausea/vomiting, malaise, and diarrhea may again help to decrease hospital visits
  3. Patients already on treatment – Patients should be continued on the treatment, making dose modifications based on toxicity and reducing the frequency of visits
  4. Palliative intent treatment – Patients need to be counseled well and treatment options should be discussed, based on the prognosis of the metastatic/recurrent disease.[16] If possible, the patients can be started on OMCT protocols. For ES, the combination of oral cyclophosphamide (50 mg once a day [OD]), etoposide (50 mg OD), both daily for 21 days in a 28-day cycle (7 days off),[17] and tamoxifen (20 mg twice a day) daily continuously, can be used.


If delivering chemotherapy is an emergency due to vital organ compromise, the patient can be referred to a local medical oncology unit (closest to the patient) with the necessary medications so that travel can be minimized. Further instructions can be confirmed telephonically.


  Osteosarcoma Top


  1. Curative intent – The standard treatment options may include three-drug protocols including high-dose methotrexate (MTX)-based or ifosfamide-based like the OGS-12 protocol.[18],[19],[20],[21] This may be delivered in fit patients with good support systems and infrastructure. De-escalation of treatment in the neoadjuvant and adjuvant treatment may be advised. Instead of a three-drug regimen, a two-drug, i.e., cisplatinum/doxorubicin-based, regimen with pegylated GCSF support every 3–4 weeks with close monitoring may be considered. Avoidance of the third drug will help to decrease complications. Increasing the interval between treatments should be executed only after explaining the pros and cons to the patient, as treatment compliance has been associated with good response.[22] Coordination for scheduling of surgery at the best possible time is required. In patients >40 years (secondary osteosarcomas), especially with comorbidities, postponement of standard intravenous chemotherapy and starting of OMCT with oral cyclophosphamide (50 mg daily for 21 days in a 28-day cycle [with 7 days off]) and MTX 12.5 mg orally once in a week or oral sorafenib 400 mg once daily to start with and escalation based on tolerance may be alternatives to bridge the gap
  2. Palliative intent – OMCT protocol with oral cyclophosphamide and MTX or alternatively oral sorafenib in the doses as above can be tried. Linking the patient to local palliative care services can also help to limit infection rates.



  Soft-Tissue Sarcomas Top


Neoadjuvant and adjuvant treatment may be continued following the general guidelines with dose modifications and increasing the dosage interval as appropriate.[23],[24] In intermediate or poor chemosensitive histologies, we may consider omitting chemotherapy. Appropriate discussion with surgical/radiation oncology colleagues will help to coordinate the timing of surgery and radiotherapy if required.

Palliative therapy – Medications such as pazopanib (based on the histological subtype) and OMCT (oral cyclophosphamide, etoposide, and tamoxifen) or the use of chemotherapy with reduced doses/frequency with growth factor support may be considered.


  Fibromatosis Top


The treatment of fibromatosis is rarely an emergency. For patients on the tamoxifen/vinblastine/MTX protocol, the weekly vinblastine and MTX doses can be temporarily withheld while continuing tamoxifen. Patients can be followed up at less frequent intervals, unless they have complications.


  Malignant Melanoma Top


Adjuvant treatment

This can be deferred for up to 12 weeks after surgery. If the estimated disease relapse chance is <50%, it may be deferred during the pandemic.[25]

Single-agent immunotherapy at the least frequent dosage (e.g., pembrolizumab 400 mg intravenously every 6 weeks) may be preferred.[25] BRAF/MEK inhibitor treatment protocols may be used as per availability.[26]

Metastatic melanoma

We should assess the burden of disease and the visceral involvement. The use of single-agent immunotherapy agent (administered at the lowest possible frequency) is preferred. The effect of immune-related adverse events on COVID-19 infection is not known. However, inability to access timely health-care and the use of steroids may have a bearing on outcomes. Oral temozolamide may be used as palliative chemotherapy.[25] Treatment interruption may be warranted in patients in whom the disease is well controlled.

For BRAF mutant melanoma, BRAF/MEK inhibitor combination may be used.

As the situation is dynamic, oncologists should be aware of the local situation and modify their practices accordingly. Overall, the benefit of well-planned oncology treatment in a controlled environment may offset the risk of COVID infection in many cases.[11] By 'C

'ontinuing social distancing, 'O'mitting unnecessary contacts with other persons, use of 'V'isage/universal precautions, 'I'nfection control measures like hand hygiene and cough/sneeze etiquette, and with a healthy balanced lifestyle including a nutritional 'D'iet, we may be able to tackle COVID with “COVID”.[10]


  Conclusions Top


There is no easy solution to the question of care of cancer patients during the COVID-19 pandemic. On a case-to-case basis, there should be prioritization of patients after discussion in an MDT. Utmost care is required to limit the spread of COVID and decrease morbidity. Iatrogenic immunosuppression must be avoided as much as possible. Elective treatments can be postponed. Oncologists should be able to maintain a balance between personal protection and quality oncology care.[8]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Osteosarcoma
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