key: cord-0964693-naqo753n authors: Martin‐Broto, Javier; Hindi, Nadia; Aguiar, Samuel; Badilla‐González, Ronald; Castro‐Oliden, Victor; Chacón, Matias; Correa‐Generoso, Raquel; de Álava, Enrique; Donati, Davide María; Eriksson, Mikael; Falla‐Jimenez, Martin; German, Gisela; Gobo Silva, Maria Leticia; Gouin, Francois; Gronchi, Alessandro; Haro‐Varas, Juan Carlos; Jiménez‐Brenes, Natalia; Kasper, Bernd; Lopes de Mello, Celso Abdon; Maki, Robert; Martínez‐Delgado, Paula; Martínez‐Said, Hector; Martinez‐Tlahuel, Jorge Luis; Morales‐Pérez, Jose Manuel; Muñoz‐Casares, Francisco Cristobal; Nakagawa, Suely A.; Ortiz‐Cruz, Eduardo Jose; Palmerini, Emanuela; Patel, Shreyaskumar; Moura, David S.; Stacchiotti, Silvia; Sunyach, Marie Pierre; Valverde, Claudia M.; Waisberg, Federico; Blay, Jean‐Yves title: Sarcoma European and Latin American Network (SELNET) Recommendations on Prioritization in Sarcoma Care During the COVID‐19 Pandemic date: 2020-09-23 journal: Oncologist DOI: 10.1634/theoncologist.2020-0516 sha: 4ef70ff794c208226d03ee8567ab2d9bec070089 doc_id: 964693 cord_uid: naqo753n BACKGROUND: The COVID‐19 outbreak has resulted in collision between patients infected with SARS‐CoV‐2 and those with cancer on different fronts. Patients with cancer have been impacted by deferral, modification, and even cessation of therapy. Adaptive measures to minimize hospital exposure, following the precautionary principle, have been proposed for cancer care during COVID‐19 era. We present here a consensus on prioritizing recommendations across the continuum of sarcoma patient care. MATERIAL AND METHODS: A total of 125 recommendations were proposed in soft‐tissue, bone, and visceral sarcoma care. Recommendations were assigned as higher or lower priority if they cannot or can be postponed at least 2–3 months, respectively. The consensus level for each recommendation was classified as “strongly recommended” (SR) if more than 90% of experts agreed, “recommended” (R) if 75%–90% of experts agreed and “no consensus” (NC) if fewer than 75% agreed. Sarcoma experts from 11 countries within the Sarcoma European‐Latin American Network (SELNET) consortium participated, including countries in the Americas and Europe. The European Society for Medical Oncology‐Magnitude of clinical benefit scale was applied to systemic‐treatment recommendations to support prioritization. RESULTS: There were 80 SRs, 35 Rs, and 10 NCs among the 125 recommendations issued and completed by 31 multidisciplinary sarcoma experts. The consensus was higher among the 75 higher‐priority recommendations (85%, 12%, and 3% for SR, R, and NC, respectively) than in the 50 lower‐priority recommendations (32%, 52%, and 16% for SR, R, and NC, respectively). CONCLUSION: The consensus on 115 of 125 recommendations indicates a high‐level of convergence among experts. The SELNET consensus provides a tool for sarcoma multidisciplinary treatment committees during the COVID‐19 outbreak. IMPLICATIONS FOR PRACTICE: The Sarcoma European‐Latin American Network (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 the COVID‐19 pandemic. A multidisciplinary team from 11 countries reached consensus on 115 recommendations. The consensus was lower among lower‐priority recommendations, which shows reticence to postpone actions even in indolent tumors. The European Society for Medical Oncology‐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 guidance in the decisions of sarcoma multidisciplinary treatment committees during the COVID‐19 outbreak. Deferral, modification, and even cessation of therapy are hindrances affecting patients with cancer during the current COVID-19 outbreak. The balance between adapting measures to minimize hospital exposure, following the precautionary principle, and offering a more relaxed diagnostic or therapeutic management while preserving the patient's survival options is not easy. More than 80 reports, often short reports and letters, have addressed the intersection of cancer and COVID-19 care. Although the risk of morbidity and mortality is almost always higher in patients with cancer than in patients infected with COVID-19 (i.e., risk of death for pancreatic cancer is greater than 90%, whereas for COVID-19infected patients, it is usually lower than 5%) [1] , the truth is that the precautionary principle has prevailed over cancer care continuation in many cases [2] . Elective surgeries were largely suspended, in some instances, because of shortage of ventilators, and thus the operating theaters became extemporaneous intensive care units. Some reports have focused on the real impact (direct and indirect) of the COVID-19 outbreak in patients with cancer. In some locales where the admissions for SARS-CoV-2 far exceeded the hospital capacity, it was to be expected that cancer care would be compromised in a variety of ways. Patients with cancer constitute a large population with a spectrum of risk with respect to immunosuppression. Cancer immunoediting, which represents the interplay between tumor and immune system, ultimately leads to changes in immune cells, immune modulators, cytokines, and