During the preparation of our oncology services to mitigate the feared peak of infections, we had discussions on adapting our treatment strategies for cancer patients. We created a short and simple online survey to explore the response of physicians treating patients with metastatic clear cell renal cell carcinoma (mccRCC) facing the COVID-19 pandemic.
Forty-one kidney cancer experts from Europe, North America, Asia Pacific, and Israel responded between April 4 and 15, 2020. Eighteen of these experts treat >50 new patients with mRCC per year.
Today, immune checkpoint inhibitors (ICI), combinations of a tyrosine-kinase inhibitor (TKI) with ICI or single-agent TKIs are standard of care for mccRCC first-line treatment.
In our survey3 the main choices for first-line mccRCC treatment in fit, favourable risk patients outside the pandemic are ICI-containing regimens (77%), most commonly pembrolizumab/axitinib (54%). During the pandemic, ICI-combinations are chosen less often (45%) in favour of TKI-monotherapies, e.g. sunitinib or pazopanib (13% outside versus 35% during; p<0.001). In fit, intermediate/poor-risk patients outside the pandemic >80% of experts choose ipilimumab/nivolumab and 41% during COVID-19 (p<0.001), again more TKI-monotherapies are recommended. In patients already responding to ICI/ICI-combinations or ICI/TKI-combinations, most experts modify treatment either by extending cycle length or holding ICIs.
Strategies among kidney cancer experts in response to SARS-CoV-2 differ substantially. It is crucial to find a balance between delivering high quality and efficacious treatment while limiting exposure to the coronavirus and possible overlapping toxicities due to systemic cancer treatment. Forgoing optimal treatment also has an ethical dimension: Should patients continue to receive mccRCC therapy with proven best long term outcome, or should physicians refrain from using active drugs with the presumed risk of aggravating COVID-19 and rendering patients in need of intensive care?
In summary, no solid recommendation can be given of withholding ICI drugs. We would rather propose a careful decision-making process for every individual patient, weighing all short-term and long-term pros and cons. Our aim is to highlight the challenges within the management of mccRCC patients, where life expectancy and quality of life have been improved with novel anticancer therapies such as immunotherapy.
Real-world data from international collaborative projects like European Society of Medical Oncology (ESMO)-CoCARE and the COVID-19 and Cancer Consortium (CCC19) cohort study may hopefully make it possible to rapidly accumulate knowledge, which will allow us to disseminate information and guidance for patients and physicians in the future.4
Furthermore, the ESMO is currently conducting a survey with the focus on finding out about key COVID-19 issues, particularly in view of how roles and cancer care may have changed during the first 6 months of the pandemic. They also measure the current well-being of physicians and the support available.5
The COVID-19 pandemic is unprecedented and poses manifold challenges to patients, relatives, healthcare workers, and the global community. It is encouraging to experience national and international efforts working towards a common goal.
Written by: Dr. Stefanie Aeppli and PD Dr. Christian Rothermundt, Medical Oncology and Haematology, Kantonsspital St. Gallen, Sankt Gallen, Switzerland
- "Cases of Coronavirus in Switzerland." Accessed here: https://rsalzer.github.io/COVID_19_CH/
- Nacoti M, Ciocca A, Giupponi A, Brambillasca P, Lussana F, Pisano M, et al. At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. NEJM Catalyst. 2020.
- Aeppli S, Eboulet EI, Eisen T, Escudier B, Fischer S, Larkin J, et al. Impact of COVID-19 pandemic on treatment patterns in metastatic clear cell renal cell carcinoma. ESMO open. 2020;5(Suppl 3).
- "ESMO-coCARE Registry." Accessed here: https://www.esmo.org/covid-19-and-cancer/collaborating-on-registries-studies-and-surveys/esmo-cocare-registry
- "ESMO Resiliance Task Force: COVID-19 — What is our current normal?" Accessed here: https://esmo.eu.qualtrics.com/jfe/form/SV_2gCNxE2YX36ZWKh