IMMUNOSCORE® and COVID-19 Colon Cancer Guidelines
Find in this page an in-depth analysis of latest COVID-19 recommendations in colorectal cancer published worldwide.
Read how precision medicine with tools such as Immunoscore® can be useful in improving patient triage without impacting their clinical outcomes.
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In response to the COVID-19 pandemic, the major international cancer societies and national health authorities have issued a flurry of guidelines for the management of cancer patients. In addition to stressing reinforced hygiene practices and particular ethical considerations, these guidelines recommend reducing exposure of cancer patients to the SARS-Cov-2 virus by reprioritising treatments on the basis of urgency and likelihood of recovery and thereby optimise hospital resources.
Organisation | Date first issued |
| American College of Surgeons3 | 13 March 2020 |
| NCCN6 | 18 March 2020 |
| NHS4 | 23 March 2020 |
| Official French guidelines5 | 25 March 2020 |
| ESMO2 | 9 April 2020 |
| ASCO1 | 28 April 2020 |
Although a number of specific guidelines for colorectal cancer (CRC) management in the current context have been published, for example, the ACS 7 and the NCCN 8 these do not cover patient triage using biomarkers in detail. However, the following guidelines include precision medicine in CRC with tumour immune response testing in order to best identify patients likely to respond to treatment and to optimise treatment schedules, and thus minimise hospital visits:
ESMO9
Chemotherapy in early stage (II, III) colon cancer 9
- Test for MSI – especially for stage II patients for treatment decisions
- Based on the IDEA trial recommendation, assess whether 3 months of adjuvant treatment will be non-inferior to 6 months of treatment (patient risk and clinical conditions-adapted strategy)
Expert oncology group (Emil Lou, et al.)10
These recommendations were issued by experts from 10 centres across the USA, offering practice tips in gastro-intestinal oncology to minimise patient risk:10
- Consider delaying or not proceeding with risk-reducing adjuvant chemotherapy for patients with resected high-risk stage II colon carcinomas
- Consider the same for patients at high risk of COVID-19 infection with resected stage III colon carcinomas versus shortening the duration (3 versus 6 months) and/or instituting oral chemotherapy as alternate tactics for adjuvant treatment approaches
Ruesch Center, Georgetown University (John Marshall, et al.)11
This reference centre for gastro-intestinal cancer, in collaboration with the Colorectal Cancer Alliance has issued comprehensive CRC management guidelines for the COVID-19 era, recommending precision medicine with immune response biomarkers as pragmatic solutions for optimising treatment:11
- Consider ctDNA for adjuvant decision making. Similarly, Immunoscore® quantifies immune cell infiltration in resected colorectal cancer and if a patient had a high-risk stage II colorectal cancer but with high Immunoscore®, adjuvant chemotherapy has a lower likelihood of benefit and should be avoided
Although it has not yet been validated in a robust clinical trial, circulating tumour DNA (ctDNA) has been shown to be effective in identifying those early stage CRC patients who are likely to relapse.12A positive tumour DNA test should thus compel the initiation of chemotherapy, even during the pandemic.11Conversely, Immunoscore® is effective in identifying early-stage colon patients for whom 3 months of adjuvant treatment will be as effective (non-inferior) as 6 months of treatment, and has been validated in major clinical study.13
Fleming Institute of Oncology, Argentina(Juan Manuel O’Connor, et AL.21
This is an independent paper published by one of the most renown LATAM cancer centers, located in Argentina.
They are experienced with Immunoscore®. They requested the test for covid period and regarding the ability of the test in chemotherapy descalation and triage, they consider that Immunoscore® helps achieve the official guidelines’ objectives for covid. The paper is written in the same journal where a previous American paper was published about precision medicine tools including IS® and covid times requirements.
