COVID-19 Neuro-oncology

Neuro-oncology during the Covid-19 pandemics: considerations for the treatment of patients with brain tumors

At present, the Covid-19 pandemic is the focus of the global community and an all-consuming threat to the health care systems all across Europe. Resources and medical staff are reallocated, and planned medical activities are delayed or cancelled.

At present, the Covid-19 pandemic is the focus of the global community and an all-consuming threat to the health care systems all across Europe. Resources and medical staff are reallocated, and planned medical activities are delayed or cancelled. Covid-19 poses a huge challenge, in terms of the medical needs of large number of infected patients, including extensive use of ICU; risk of disease among health professionals; and, not least, diminished health care for other patient groups.

The care of brain tumor patients must be a main concern of European neuro-oncologists throughout the time of the pandemic. Data are still very sparse regarding Covid-19 in cancer patients in general (1). We do not have data of how Covid -19 infections affect patients with brain tumors. Patients with brain tumors comprise a heterogeneous group with regard to age, symptom severity and prognosis. Thus, we should make clinical decisions on a case-by-case basis. One should consider the best possible timing of surgery or oncological therapy, the risk to the patient if treatment is delayed, medical co-morbidities, other prognostic factors and consequences of prolonged hospital stay, including exposure to infection. In addition to this, we must consider the degree of immunosuppression and concerns for family and caregivers. Finally, we must take into account the availability of postoperative ICU care, rehabilitation facilities and risk related to travelling.

We advise the following, which is in line with the statement from the EANO board, by Martin van den Bent and colleagues LINK(2):

  • Patients with brain tumors should exert high levels of care in regard to hygiene measures
  • Patients with brain tumors should seek medical advice at once if Covid-19 infection is suspected
  • Keep regular follow-up intervals, but employ teleconsultations when safe and feasible
  • Consider prolonging follow-up MRI appointments in asymptomatic, long-term survivors of less malignant brain tumors, for instance, meningiomas and schwannomas
  • Consider hypofractionated radiotherapy in certain patient groups where outcome is not likely to be affected considerably, in particular elderly glioblastoma patients
  • Consider postponing radiotherapy if it seems safe and feasible
  • Consider refraining from invasive procedures in some cases, for instance biopsy in elderly patients with typical radiological features of glioblastoma, or postpone surgery in some patients if safe
  • Due to the risk of immunosuppression, consider avoiding chemotherapy in subgroups of patients in whom the efficacy is uncertain, such as elderly patients with MGMT unmethylated glioblastoma, patients with low grade glioma without progression or standard risk adult medulloblastoma
  • Optimize antiepileptic therapy, according to the recommendations of the SP for epilepsy (LINK)
  • Taper steroids to the lowest effective dose, if possible
  • Consider end-of-life decisions in severely ill patients, in case of infection or need of emergency hospitalization
  • Consider methods to give additional support and information, for instance nurse-led support telephone services, online medical counselling and collaboration with national brain tumor patients organizations

Patients with brain tumors are aware of their vulnerability. Social isolation and physical distancing may add to anxiety and distress. These are challenging times for patients, patients’ caregivers and the professional neuro-oncological community. We do not know the duration or outcome of the pandemic, but we know for sure that it will affect our patients with brain tumors, directly and indirectly.
We call for sharing of experiences on presentation of infected patients with brain tumors, with the aim of gaining knowledge on best management of our patients in the midst of a pandemic.

References
1) Lian W, Guan W, Chen R et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/S1470-2045(20)30096-6.
2) Statement from the EANO board: www.eano.eu

The management group of the EAN Scientific Panel of Neuro-oncology;

Anette Storstein
Senior consultant, Vice Head, Department of Neurology
Haukeland University Hospital
Bergen, Norway

Prof. Riccardo Soffietti
Professor of Neurology and Neuro-Oncology
Head, Department of Neuro-Oncology,
University of Turin and
City of Health and Science University Hospital
Torino, Italy

Prim. Assoc. Prof. PD Dr. Stefan Oberndorfer, FEAN
Abteilungsvorstand
Klinische Abteilung für Neurologie
Universitätsklinikum St. Pölten – Lilienfeld
St. Pölten, Austria