Take a peek behind the latest paper published in Colorectal Cancer, discussing various strategies that could reduce the risk and maintain the benefit of colorectal cancer (CRC) treatment during the COVID-19 pandemic. Here, Benjamin Weinberg, medical oncologist at the Lombardi Comprehensive Cancer Center (DC, USA), talks about the importance of adapting treatment guidelines, and the potential treatment environment post-pandemic. Weinberg specializes in the treatment of patients with CRC and pancreatic cancers.
Why is it so important to consider changing treatment guidelines for oncologists during the COVID-19 pandemic?
We must be careful to not restrict beneficial cancer treatments, whilst also ensuring safety to our vulnerable patient population. Cancer care is not ‘elective’, as certain interventions – including chemotherapy – can increase the odds of cure for patients with localized CRC, as well as improve symptoms in patients with advanced CRC. Thus, we do not want to de-escalate treatment to lower risk in the short term, which could put patients at long-term risk of cancer recurrence. We must also balance the risk of exposing patients coming in for infusions and risking myelosuppression with controlling tumor growth and palliating symptoms.
Could you outline the guidelines for CRC treatment presented in your recent report?
Our basic principles are:
Avoid clinic and hospital exposure
Maintain optimal clinical outcomes, especially in the curative setting
Avoid toxicities requiring emergency room visits or hospitalizations
Plan for 2–3 months (not a few weeks)
To accomplish these principles, we recommend:
Dropping the 5-FU bolus
Changing IV 5-FU to oral capecitabine
Drop infusions, if able
Manage oral agents with telemedicine visits and outside labs
Spread out mediport flushes
Use short-course radiation, if able
Consider using ctDNA or Immunoscore to modify decision making around adjuvant therapy to minimize excessive treatment
Delay surgery, if appropriate
What do you think the major challenges will be for CRC management during the pandemic?
We have frequent conversations with patients regarding the risks and benefits of not only therapies, but also procedures such as clinic visits, blood tests and imaging. End-of-life conversations are especially difficult when conducted virtually. Moreover, patients admitted to the hospital are especially isolated as they are not allowed any visitors, losing key advocates at a crucial time. Maintaining the balance between keeping pressure on cancer and not placing patients at increased risk is an ongoing struggle for patients with advanced disease.
How will your proposed guidelines help to overcome these challenges?
We believe our guidelines are practical and easy to implement. Many principles are common-sense and reflect methods we use to dose-modify to minimize risk.
Do you think oncology guidelines updated due to COVID-19 will continue to be implemented post-pandemic?
We do think that certain changes such as dropping the 5-FU bolus and performing more clinic encounters virtually are likely to persist post-pandemic.
Where do you see colorectal cancer management evolving in the next 5–10 years?
It’s hard to predict the next few months much less the next 5-10 years. We do envision smarter decision making regarding selection and duration of adjuvant therapy using ctDNA, Immunoscore, and other technologies. We also foresee using telemedicine to provide more access to patients, especially those who live far away, to a multidisciplinary tumor board evaluation.