key: cord-0983987-1i6n6tv6
authors: Rossi, David
title: Metronomic oral vinorelbine and lung cancer therapy during the COVID 19 pandemic: a single-center experience
date: 2020-05-06
journal: Lung Cancer
DOI: 10.1016/j.lungcan.2020.05.001
sha: b6839bb674397276664982c003a57fa5a7983502
doc_id: 983987
cord_uid: 1i6n6tv6

• Intravenous vinorelbine is a standard treatment for advanced NSCLC; • Oral vinorelbine is equally effective as compared to intravenous vinorelbine; • Metronomic oral formulation of vinorelbine is a safe and active treatment for advanced NSCLC; • No established treatment is a “gold standard” during COVID19 era; • Metronomic oral vinorelbine permitted to carry on active treatment during COVID Emergency; • Metronomic oral vinorelbine reduce side effects and hospital visits to lung cancer patients; • Management of lung cancer patients may be improved by metronomic oral vinorelbine.

During Covid19 pandemic, oncologists worldwide must choose the best strategy for these "frail" patients in order to reduce side effects and maximize the outcomes.

ESMO-Guidelines during Covid19 era (1) shows HIGH PRIORITY for "1st-line treatment including chemotherapy, chemotherapy plus Immunotherapy, Immunotherapy alone or TKIs to improve prognosis, cancer-related symptoms and QoL". In patients without oncogene-drivers (PDL-1 ≥ 50%, EGFR-mutations, B-RAF mutations, ALK and ROS-1 rearrangements), immunotherapy alone or TKIs are not suitable therapies and chemotherapy -alone or plus immunotherapy -is the treatment of choice.

Conventional chemotherapy with intravenous formulation may induce severe neutropenia causing fever and infectious episodes: pneumonitis can occur in up to 16% of treated patents (2). Moreover, it is well known that chemotherapy has immunosuppressive activity (3). On the other hand, Immune check-point inhibitors are related with risk of interstitial pneumonitis that can occur in about 2% of cancer patients with higher incidence in lung cancer (4).

Therefore, it seems well known that the treatment of patients with not-oncogene addicted lung cancer is a real challenge during COVID-19 era. The choice of best therapy becomes harder in elderly and unfit patients. The first strategy for these patients is simply delaying treatment in order to overcome emergency period, hoping to reduce the impact of side effects. However, this option is not suitable for symptomatic patients that require an immediate treatment to improve quality of life.

It's reasonable that these patients undergo systematic testing for SARS-CoV-2 at the beginning of treatment In 2019, a Meta-analysis of metronomic oral vinorelbine has been published (6): 9 studies, in first and second line, was selected to be included. Results were as follows: median progression-free-survival 4,2 months, median overall survival 8,7 months, grade 3-4 toxicity 15.8% (main toxicity: anaemia). The authors concluded that "metronomic oral vinorelbine is an active and well-tolerated single-drug chemotherapy regimen in metastatic NSCLC and is a manageable therapy in frail patients". In 2017, we started to use this oral metronomic formulation with vinorelbine at the dose of 40 mg three times a week (Monday, Wednesday, Friday), continously. Here, we report our experience in 10 out of 36 treated patients during COVID19 pandemic. Before Coronavirus emergency, our protocol required that patients perform blood test and hospital visit every 4 weeks; after March 8 th 2020 (Prime Minister Decree-law, in Italy), we still had 10 patients in treatment with metronomic vinorelbine. So, we decided to avoid hospital visits to these patients following them by phone interviews according their needs. The patients performed blood tests at home by Oncological home-care institutions and the oncologist received laboratory reports by fax in order to confirm therapy without risk of haematological renal or liver toxicity. The drugs were delivered at home by volunteers or by patients' relatives. We did not record any grade 3 or 4 side effects in these 10 patients that carried on treatment regularly in this emergency period without need to postpone chemotherapy and avoiding frequent hospital visits. In conclusion, we think that this vinorelbine formulation may be a valuable option allowing to treat frail lung cancer patients during Covid19 era. No other author collaboration was requested for the idea or the manuscript preparation.

THE COVID-19 ERA: LUNG CANCER. ESMO OPEN 2020

Adverse event profile for immunotherapy agents compared with chemotherapy in solid organ tumors: a systematic review and meta-analysis of randomized clinical trials

Pulmonary toxicity of cytotoxic and immunosoppressive agents. A review

PD-1 inhibitor-related pneumonitis in advanced cancer patients: Radiographic patterns and clinical course

Challenges in lung cancet therapy during the Covid-19 pandemic

An individual patient-data metanalysis of metronomic oral vinorelbine in metastatic non-small cell lung cancer