Treatment approach in locally advanced rectal cancer during coronavirus (COVID‐19) pandemic: long course or short course?

Abstract

In the last few weeks, coronavirus disease 2019 (COVID-19) has spread rapidly in Italy [1]. Despite the Italian Government’s tremendous efforts to contain and minimize the progression of the COVID-19 infection, by 20 March 42 220 cases were confirmed, with 3200 deaths [1, 2]. Because of their compromised immune system, cancer patients are potentially more prone to coronavirus infection with a greater need for intensive support than the healthy population [3]. Therefore precautionary measures are mandatory in the oncological scenario, especially when a multidisciplinary treatment approach is the standard of care. In view of these findings, the management of patients with locally advanced rectal cancer (clinical T3–4 and/or clinical N positive) poses the question of the risk/benefit of the standard treatment protocol. Traditionally, there are two multidisciplinary modalities: (i) short-course radiotherapy (25 Gy in 5 Gy per fraction) followed by immediate (2–3 days after the end of radiotherapy) surgery [4]; (ii) long-course radiotherapy (50.4–54 Gy in 1.8 Gy per fraction) combined with concurrent fluoropyrimidine-based chemotherapy followed by surgery after a 6–8-week break [4]. In the case of T3N0 or T1–3N1–2 rectal cancer with clear circumferential margins, these approaches are equivalent and the decision is left to the multidisciplinary team’s discretion. In the case of an involved circumferential margin or clinical T4 disease, long-course chemoradiotherapy is mandatory [5]. In order to ensure the best care and reduce the impact of the COVID-19 pandemic on these patients, we share some suggestions. (i) Short-course radiotherapy followed by delayed surgery (5–13 weeks) may be the best option. It has been demonstrated that the pathological complete response rate was significantly higher in delayed surgery (5–13-week interval), with no differences in sphincter preservation and negative margin resection rates, compared to immediate surgery [6]. Therefore, this approach seems to guarantee oncological results comparable to those obtained with more traditional treatment schedules [7, 8] and has the benefits in epidemic areas of reducing the length of patients’ exposure to the hospital environment during radiotherapy and of postponing surgery to a period when the epidemic will be contained or controlled. However, attention should be paid to the increased relative risk of postoperative complications, mainly due to bowel obstruction [9] (ii) In the case of clinical T4 disease, long-course treatment should remain the standard. However, due to the proven non-inferiority over prolonged continuous infusion, the concomitant oral 5-fluorouracil prodrug (capecitabine) should be preferred [10, 11]. For patients having completed the neoadjuvant radiochemotherapy protocol, with already scheduled surgery in endemic areas, surgery may be postponed up to 11 weeks without deleterious consequences on 3-year overall survival and disease-free survival, as reported by the GRECCAR 6 randomized trial [12]. However, postponed surgery was associated with a significant increase in the postoperative rate of medical complications (32.8% vs 19.2%; P = 0.0137) and worse quality of mesorectal resection (complete mesorectum 78.7% vs 90%; P = 0.0156) [13], and these risks should be balanced with the risk of postoperative COVID-19 infection. At present, little is known about the incidence and impact of postoperative COVID-19 infections, but the first observations suggest a high fatality rate even for operations usually associated with a very low morbidity [14]. Of course, it is imperative to guarantee a safe treatment. Adequate screening and preventive measures for the patients and staff should be adopted. The linear accelerators should be disinfected and cleaned by trained staff and a separation of the location of emergency from elective surgical operations should be assured. There is no need to delay treatment in uninfected patients. Patients should be informed about the risk of cross-contamination during treatment. This is expected to represent an opportunity to define a homogeneous multidisciplinary management in locally advanced rectal cancer patients. We should remain vigilant and share the basis on which important clinical decisions are made in this critical period. None. There are no conflicts of interest.

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