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.
The latest Expert Perspective, published by the Video Journal of Biomedicine, brings together the authors of two recent publications in the journal Colorectal Cancer, who provide valuable insights into the multidisciplinary approaches to colorectal cancer management that are needed in the COVID-19 era.
The authors, Dr Matías Chacón, Dr Juan Manuel O’Connor (both Instituto Alexander Fleming, Buenos Aires, Argentina) and Dr Benjamin Weinberg (Georgetown University, DC, USA), discuss their articles and recount their own personal experiences using precision medicine tools for making treatment sequencing decisions for their patients with colorectal cancer.
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.
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:
Chemotherapy in early stage (II, III) colon cancer 9
These recommendations were issued by experts from 10 centres across the USA, offering practice tips in gastro-intestinal oncology to minimise patient risk:10
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
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
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.
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® 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
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
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
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.
Specialty guides for patient management during the coronavirus pandemic: Clinical guide for the management of non-coronavirus patients requiring acute treatment: Cancer. Version 2. National Health Service, 2020.
Pagès F, André T, Taieb J, et al. Prognostic and predictive value of the Immunoscore in stage III colon cancer patients treated with oxaliplatin in the prospective IDEA France PRODIGE-GERCOR cohort study. Ann Oncol 2020.
Galon J, Hermitte F, Mlecnik B, et al. Immunoscore clinical utility to identify good prognostic colon cancer stage II patients with high-risk clinico-pathological features for whom adjuvant treatment may be avoided. J Clin Oncol 2019;37:487.