COMMENTARY

Colorectal Cancer: Proposed Treatment Guidelines for the COVID-19 Era

David J. Kerr, CBE, MD, DSc, FRCP, FMedSci; Rachel S. Kerr, MBChB

Disclosures

April 03, 2020

In light of the rapid changes affecting cancer clinics due to the COVID-19 pandemic, Drs David Kerr and Rachel Kerr, both specialists in gastrointestinal cancers at the University of Oxford in Oxford, United Kingdom, drafted these guidelines for the use of chemotherapy in colorectal cancer patients.

Drs Kerr and Kerr are putting forth this guidance as a topic for discussion and debate, and Medscape encourages readers to comment and submit their own modifications via the comments section of this article.

Our aim in developing these recommendations for the care of colorectal cancer patients in areas affected by the COVID-19 outbreak is to reduce the comorbidity of chemotherapy and decrease the risk of patients dying from COVID-19, weighed against the potential benefits of receiving chemotherapy. These recommendations are also designed to reduce the burden on chemotherapy units during a time of great pressure.

We have modified the guidelines in such a way that, we believe, will decrease the total number of patients receiving chemotherapy—particularly in the adjuvant setting—and reduce the overall immune impact of chemotherapy on these patients. Specifically, we suggest changing doublet chemotherapy to single-agent chemotherapy for some groups; changing to combinations involving capecitabine rather than bolus and infusional 5-FU for other patients; and, finally, making reasonable dose reductions upfront to reduce the risk for cycle 1 complications.

By changing from push-and-pump 5-FU to capecitabine for the vast majority of patients, we will both reduce the rates of neutropenia and decrease throughput in chemotherapy outpatient units, reducing requirements for weekly line flushing, pump disconnections, and other routine maintenance.

We continue to recommend the use of ToxNav germline genetic testing as a genetic screen for DPYD/ENOSF1 single-nucleotide polymorphisms (SNPs) to identify patients at high risk for fluoropyrimidine toxicity.

Use of biomarkers to sharpen prognosis should also be considered to refine therapeutic decisions.

Recommendations for Stage II-III Colorectal Cancer

Table. Recommendations for Adjuvant Therapy

  Stage II Stage III
Age/fitness T3N0 T4N0 T3N1 T4 N1/2 T3 N2
Under 70 and fit Discuss pros and cons of Cape alone for

 

6 months

Discuss pros and cons of

 

Cape alone for

6 months

Discuss pros and cons of

 

Cape alone for

6 months

Cape/Ox for 3 months Cape/Ox for 3 months
Over 70 or under 70 and significant comorbid conditions No chemo No chemo

 

or

Cape* alone for

6 months

NO chemo

 

or

Cape* alone for

6 months

Cape*/Ox* for 3 months Cape*/Ox* for 3 months
Over 70 and significant comorbid conditions No chemo No chemo No chemo NO chemo or

 

Discuss Cape*/Ox* for 3 months

NO chemo

 

or

Discuss

Cape*/Ox* for 3 months

Cape = capecitabine; Cape/Ox = capecitabine/oxaliplatin

*If over 70 years of age or other comorbid conditions that contribute to COVID-19 risk for morbidity and death, reduce capecitabine down to 80% standard dose and reduce oxaliplatin down to 80% standard dose. If either of these apply and the patient also suffers mild to moderate renal impairment, then give 60% of the standard dose of capecitabine.

Any patients who are presently undergoing adjuvant chemotherapy should have a discussion about continuing with their treatment, given the changes outlined above, especially patients who were originally scheduled to receive 6 months of treatment or those in COVID-19 high-risk groups.

Comments

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