Patient risk assessment and prognosis can be sharpened by using biomarkers: Colorectal Cancer: Proposed Treatment Guidelines for the COVID-19 Era 14
• Testing microsatellite status9
• Using ctDNA analysis in early-stage CRC to guide treatment escalation12
• Assessing the Immunoscore® in stage III colon cancer to guide treatment de-escalation13
Prognosis for patients with resectable colon cancer has traditionally depended on histological sample examination, but the advent of individualised precision medicine and particularly, digitised analysis of biomarkers offers a new paradigm in the management of CRC.15Indeed, the World Health Organization (WHO) in the latest edition of Digestive System Tumours (5th edition) has introduced immune response as an essential and desirable diagnostic criteria for colorectal cancer in addition to traditional histological parameters.16 This inclusion as a gold standard by this international authority is a recognition of the value of precision medicine in the management of colorectal cancers.
Immunoscore®
Immunoscore® is an in vitro diagnostic assay to assess the risk of relapse in colon cancer patients, and, used in conjunction with TNM staging, it helps to guide treatment strategies.17 Immunoscore® assesses immune response at the site of the tumour using a digital pathology-based methodology involving measurement of CD3+ and CD8+ T-lymphocytes in defined regions of the tumour. An “immunoscore” is then generated, which is strongly correlated with the patient’s risk of recurrence.17
Immunoscore® – Improving risk assessment for better patient management.17
Validated for prognosis in stage II and III colon cancer
The ability of Immunoscore® to identify which patients are most likely to experience a recurrence has been shown to be reproducible, reliable and robust.18 In the large SITC-led study involving more than 3,000 stage I-III colon cancer patients, Immunoscore® was strongly predictive of patient outcomes, and to a greater degree than established indicators such as TNM classification or microsatellite instability (MSI).18 These findings have been confirmed in two prospective-retrospective studies of over 1,500 stage III colon cancer patients.13,19
Immunoscore® – Independent and stronger ability to predict survival than MSI.18, 19
Validated for treatment adjustment
In addition to more accurate prognostication, Immunoscore® has been demonstrated to be a predictive factor for facilitating treatment adjustment. In high-risk stage II colon cancer patients, Immunoscore® identified patients for whom adjuvant treatment could be avoided.20 This was shown in a sub-group analysis of the SITC study data of stage II patients (n = 1,130).20
Immunoscore® has also been demonstrated to be a predictive factor for identifying stage III patients who benefit from longer FOLFOX treatment. In an analysis of the prospective IDEA French cohort data (n = 1,322), comparing 3 versus 6 months of oxaliplatin-based adjuvant chemotherapy in stage III colon cancer patients, Immunoscore® identified those patients who benefitted from a longer duration of treatment.13
Facilitating a 70% reduction in adjuvant chemotherapy in high-risk stage II patients, and around a 50% reduction from 6 to 3 months of FOLFOX therapy in patients with stage III colon cancer.13,20
Immunoscore® – Identifying patients eligible for chemotherapy de-escalation.13
Precision medicine with Immunoscore® allows documentation of:
• Risk assessment profiling of stage II patients18
• Optimisation of treatment duration in stage III patients13
Individualised precision medicine in early-stage colon cancer facilitates putting the patient at the centre of their treatment,15 with a digital process enabling rapid and contactless triage to optimise treatment schedules and avoid overtreatment, minimising risk and maximising outcomes.13,17,18
Implementation of more precise diagnostic tools will ensure better patient outcomes, heralding the widespread use of these tools and the beginning of a new era in precision medicine post-COVID-19.
ACS: American College of Surgeons; ASCO: American Society of Clinical Oncology; COVID-19: coronavirus 19; ctDNA: circulating tumour DNA; IDEA: International Duration Evaluation of Adjuvant Chemotherapy; ESMO: European Society of Clinical Oncology; MSI: microsatellite instability; NCCN: National Comprehensive Cancer Network; NHS: National Health Service; SARS-Cov-19: severe acute respiratory syndrome-related coronavirus 19; SITC: Society for the Immunotherapy of Cancer.