UK Consensus on the Treatment of Pancreatic Cancer During the COVID-19 Pandemic

Dawn O'Shea

July 20, 2020

A group of UK experts have published a consensus statement on considerations for the treatment of pancreatic cancer during the COVID-19 pandemic. Below is a summary of the key recommendations.

Diagnosis

  • Upper gastrointestinal endoscopy is an aerosol-generating procedure.

  • All elective and non-essential endoscopic procedures should stop.

  • Endoscopic therapy should continue for malignant biliary obstruction.

  • Percutaneous biopsy may be feasible for more advanced disease.

  • Percutaneous fine-needle aspiration may be considered for localised disease.

Treatment

  • There is emerging but low-level evidence that COVID-19 confers additional risk for patients with cancer.

  • Systemic anticancer therapy for patients with resectable disease (priority levels 2-4) should be ranked over locally advanced pancreatic cancer (priority levels 4 and 5) and metastatic disease (priority levels 4-6).

  • Consider phone consultations and remote assessments.

  • Clinical trials and technical initiatives should stop to minimise resource burden.

  • Consider referring patients to other regions.

Resectable and borderline resectable disease

  • Options for upfront resection are likely to be severely limited.

  • Ringfenced clean sites helped support some surgical capacity during the first COVID-19 peak.

  • Regional pandemic burden and hospital resources should be considered when selecting patients for surgery.

  • Consider upfront chemotherapy and/or chemoradiotherapy (CRT) if surgery is unavailable.

  • For radiotherapy (RT) consider a dose of 25-35 Gy/five fractions (RT alone, depending on expertise; level 4) or 36 Gy/15 fractions CRT with concurrent capecitabine (level 1b).

  • For systemic anti-cancer therapy (SACT), a combination of 5-fluorouracil, folinic acid, irinotecan and oxaliplatin (FOLFIRINOX) is preferred.

  • FOLFIRINOX may be most appropriated for patients with a good performance status without significant co-morbidities.

  • Treatment could be deferred for up to 12 weeks from surgery (level 1b).

Locally advanced cancer

  • Given the increasing risks of COVID-19 with age, the risks of treatment in those aged >80 years are likely to outweigh any benefit.

  • For fit patients without significant co-morbidities, consider four cycles of modified FOLFIRINOX with or without consolidation hypofractionated CRT or five-fraction RT alone (level 2a).

Metastatic disease

  • Risks of treatment are likely to outweigh benefits in many patients with metastatic disease as median improvement in survival is usually <6 months.

  • Second-line chemotherapy should not be routinely offered (level 5).

Hypofractionated radiation

  • Avoid conventional CRT (25-30 fractions), as frequent hospital visits increase COVID-19 risk.

  • Hypofractionated RT (five to 15 fractions) can reduce footfall, time in hospital and immunosuppression.

  • Detailed RT delivery guidance is available at www.uppergicancer.com.

Radiotherapy

  • Dose fractionation: 30 Gy/five fractions (range, 25-35 Gy/five fractions daily or alternate day).

  • Oncologists with experience of delivering upper abdominal/pancreatic stereotactic ablative radiotherapy (SABR) could deliver doses of 33-35 Gy/five fractions using SABR.

  • For those without expertise, consider 30 Gy/five fraction.

  • Consider simultaneous integrated boost to tumour/vessel contact (40 Gy).

Chemoradiotherapy

  • Dose fractionation: 36 Gy/15 (preoperative) or 45 Gy/15 fractions (definitive) with capecitabine (830 mg/m2 bd on days of RT).

  • 45-50 Gy/15 fractions is radiobiologically equivalent to conventionally fractionated regimes used in the UK.

The full consensus position is available here.

Jones CM, Radhakrishna G, Aitken K, Bridgewater J, Corrie P, Eatock M, Goody R, Ghaneh P, Good J, Grose D, Holyoake D, Hunt A, Jamieson NB, Palmer DH, Soonawalla Z, Valle JW, Hawkins MA, Mukherjee S. Considerations for the treatment of pancreatic cancer during the COVID-19 pandemic: the UK consensus position. Br J Cancer. 2020 Jul 8 [Epub ahead of print]. doi: 10.1038/s41416-020-0980-x. PMID: 32641867.

This article originally appeared on Univadis, part of the Medscape Professional Network.

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