Will COVID-19 affect my treatment plan?

Many of you received communications from your healthcare team to inform that your surgery, treatment plan or follow-up tests is reviewed in light of the COVID-19 pandemic. This raises legitimate cause for concern for many of you but rest assured, cancer patients are not being overlooked in favour of people who have contracted COVID-19. Quite the contrary, measures and guidelines have been put in place to ensure your safety, weighing in the benefits and risks in each patient’s situation to deliver safe, effective and feasible care in the setting of a pandemic.

The Canadian Urological Association published a guidance document with the participation of eighteen academic genitourinary (GU) medical oncologists from 11 cancer centres across Canada to provide recommendations for managing patients during the COVID-19 pandemic.

Note: the authors emphasize the need for frequent re-evaluation of recommendations as the COVID-19 trajectory evolves with the need to adapt in real time.

The summary below focuses on the recommendations outlined for kidney cancer treatment.

See full document on this link

SURGERY
ADVANCED (METASTATIC) KIDNEY CANCER – FIRST LINE TREATMENT (favourable risk)
ADVANCED (METASTATIC) KIDNEY CANCER – FIRST LINE TREATMENT (intermediate and poor risk)
ADVANCED (METASTATIC) KIDNEY CANCER – SECOND LINE THERAPY AND BEYOND
VIRTUAL CARE

Surgery

Your kidney cancer surgery may be delayed. The degree of delay depends on the size and stage of the kidney cancer. In general, stage I kidney cancers (T1, less than 7 cm) can be safely delayed 3-6 months. However, higher stage cancers (T2-T4, over 7 cm, or grown into the blood vessels of the kidney) should be removed within 1-3 months. These surgeries should not be delayed significantly and many centers are allowing these advanced kidney cancers to go ahead with surgery during COVID-19, with the appropriate pre-operative COVID-19 testing and personal protective equipment precautions.

If removing the kidney is considered in the event of a significant response to systemic therapy given prior to surgery, then surgery could be considered after multi-disciplinary discussion and once hospital resources resume normal practice.

Advanced (metastatic) kidney cancer

FIRST LINE TREATMENT FOR FAVOURABLE RISK ADVANCED RENAL CELL CARCINOMA
Your doctor might discuss the following treatment scenarios:

If systemic therapy is not immediately required and can be delayed safely, active surveillance is recommended.

If systemic therapy is required, oral VEGF targeted therapy, at minimum, is recommended (i.e. sunitinib, axitinib, pazopanib). A thorough discussion about the available treatment options and associated benefits and risks should be conducted with your doctor.

When considering adding immunotherapy to an oral VEGF targeted therapy (i.e. pembrolizumab + axitinib) the doctor-patient discussion should reflect on:

hospital resources available for intravenous treatment
hospital constraints to manage immune-related side effects
the added benefit of immunotherapy

For patients currently on first-line treatment, doctor-patient discussion should reflect on:

whether treatment can continue
where safe and available, longer intervals between dosing of immunotherapy should be practiced

What does VEGF means?
Dr. Naveen Basappa

What is a favourable risk patient?
Dr. Christian Kollmannsberger

Does being a favourable risk patient mean that I will die soon?
Dr. Christian Kollmannsberger

Advanced (metastatic) kidney cancer

FIRST LINE TREATMENT FOR INTERMEDIATE OR POOR RISK ADVANCED RENAL CELL CARCINOMA

The recommendation for eligible patients is the combined dual immunotherapy (i.e. ipilimumab + nivolumab) or immunotherapy with an oral VEGF targeted therapy (i.e. pembrolizumab + axitinib). However, with the COVID-19 climate the combination immunotherapy with oral VEGF targeted therapy may be preferred over the dual immunotherapy because of less side effects and the potential of prolonged use of steroids. Your doctor might discuss the following treatment scenarios with you.

Prior to taking a new therapy the patient-doctor discussion should reflect on:

whether treatment can be delayed during an escalating COVID-19 period
whether hospital resource constraints will allow for both intravenous treatment (immunotherapy) and adequate management of severe side effects

If the COVID-19 situation is particularly volatile, starting with a VEGF targeted therapy may be a reasonable option as first line treatment to minimize risk of severe side effects.

For patients currently on first-line treatment, patient-doctor discussion should reflect on:

whether treatment can continue
where safe and available, longer intervals between dosing of immunotherapy should be practiced

What is an intermediate risk patient?
Dr. Christian Kollmannsberger

Does being an intermediate risk patient mean that I will die soon?
Dr. Christian Kollmannsberger

What is a poor risk patient?
Dr. Christian Kollmannsberger

Does being a poor risk patient mean that I will die soon?
Dr. Christian Kollmannsberger

Advanced (metastatic) kidney cancer

SECOND LINE THERAPY AND BEYOND FOR ADVANCED RENAL CELL CARCINOMA
Your doctor might discuss the following treatment scenarios with you:

Prior to new treatment initiation, considerations should balance resource utilization as well as assessment and treatment intervals for potential next line options.

For patients currently on one immunotherapy (i.e. nivolumab only) patient-doctor discussion should reflect on:

whether treatment can continue
where safe and available, longer intervals between dosing of immunotherapy should be practiced

In an escalating COVID-19 pandemic where disease progression has been demonstrated on both VEGF targeted therapy and immunotherapies, then careful consideration should be given to risks and potential benefits before starting third line therapy or beyond.

Virtual care

Institutions should provide logistic support for telephone and video conferencing solutions to facilitate patient assessment, tumour board discussion and where suitable, treatment.

For your safety, your new patient consultation or follow up appointment may occur over the phone or in a video conference setting during the COVID-19 pandemic, until hospitals resume normal practice.

Your doctor may try to book blood work or imaging tests in different local centres to prevent COVID-19 exposure. In some cases, there may be some delays in follow-up imaging tests due to the pandemic.

Healthcare infrastructure should be nimble to ensure a coordinated approach when delivering virtual care for patients including:

outpatient pharmacy mechanisms to allow the ordering of anti-cancer or supportive therapy outside of usual office/clinic settings
delivery of oral treatment to patient’s homes

For necessary in-person patient appointments, you may notice screening policies and safe physical distancing at hospitals and clinics. This is done for your safety and with provincial public health guidance.

Often, any urgent surgical planning for advanced kidney cancer surgery would require an in-person meeting with the operating surgeon, with the appropriate COVID-19 precautions in place.

April 27, 2020