molecules expression toward the escape phase and the development of an immunosuppressive tumor microenvironment [3] . Both specific diagnoses and their treatment with chemotherapy, surgical resection, and newer treatments variably compromise immune function and render some patients with cancer more susceptible to infections [4] . As with other infections, the innate and adaptive arms of the immune system play different key roles in the COVID-19 infection and evolution. SARS-CoV-2 causes an overwhelming persistent innate-induced inflammation that can lead to a cytokine storm, cytokine-associated lung injury, and diffuse organ involvement [5] . Alterations of the CD4 + and CD8 + T cells subsets have been observed, with loss of functional diversity in CD4 + T cells and increased expression of regulatory molecules in CD8 + T cells [6, 7] . Hence, it can be assumed that the systemic immunosuppressive state of patients with cancer might result in an increased risk of COVID-19 infection and poorer prognosis for this group of patients. Epidemiological statistics of the cases in China suggested that patients with cancer were at greater risk than the general population, data which appear to be borne out more for hematologic malignancies than solid tumors, although there still appears to be greater risk even for patients with solid tumor for fatal outcomes from SARS-CoV-2 [8] . Noteworthy, it has been reported that COVID-19related deaths were strongly associated with male sex, older age, and deprivation; severe asthma; uncontrolled diabetes; cancer; and several other previous, clinical conditions [9] . Importantly, a recent epidemiological report from the U.K. based on 800 patients with cancer with COVID-19 infection observed a mortality rate of 28%, with older age, male gender, and comorbidities, such as cardiovascular disease, significant prognostic factors related to higher mortality. Remarkably, chemotherapy or other systemic therapy administered within 4 weeks of testing positive for COVID-19 did not have significant effect on mortality from COVID-19 disease [10] . Taken together, rapidly evolving data indicate that oncologic patients, such as patients with sarcoma, constitute a high-risk group more likely to suffer higher mortality and morbidities than in the general population if infected by SARS-CoV-2. Additionally, during the COVID-19 outbreak, the major risk for patients with cancer is the inability to receive necessary medical services. Decisions on whether or not to postpone cancer treatment and clinical trials need to be made on a patient-by-patient basis and according to the inherent tumor risk in each patient and the prevailing situation, because delays could lead to tumor progression and, ultimately, poorer outcomes [11] . An article on patients' perspectives reported that up to 30% of oncologic patients have had changes in their treatment or follow-up care during the COVID-19 pandemic [12] . Beyond the increased risks, including requiring mechanical ventilation and death, that should be prospectively analyzed in oncologic patients with COVID-19 infection, it is also relevant to take into account the impact of the precautionary principle that is implemented in our patients [13] . The latter implies that patients with cancer have suffered delays or cancellation of diagnostic tests, surgeries, radiation therapies, or systemic treatments. The aim of this article is to build a consensus on prioritization aspects in sarcoma care during the current COVID-19 outbreak or future outbreaks, which could appropriately balance the precautionary principle while preserving the highest survival probabilities in sarcoma patients. This consensus has been developed within the Sarcoma European-Latin American Network (SELNET). This is a consortium granted by the European Commission within the Horizon 2020 Call, within the program H2020-SC1-BHC-2018-2020 (better health and care, economic growth, and sustainable health systems). The aim of the SELNET consortium is to improve clinical outcome in sarcoma care, through a network of reference centers in sarcoma [14] . These guidelines are intended to add value over and above other clinical practice guidelines reported for oncologic patients in the context of COVID-19 outbreak. Thus, our guidance focuses specifically on patients with sarcoma and thoroughly provides precise details on prioritization of 125 clinical sarcoma situations, whereas the National Institute for Health and Care Excellence (NICE) offers a general recommendation for any oncologic patient [15] , and the European Society for Medical Oncology (ESMO) offers a more general recommendation of prioritization for patients with sarcoma [16]. The recommendations have been divided into two scenarios, higher and lower priority, to make them simple and replicable. Higher priority is defined as an undelayable procedure, because the inherent risk of the tumor, affecting survival or morbidity, would likely exceed the risk of COVID-19 infection if this procedure had not been performed. By contrast, lower priority is defined as a delayable procedure (at