Colorectal Cancer: Management Suggestions

1. Regarding surveillance and follow-up:

• • Telephone and telemedicine visits should replace routine in-clinic visits for nearly all patients.
  • Minimize blood tests, scans and prescriptions.
  • Strongly consider delaying routine surveillance scans and colonoscopies, as well as carcinoembryonic antigen (CEA) monitoring.
    • In patients with metastatic disease and abnormal CEA, controlling CEA at intervals that scans would otherwise be considered can suffice to orient clinical decision-making.
  • Consider biopsies only when necessary for short-term clinical decision-making. Weigh oncologic benefit of biopsy against possible risk of virus exposure and evaluate whether observation with repeat imaging in 12 weeks may be an acceptable alternative.
  • Consider postponing enrollment to clinical trials that require sequential biopsies, other invasive interventions or regular hospital visits.

2. Regarding systemic therapies:

• • Favor oral therapies when clinically appropriate.
  • For patients in whom single-agent capecitabine is a reasonable option, consider management without routine labs; the alternative capecitabine dosing schedule of 1000 mg/m2 b.i.d., days 1–7 and 15–21 of a 28-day cycle, can reduce toxicity and need for intensive monitoring.
  • For adjuvant therapy, weigh the incremental survival benefit of therapy against the risk of viral exposure for each candidate, factoring in the patient’s comorbidities and functional status as well as the level of support at home.
    • In stage III colon cancer, 3 months of capecitabine/oxaliplatin (CapeOx) would be a preferred regimen in most cases, given the data from the IDEA trial and the incremental risk of further exposure beyond 3 months.
    • Even in high-risk stage III colon cancer patients, consider the incremental benefit of 6 months of adjuvant therapy versus the risk of frequent face-to-face encounters.
    • For patients unable to receive CapeOx, consider leucovorin/5-fluorouracil (5-FU)/oxaliplatin (FOLFOX) without bolus 5-FU.
  • For patients with newly diagnosed stage 2-3 colon cancer in whom surgery is delayed due to COVID-19 restrictions on operating room availability, consider a bridging course of neoadjuvant capecitabine or CapeOx chemotherapy.
  • For metastatic disease, consider single-agent capecitabine when reasonable or CapeOx on a 21-day cycle rather than usual 14-day cycle regimens; leucovorin/fluorouracil/oxaliplatin/irinotecan (FOLFOXIRI) should only be used under exceptional circumstances. Treatment holidays lasting up to 12 weeks may be appropriate.
  • Consider empiric dose reductions for comorbid patients at high risk of COVID-19 complications, rather than use of pegfilgrastim, unless a take-home self-administered option is available.
  • Consider longer treatment intervals as is consistent with drug kinetics; target engagement data suggest that the efficacy of checkpoint inhibitors can be maintained with the dose administrated at twice the interval (nivolumab 480 mg every 8 weeks or pembrolizumab 200 mg IV every 6 weeks).
  • Consider anti-PD1 therapy, rather than cytotoxic chemotherapy, for metastatic MMR-deficient (dMMR)/microsatellite instability-high (MSI-H) cancers.
  • For maintenance therapy, consider giving capecitabine alone without a parenteral biologic agent; for example, de-escalating FOLFOX + bevacizumab to capecitabine monotherapy might be appropriate.
  • Consider initiating, or switching to, targeted therapies, without concurrent use of cytotoxic chemotherapy, for patients whose cancers require treatment, are refractory to 5- FU/capecitabine as a single agent and express either HER2 amplification, BRAF V600 mutations or RAS/RAF wild-type phenotypes. Regimens with every-other-week anti-EGFR dosing should be prioritized; weekly cetuximab should not be used.

3. Regarding localised therapies

• • The authors endorse the surgical recommendations from the Society of Surgical Oncologists for Colorectal Cancer.²
  • Strongly consider using only short-course pelvic radiation therapy (RT). Recent evidence indicates that it is safe, with improved tumor downstaging, to delay by 6 to 8 weeks or longer the resection of rectal cancer after short-course radiation.
  • Consider postponing local or locoregional therapies (intra-arterial chemotherapy/metastasis resection/ablation/intra-arterial therapy/radiotherapy).

The COVID-19 Working Group of the NCCN Colon, Rectal, and Anal Cancers Guidelines Panel published, on April 10, the first version of its guidelines on the management of colorectal cancer patients; it provides clues and recommendations to medical oncologists as to how they can adapt their practice and clinical decision-making in the time of COVID-19. The Society of Surgical Oncology also recently published its recommendations on the surgical management of colorectal cancer in this context; their resource was only referred to (not summarised) in our article, and it is available online for consultation.

Sources:

1. COVID-19 Working Group of the NCCN Colon, Rectal, and Anal Cancers Guidelines Panel. Principles for Management of Colorectal Cancer Patients During the COVID-19 Pandemic. Consulted on April 14, 2020. https://www.nccn.org/covid-19/
2. Society of Surgical Oncology. Resource for Management Options of Colorectal Cancer During COVID-19. Consulted on April 14, 2020. https://www.surgonc.org/resources/covid-19-resources/