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Sarcoma European & Latin American Network (Selnet Sarcomas SARCOMA EUROPEAN & LATIN AMERICAN NETWORK (SELNET) RECOMMENDATIONS ON PRIORITIZATION IN SARCOMA CARE DURING COVID-19 PANDEMIC a,b a,b c d JAVIER MARTIN-BROTO,MDPHD , NADIA HINDI, MD, SAMUEL AGUIAR JR MD, RONALD BADILLA-GONZÁLEZ, MD, e f g h,i,j VICTOR CASTRO-OLIDEN, MD, MATIAS CHACÓN, MD, RAQUEL CORREA-GENEROSO, MD, ENRIQUE DE ALAVA,MDPHD, k l m n DAVIDE MARÍA DONATI, MD, MIKAEL ERIKSSON, MD, MARTIN FALLA-JIMENEZ, MD, GISELA GERMAN, MD, o p q e MARIA LETICIA GOBO SILVA, MD, FRANCOIS GOUIN, MD, ALESSANDRO GRONCHI, MD, JUAN CARLOS HARO-VARAS, MD, r s t u NATALIA JIMÉNEZ-BRENES, MD, BERND KASPER, MD, CELSO ABDON LOPES DE MELLO, MD, ROBERT MAKI,MDPHD, a v w x PAULA MARTÍNEZ-DELGADO,PHD, HECTOR MARTÍNEZ-SAID, MD, JORGE LUIS MARTINEZ-TLAHUEL, MD, JOSE MANUEL MORALES-PÉREZ, MD, y z aa FRANCISCO CRISTOBAL MUÑOZ-CASARES, MD, SUELY A. NAKAGAWA, MD, EDUARDO JOSE ORTIZ-CRUZ,MDPHD, bb cc a dd EMANUELA PALMERINI,MDPHD, SHREYASKUMAR PATEL, MD, DAVID S. MOURA,PHD, SILVIA STACCHIOTTI, MD, ee ff f gg MARIE PIERRE SUNYACH, MD, CLAUDIA M. VALVERDE, MD, FEDERICO WAISBERG, MD, JEAN-YVES BLAY,MDPHD aGroup of Advanced Therapies and Biomarkers in Sarcoma, Institute of Biomedicine of Seville (IBIS, HUVR, CSIC, Universidad de Sevilla), Sevilla, Spain; bDepartment of medical oncology, University Hospital Virgen del Rocio, Seville, Spain; cDepartment of Pelvic Surgery, A.C. Camargo Cancer Center, S~ao Paulo, Brazil; dDepartment of medical oncology, Rafael Angel Calderón Guardia Hospital, San José, Costa Rica; eDepartment of medical oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru; fDepartment of medical oncology, Alexander Fleming Cancer Institute, Buenos Aires, Argentina; gRadiotherapy department, Virgen de la Victoria University Hospital, Málaga, Spain; hPathology department, University Hospital Virgen del Rocío, Seville, Spain; iCIBERONC, Madrid, Spain; jDepartment of Normal and Pathological Cytology and Histology, School of Medicine, University of Seville, Seville, Spain; kUnit of Orthopedic Pathology and Osteoarticular Tissue Regeneration, Rizzoli Orthopedic Institute, Bologna, Italy; lDepartment of medical oncology, Skane University Hospital-Lund, Lund, Sweden; mDepartment of breast and soft tissues surgery, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru; nDepartment of medical oncology, Hospital Oncológico Provincial, Córdoba, Argentina; oDepartment of radiation therapy, A.C. Camargo Cancer Center, S~ao Paulo, Brazil; pDepartment of orthopedic surgery, Centre León Bérard, Lyon, France; qDepartment of surgery, Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, Milan, Italy; rDepartment of medical oncology,San Vicente de Paúl Hospital, Heredia, Costa Rica; sDepartment of medical oncology, Mannheim University Medical Center, Mannheim, Germany; tDepartment of medical oncology, A.C. Camargo Cancer Center, S~ao Paulo, Brazil; uDepartment of medical oncology, Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA; vDepartment of medical oncology, Instituto Nacional de Cancerología, CDMX, Mexico; wDepartment of surgery, Instituto Nacional de Cancerología, CDMX, Mexico; xRadiology Department, University Hospital Virgen del Rocio, Seville, Spain; yDepartment of surgery, University Hospital Virgen del Rocio, Seville, Spain; zOrthopedic department, A.C. Camargo Cancer Center, S~ao Paulo, Brazil; aaOrthopedic surgery and traumatology department, La Paz University Hospital, Madrid, Spain; bbDepartment of medical oncology, Rizzoli Orthopedic Institute, Bologna, Italy; ccDepartment of Melanoma Medical Oncology University of Texas M. D. Anderson Cancer Center, Houston, TX, USA; ddDepartment of medical oncology, Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, Milan, Italy; eeDepartment of radiation therapy, Centre León Bérard, Lyon, France; ffDepartment of medical oncology,Vall d’Hebron Hospital, Barcelona, Spain; and ggDepartment of medical oncology, Centre León Bérard, Lyon, France †FUNDING: No dedicated funding has been used for this work. Key Words. COVID-19 • Sarcoma • Guidelines • Patient care • Multidisciplinary ABSTRACT Background. COVID-19 outbreak has resulted in collision hospital capacity, especially in intensive care units, causing between SARS-CoV-2-infected patients and cancer patients a domino effect, displacing areas from their primary use. on different fronts. Serious SARS-CoV-2 cases overwhelmed Cancer patient has been impacted by deferral, modification CORRESPONDING AUTHOR Dr. Javier Martin-Broto Department of Medical Oncology, University Hospital Virgen del Rocío Instituto de Bio- medicina de Sevilla, LAB 214 C/Antonio Maura Montaner s/n 41013 – Sevilla Spain Telephone: +34 955923113 jmartin@mustbesevilla. org Received June 3, 2020; accepted for publication August 14, 2020. http://dx.doi.org/10.1634/theoncologist.2020-0516 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adapta- tions are made. The Oncologist 2020;9999:•• www.TheOncologist.com © 2020 The Authors. The Oncologist published by Wiley Periodicals LLC on behalf of AlphaMed Press. 