least 2-3 months), because the inherent risk of the tumor, affecting survival or morbidity, would be low enough that the patient could minimize or avoid hospital frequentation and, consequently, reduce the risk of infection by COVID-19. A total of 125 recommendations have been proposed in soft tissue, bone, and visceral sarcomas to thoroughly cover details for diagnosis, surgery, radiation therapy, systemic treatments, follow-up, and clinical research. These recommendations were proposed by the SELNET coordinator team and shared with the official partners of SELNET network. Associated partners were not involved in this consensus. Each point derived from multidisciplinary (MDT) expertise discussion from the SELNET coordination aimed to be pragmatic, detailed, and patient-oriented for each recommendation. Official partners had the competence to give their own opinion if this was clear enough for them or to give the opinion of their MDT on certain recommendations. In Among 31 participating experts in the consensus, there were 18 oncologists (15 for adults and 3 for pediatrics), 4 orthopedic surgeons, 4 surgical oncologists, 2 radiation oncologists, 1 pathologist, and 1 radiologist. As SELNET mainly focuses on adult-type sarcomas, no exclusive pediatric oncologist participated in the consensus. Fourteen Latin American sarcoma experts participated in the consensus: nine oncologists, four surgeons, and one radiation therapist. Correlations between Latin American and European Union (E.U.)-U.S. expert recommendations were evaluated using Pearson's χ 2 test for bivariate options (agreement or disagreement) and Mann-Whitney U test for multivariate options (strongly agree, agree, disagree, and strongly disagree). For each recommendation, every participant chose from the following options: strongly agree, agree, disagree, and strongly disagree. The neutral option was not offered to avoid ambiguity. Those recommendations with ≥90% of consensus (at least strongly agree plus agree obtained in ≥90% of participants) were considered as strongly recommended. Those with ≥75% but <90% were considered as recommended, and the remaining recommendations were considered as "no consensus was obtained." The cutoff of 75% has been the median threshold to define consensus in Delphi studies [17] , whereas the demanding 90% cut-off was arbitrarily chosen to indicate the highest consensus range if at least this percentage was reached. To mitigate the subjectiveness, the ESMO-Magnitude of Clinical Benefit Scale (MCBS) V1.1 was applied to recommendations involving systemic treatments to support this prioritization strategy (supplemental online Appendix 1) [18, 19] . Although MCBS has not been formally evaluated for sarcoma therapies, MCBS methodology was followed for the estimation of the benefit obtained with different sarcoma systemic treatments (supplemental online Appendix 2). From a total of 31 fulfilled questionnaires analyzed, the recommendations were distributed as strongly recommended (SR) in 80, recommended (R) in 35, and no consensus (NC) in 10. The consensus was higher among the 75 higherpriority recommendations (85%, 12%, and 3% for SR, R, and NC, respectively) than in the 50 lower-priority recommendations (32%, 52%, and 16% for SR, R, and NC, respectively). Table 1 describes the consensus level for each recommendation and indicates the MCBS in most contexts of systemic treatments. The statistical distribution for each recommendation is presented in supplemental online Appendix 1. Of note, statistically significant differences between Latin American and E.U.-U.S. expert recommendations were only detected by Pearson's χ 2 and Mann-Whitney U test in 3 of 125 recommendations ( Table 2 ). E.U.-U.S. experts proved to be more conservative for the advice of adjuvant chemotherapy in high grade chondrosarcoma, the advice of adjuvant radiotherapy in low-grade, deep soft-tissue sarcoma (STS) larger than 5 cm, and for the advice of adjuvant radiotherapy in superficial STS larger than 5 cm. Because sarcoma multidisciplinary committees are so critical to patient outcomes [20] [21] [22] [23] [24] [25] [26] [27] , we emphasize the message that these meetings should continue, at least in tele-committee format, in the COVID-19 era. Telecommittees should be scheduled on a regular basis (e.g., weekly), and the following specialists should participate: pathologists, radiologists, surgeons, radiation oncologists, and medical oncologists. In this article, a prioritization of diagnostic, care, and follow-up procedures across different sarcoma contexts has been reached by consensus among sarcoma experts from different disciplines and from 11 countries among Latin American, North America, and Europe. This consensus has been developed within the SELNET consortium as a guide to protect cancer care in the complex and heterogeneous field of sarcoma during the COVID-19 outbreak. This consensus is intended to offer precise advice on different clinical sarcoma scenarios that the oncology community could face, with the aim of prioritizing or postponing different clinical decisions in