UK and Ireland Neuroendocrine Tumour Society- UKINETS
COVID-19 pandemic strategy for the interim management of patients with Neuroendocrine Tumours/Neuroendocrine Cancer
Prepared by the Executive Committee of UKINETS
PRINCIPLES OF CARE
• Minimise outpatient attendance at time of high COVID-19 virus prevalence to reduce risks to patients and hospital staff. Telephone/video clinics should be used as the preferred option for the vast majority of patients.
• Patients should follow the government guidance on social distancing and self- solation.
• Minimise imaging requests at time of high COVID-19 virus prevalence to reduce risks to patients and hospital staff, and emergency pressure on the radiology service.
• Surveillance imaging and biochemistry in otherwise stable patients to be deferred at time of high COVID-19 virus prevalence.
• Good communication is essential to explain the potential trade-offs that will result from instituting this guidance with respect survival, quality of life and functional outcomes, and risk of acquiring COVID-19 and the resulting sequelae.
GUIDANCE AND RECOMMENATIONS
1.Somatostatin analogue therapy
i) Patients on existing treatment
Somatostatin Analogues (Sandostatin LAR, Lanreotide and octreotide s.c.) confer no known added risk with respect to susceptibility to infection, including COVID-19. The practicalities of delivering the medication may need to be changed on a patient-by-patient basis in that some patients may need to be taught self-injection, some may be able to be managed by having injections at GP or via the home care delivery teams. The ideal is to minimise the number of patients attending the hospital for injections. For some patients with known stable non- functioning tumours the dose interval may be extended or doses omitted if this means that an at-risk patient would need to travel to have the injection. This is a highly individualised discussion and decision to be had on a patient by patient basis.
ii) Patients due to start treatment
a) Patients with highly functional tumours – e.g. causing carcinoid syndrome will need initiation of therapy to control their condition. In some circumstances prolonged use of octreotide s.c. may be preferable to depot injections if the logistics of administering the depot injection are insurmountable. Patients may need access for s.c. octreotide as rescue therapy.
b) Patients with non-functioning tumours – initiation of treatment will depend on an assessment by the treating team of overall patient fitness and tumour characteristics – e.g. low histological grade and apparent stability on imaging (if available) may for some be indications for deferral of initiation of treatment. This decision will need to be made on a case-by-case basis.
2) Peptide Receptor Radiotherapy – PRRT
There are limited data on the risks associated with either having PRRT and having recently had PRRT treatments, like Lutathera, in the context of COVID-19 susceptibility. Nevertheless, bone marrow suppression is a recognised potential complication that could put patients at risk of infections. In addition, there may be complexities of monitoring e.g. FBC after therapy particularly in patients who are self-isolating. There will be many circumstances taking into account risk:benefit for each patient where PRRT will either not be started or treatments for those patients already on a course of treatment may be deferred. This highly individualised decision and discussion should be made at a formal NET MDT and discussed with the patient.
As appraised by NICE there are significant risks associated with chemotherapy during the COVID-19 pandemic. The risks vs. benefits will need individualised patient discussion by the NET MDT, and the discussion then be had and communicated with the patient concerned.
During the COVID-19 pandemic it is likely that only life-saving surgery will be appropriate for patients with NETs. There might be consideration for potentially curative surgery in higher grade NETs.
5) Clinical Trials
Access to clinical trials specific for NET patients during the COVID-19 pandemic will be extremely limited. Those on existing trials will be contacted by the local trial team
Version 1: 30 March 2020