2 SELNET recommendations in sarcoma during COVID-19 or even cessation of therapy. Adaptive measures to mini- Results. There were 80 SR, 35 R and 10 NC among the mize hospital exposure, following the precautionary princi- 125 recommendations issued and completed by 31 multi- ple have been proposed for cancer care during COVID-19 disciplinary sarcoma experts. The consensus was higher era. We present here a consensus on prioritizing recom- among the 75 higher-priority recommendations (85%, 12% mendations across the continuum of sarcoma patient care. and 3% for SR, R and NC, respectively) than in the 50 lower- Material and methods. A total of 125 recommendations priority recommendations (32%, 52% and 16% for SR, R and were proposed in soft-tissue, bone and visceral sarcoma NC, respectively). care. Recommendations were assigned as higher- or lower- Conclusion. The consensus on 115 of 125 recommendations priority if they cannot or can be postponed at least 2-3 indicates a high-level of convergence among experts. The months, respectively. The consensus level for each recom- SELNET consensus provides a tool for sarcoma multi- mendation was classified as “strongly recommended” (SR) if disciplinary treatment committees during the COVID-19 more than 90% of experts agreed, “recommended” (R) if outbreak. The details of different recommendations and 75-90% of experts agreed and “no consensus” (NC) if fewer the distinction between two priority levels enables a practi- than 75% agreed. Sarcoma experts from 11 countries within cal approach for both Latin-American and other health-care the SELNET consortium participated, including countries in providers, and sarcoma expert centres. The Oncologist the Americas and Europe. The ESMO-Magnitude of clinical 2020;9999:•• benefit scale was applied to systemic-treatment recommen- dations to support prioritization. Implications for Practice: SELNET consensus on sarcoma prioritization care during the COVID-19 era, issued 125 pragmatical recommendations distributed as higher or lower priority, to protect critical decisions on sarcoma care during COVID-19 pan- demic. A multidisciplinary team from 11 countries, including countries in the Americas and Europe, reached consensus on 115 recommendations. The consensus was lower among lower-priority recommendations, which shows reticence to post- pone actions even in indolent tumors. The ESMO-magnitude of clinical benefit scale was applied as support for prioritizing systemic treatment. Consensus on 115 of 125 recommendations indicates a high-level of convergence among experts. The SELNET consensus provides a practice tool for the guidance in the decisions of sarcoma multidisciplinary treatment commit- tees during the COVID-19 outbreak. INTRODUCTION immune cells, immune modulators, cytokines, and mole- cules expression towards the escape phase and the devel- Deferral, modification or even cessation of therapy consti- opment of an immunosuppressive tumor tute hindrances that cancer patients have been impacted microenvironment.[3] Both specific diagnoses and their with during the current COVID-19 outbreak. The balance treatment with chemotherapy, surgical resection, and between adapting measures to minimize hospital exposure, newer treatments variably compromise immune function, following the precautionary principle, and offering a more and render some cancer patients more susceptible to infec- relaxed diagnostic or therapeutic management while pre- tions.[4] serving the patient’s survival options, is not easy at all. As with other infections, the innate and adaptive arms More than 80 reports, often short reports and letters, of the immune system play different key roles in the have addressed the intersection of cancer and COVID-19 COVID-19 infection and evolution. SARS-CoV-2 causes an care. Even when the risk of morbidity and mortality is overwhelming persistent innate-induced inflammation that almost ever higher in cancer patient that in COVID-19 can lead to a cytokine storm, cytokine-associated lung infected patients (i.e. risk of death for pancreatic cancer is injury, and diffuse organ involvement.[5] Alterations of the over 90% while for COVID-19 infected patient is usually CD4+ and CD8+ T cells subsets have
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