patients with sarcoma. The general oncology community should network with expert centers from sarcoma suspicion, and these guidelines can be used to determine which actions can and cannot be postponed in the management of patients with sarcoma in the COVID-19 era. Several oncology societies and health care providers issued recommendations, most often on their websites, regarding adaptive strategies for emergent standards of care in patients with cancer during the COVID-19 pandemic [28] . The Cancer Core Europe, which encompasses seven cancer centers and oncologic institutes in seven European countries, published a general consensus on the adaptive measures to minimize the number of hospital visits and to prevent anticancer treatment that could induce complications of COVID-19 infections. The methodology for these recommendations was not defined, however [29] . The NICE issued prioritization guidelines on the use of systemic and radiation treatments for cancer. This guide established six prioritization levels, from the first for curative treatments offering more than 50% chance of success and adjuvant or neoadjuvant treatment that adds at least 50% chance of cure compared with surgery or radiation therapy alone, to the last level, which is defined as a noncurative regimen with a 15%-50% chance of palliation or temporary tumor control and less than 1 year expected extension of life [30] . Similarly, a radiotherapy prioritization guide was issued with five levels. The general modifications are based on postponing or avoiding radiation therapy in cases of little added value or changing treatment plans to shorten the number of visits to a health care facility [15] . ESMO issued several guidelines, by tumor type, for prioritizing care into three or four categories. In the case of sarcoma, the low-priority profile is typified by a stable patient who can safely have delays in treatment for the duration of the COVID-19 pandemic. The intermediate profile is exemplified by a patient with a noncritical situation but one in which delay beyond 6 weeks could impair clinical outcomes [16] . The Society of Surgical Oncology has joined individual sarcoma expert opinions and has issued six recommendation points based on prioritizing actions considering several sarcoma contexts [31] . Certainly, this prioritization does not focus only on individual patient risk but also highlights the community risks and benefit: the reduction of people in transit and the isolation of patients in general decreases contagion risk in the community, leaving more resources to treat the impact of COVID-19 pandemic. However, there are consequences for other group of patients, such as patients with cancer. In The Netherlands, a remarkable drop in cancer diagnosis was noticed from pandemic initiation according to a nationwide cancer registry [32] . There are three principal approaches to conducting consensus methodology research: the consensus development panel, the nominal group process, and the Delphi technique [33] . The latter two require at least two sessions or rounds, being more complex. The consensus development panel is the most common approach used in health care research. This approach consists of organized meetings of experts in a given field and usually requires experts in different disciplines to make a multidisciplinary consensus. Usually, this approach is supported by the literature evidence, and there are some face-to-face discussions. In sarcoma oncology, ESMO The benefit from ifosfamide, vincristine, actinomycin D when compared with other regiments with more drugs (IVA + Carbo-etoposide-epirubicin and IVA (ifosfamide, vincristine, actinomycin D) + doxorubicin) in rhabdomyosarcoma [41, 42] shows level B of recommendation when applying the ESMO-MCBS V1Á1: Form 1 (IVA is the recommended option as resulted in less toxicity with the same survival outcome). approach [25, 27, 34] . The consensus we present here has two main differences in comparison with the consensus development panel. Despite the proposed prioritizing recommendations based on the published evidence, there are no comparative studies analyzing, for instance, the delay of some treatments in patients with sarcoma. In addition, no formal face-to-face meeting was organized because of inherent confinement constraints. In contrast, the fact that all expert participants provided their own opinion on each recommendation ensures more independence and the quality of the conclusions, avoiding interferences that could arise in a face-to-face discussion. In contrast, with the aim to minimize the subjectivity in the recommendation process, the ESMO-MCBS was fulfilled, at least for systemic therapies applied in sarcoma. We tried to adopt the grade 3 or higher and grades A or B scores, in the systemic treatment, as the cut-off for preserving the use of such treatments in the COVID-19 pandemic era. The ESMO-MCBS v1.1 is a validated scale measuring the magnitude of clinical benefit and adds value with just the statistical significance focus [18] . Although there is not yet an ESMO-MCBS for sarcoma, our exercise has