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.
- 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.
- 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).
- Risks of treatment are likely to outweigh benefits in many patients with metastatic disease as median improvement in survival is usually
- Second-line chemotherapy should not be routinely offered (level 5).
- 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.
- 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).
- 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.