ESMO guidance on management of colorectal cancer during COVID-19 outbreak

The European Society of Medical Oncology (ESMO) has issued adapted guidance on the management and treatment of colorectal cancer (CRC) in the COVID-19 era. The guidelines have been released to maintain the highest levels of care to all patients, ensure the safety of patients and healthcare workers and save as many lives as possible. The guidelines have been published in the journal ESMO Open.

Patients with cancer often need to leave their homes and visit the hospital for cancer treatment, check-ups and the management of cancer-related or treatment-related complications. Often, they also require home assistance from palliative healthcare teams or simply from their family members.

European Society of Medical Oncology proposes a three-tier prioritisation system based on expert clinical judgement and the magnitude of benefit expected from specific interventions. Since the availability of resources for diagnostic procedures, surgery and postoperative care, systemic therapy and radiotherapy may differ, separate prioritisation analyses has been made by authors.

Priorities for patients with colorectal cancer (CRC): outpatient visit priorities

High priority

Potentially unstable (acute abdominal pain, intestinal occlusion, ascites, complications after surgery/endoscopy or radiological interventions, diarrhoea, severe skin toxicity, new symptoms, clinical progression).

Symptomatic new patients (symptomatic ascites, intestinal occlusion, chronic diarrhoea).

Medium priority

Newly diagnosed asymptomatic patients, no prior surgery.

Newly diagnosed asymptomatic patients after surgery for treatment strategy planning in case of adjuvant and first-line treatment.

Chemo/radiotherapy-related serious side effects.

Established patients with new problems or symptoms from treatment—convert as many visits as possible to telemedicine appointments.

Low priority

Second opinion.

Secondary prevention of CRC; if possible, schedule blood tests and imaging close to home and convert to telemedicine.

Follow-up visit out of study.

Restaging in metastatic setting when the goal is not to perform surgery with curative intent on metastatic and primary lesions.

Restaging in third-line and fourth-line treatment.

Follow-up visit on maintenance treatment; if possible, schedule blood tests and imaging close to home and convert to telemedicine.

Priorities for colorectal cancer (CRC): imaging and radiological/endoscopic interventions

High priority

Radiological confirmation of intestinal occlusion, bleeding, perforation, postsurgical complications and postinterventional procedures.

Radiological confirmations of bone fractures due to metastasis.

Medium priority

Diagnostic imaging/endoscopy for clinically suspected CRC (clinical, biomarkers, family history).

Diagnostic imaging/endoscopy for high-risk categories (familial cases of CRC, serrated polyps).

Low priority

Secondary prevention of CRC, prefer to perform occult test; if possible, schedule blood tests and imaging close to home and convert to telemedicine.

Follow-up visit out of study.

Restaging in metastatic setting when the goal is not to perform surgery with curative intent on metastatic and primary lesions.

Restaging in third-line and fourth-line treatment.

Priorities for colorectal cancer (CRC): surgical oncology

High Priority

Radiologically confirmed intestinal occlusion in newly diagnosed patients.

Bowel perforation, peritonitis.

Massive gastrointestinal bleeding.

Postsurgical complications (perforation, anastomotic leak).

Postcolonoscopy complications (perforation, bleeding).

Postinterventional procedure such as liver and lung biopsies (perforation, organ damage, peritonitis, abscess, massive bleeding).

Bone fractures with spinal cord compression due to metastasis.

Medium priority

Clinical stage I, II and III colon cancer.

Clinical stage I rectal cancer.

Clinical stage II–III rectal cancer after neoadjuvant treatment.

Resection of metastasis in oligometastatic patients with curative intent as front line or after neoadjuvant treatment.

Low priority

Early stage rectal cancer after complete radiological response following radiotherapy (watch-and-wait strategy).

Prophylactic surgery—for familiar cases of CRC.

Biopsy of metastatic lesions for molecular analysis for late-line treatments. Start last-line options and wait until the end of the COVID-19 pandemic for such evaluation. When possible, use liquid biopsies for such analyses rather than biopsies.

"Colorectal cancer demands a considerable amount of medical resources. Therefore, the redefinition of its diagnostic and therapeutic algorithms with a rigorous method is crucial in order to ensure the highest quality of continuum of care in the broader context of the pandemic and the challenged healthcare systems," ESMO states.

Telemedicine has proved to be a functional and effective way of limiting patients' need to travel to centres and thereby has the potential to reduce diffusion of SARS-CoV-2.

For further reference log on to:

ESMO Open 2020;5:e000826.