followed the rules of the scale and is an additional support for this consensus. The fact that 80 of 125 recommendations were "strongly recommended" and only 10 were "no consensus" indicates a high grade of accord among sarcoma experts in this consensus on prioritization. The fact that lower consensus was obtained in the low priority group might indicate the reticence of sarcoma experts in postponing treatment, even in indolent or low-risk cases. This consensus has been mainly addressed keeping in mind Latin-American communities, and thus it has pursued simplicity and concision, taking into consideration that there are many health care providers in each country. Hence, assigning higher or lower priority to those undelayable or delayable treatments, respectively, facilitates the decision-making process in patients with sarcoma. Additionally, this SELNET consensus issues 125 recommendations, which indicates a high level of thoroughness, covering a substantial spectrum of sarcoma care. Follow-up recommendations in the context of sarcoma remains largely unstudied [35] and usually are based on conventions; thus, in high-risk patients, for example, the imaging tests are performed every 3-4 months for the first 3 years, then every 6 months for the 4th and 5th years, and so on, once per year. This strategy is based on the higher risk of recurrence observed in the first 3 years after treatment for localized disease and the fact that the asymptomatic recurrence, detected by computed tomography scan for instance, could potentially have higher curative options. There are some reports addressing the relevance of smaller size as independent prognostic relevance, at the time of metastatic disease, for longer survival [36] [37] [38] . Nevertheless, the truth is that convincing evidence that determined strategy is related with better survival is lacking, and a lead-time bias can occur in highly interventionist follow-up. the combination of gemcitabine and docetaxel in advanced STS [51] and in advanced leiomyosarcoma [52] shows level 1 of recommendation when applying the ESMO-MCBS V1Á1: Form 2C. The benefit from high-dose ifosfamide in advanced STS [53] shows level 4 of recommendation when applying the ESMO-MCBS V1Á1: Form 3. The benefit from doxorubicin in advanced STS [54] shows level 4 of recommendation when applying the ESMO-Magnitude of Clinical Benefit Scale (MCBS) V1Á1: Form 3. f The benefit from adjuvant chemotherapy in resected conventional osteosarcoma [55, 56] shows level A of recommendation when applying the ESMO-MCBS V1Á1: Form 1. g The benefit from the addition of Mifamurtide to adjuvant chemotherapy in resected conventional osteosarcoma [57] shows level A of recommendation when applying the ESMO-MCBS V1Á1-Form 1. h The benefit from cisplatin in advanced osteosarcoma [58] shows level 4 of recommendation when applying the ESMO-MCBS V1Á1: Form C. The benefit from cisplatin + doxorubicin + ifosfamide in advanced osteosarcoma [59] shows level 4 of recommendation when applying the ESMO-MCBS V1Á1: Form C. The benefit from ifosfamide-etoposide in advanced osteosarcoma [60] shows level 3 of recommendation when applying the ESMO-MCBS V1Á1: Form C. The benefit from high-dose ifosfamide in advanced osteosarcoma [61] shows level 4 of recommendation when applying the ESMO-MCBS V1Á1: Form C. The benefit from sorafenib plus everolimus [62] and regorafenib [63] in advanced osteosarcoma shows level 2 of recommendation when applying the ESMO-MCBS V1Á1-Form C. i The benefit from gemcitabine and docetaxel in Ewing sarcoma [64, 65] shows level 2 of recommendation when applying the ESMO-MCBS V1Á1: Form C. The benefit from Cyclophosphamide-topotecan cannot be properly assessed with the currently available evidence. The benefit from high-dose ifosfamide in Ewing sarcoma [66] shows level 3 of recommendation when applying the ESMO-MCBS V1Á1-Form C. j The benefit from 3 years of adjuvant imatinib in localized GIST [67] shows level A of recommendation when applying the ESMO-MCBS V1Á1-Form 1. k The benefit from imatinib in advanced GIST [68] shows level 4 of recommendation when applying the ESMO-MCBS V1Á1: Form 3. The benefit from sunitinib in advanced GIST [69, 70] shows level 4 of recommendation when applying the ESMO-MCBS V1Á1: Form 2B and Form 2A, respectively. The benefit from regorafenib in advanced GIST [71] shows level 3 of recommendation when applying the ESMO-MCBS Nadia Hindi Provision of study material or patients Jean-Yves Blay Collection and/or assembly of data Jean-Yves Blay Data analysis and interpretation Morphotek Immune Design Janssen, Pharma Mar Novartis (RFinstitution), PharmaMar, Eisai, Celgene, Bayer, Pfizer (Other). 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SELNET has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No. 825806. This SELNET consensus provides a tool for multidisciplinary sarcoma committees during the COVID-19 outbreak. The detail of different recommendations and the distinction between the two levels of prioritization enables a practical approach for Latin-American health care providers and sarcoma expert centers.