The impact of COVID-19 on clinical cancer care: An individual-patient level analysis

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Background: At the outset of the COVID-19 pandemic, concerns for the safety of patients receiving anti-cancer treatment coupled with pressures on healthcare services prompted review of standard clinical care pathways in the UK. Revised consensus treatment guidelines were generated. Individual patient-level data regarding actual treatment modifications implemented in clinical practice are lacking. Methods: All anti-cancer treatment plans of patients with breast, lung, renal, hepatopancreatobiliary, CNS cancers and melanoma attending a single academic cancer centre in the UK between 16 March and 31 May 2020 were reviewed and any modifications to standard practice were documented. The effect of patient (age, ECOG performance status [PS], sex) and cancer (site, stage, treatment intent) characteristics on likelihood of treatment modifications were analysed using univariable and multivariable models. Results: Treatment plans for 925 patients were reviewed: median patient age was 63 (range 19-97); 66% were female; 73% were PS 0-1; 45% were on a curative pathway. Overall, 47% of all patients had one or more modifications made to their treatment plans: 53% of surgeries (primarily being delayed); 41% of radiotherapy (primarily reduced fractions delivered); 39% of systemic therapy prescriptions. 96-100% of all systemic therapy modifications resulted in treatment de-escalation, excluding endocrine therapy used as a bridge to defer primary breast cancer surgery. Biological therapy was predominantly interrupted (49%), immunotherapy was mostly omitted entirely (36%), and chemotherapy varied between interruptions (39%) or omissions (31%). Relative to the likelihood of modification to chemotherapy, surgery was significantly more likely to be modified (OR 1.69 95%CI 1.20-2.38). Chemotherapy, radiotherapy, biological therapy and immunotherapy were all modified to a similar degree. Multivariate analysis identified PS ≥2 (OR 1.79, 95% CI 1.18–2.75), but not patient age, as a predictor of treatment modification. Some tumour types were less likely to undergo any modification: stage 1-3 lung (OR 0.13, 95%CI 0.04-0.37), stage 4 lung (OR 0.26 95%CI 0.24–0.60) and stage 4 renal cancer (OR 0.22 95%CI 0.09-0.52). Conclusions: This single centre analysis demonstrated almost half of cancer patients had their treatment modified, the overwhelming majority resulting in treatment de-escalation. The impact of the treatment modifications on overall cancer patient outcomes remains to be determined.

Serum carcinoembryonic antigen trends for diagnosing colorectal cancer recurrence in the FACS randomized clinical trial

BACKGROUND

Most guidelines recommend that patients who have undergone curative resection for primary colorectal cancer are followed up for 5 years with regular blood carcinoembryonic antigen (CEA) tests to trigger further investigation for recurrence. However, CEA may miss recurrences, or patients may have false alarms and undergo unnecessary investigation.

METHODS

The diagnostic accuracy of trends in CEA measurements for recurrent colorectal cancer, taken as part of the FACS (Follow-up After Colorectal Surgery) trial (2003-2014), were analysed. Investigation to detect recurrence was triggered by clinical symptoms, scheduled CT or colonoscopy, or a CEA level of at least 7 μg/l above baseline. Time-dependent receiver operating characteristic (ROC) curve analysis was used to compare the diagnostic accuracy of CEA trends with single measurements. CEA trends were estimated using linear regression.

RESULTS

The area under the ROC curve (AUC) for CEA trend was at least 0·820 across all 5 years of follow-up. In comparison, the AUCs for single measurements ranged from 0·623 to 0·749. Improvement was most marked at the end of the first year of follow-up, with the AUC increasing from 0·623 (95 per cent c.i. 0·509 to 0·736) to 0·880 (0·814 to 0·947). However, no individual trend threshold achieved a sensitivity above 70 per cent (30 per cent missed recurrences).

CONCLUSION

Interpreting trends in CEA measurements instead of single CEA test results improves diagnostic accuracy for recurrence, but not sufficiently to warrant it being used as a single surveillance strategy to trigger further investigation. In the absence of a more accurate biomarker, monitoring trends in CEA should be combined with clinical, endoscopic and imaging surveillance for improved accuracy.

What is the true incidence of metachronous colorectal liver metastases? evidence from the UK Follow-up After Colorectal Surgery (FACS) trial

The 2013 Alpine Liver and Pancreatic Surgery meeting was held in Madonna di Campiglio, Italy. The meeting was organised by the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The following abstracts were selected for presentation at the meeting.

Effect of 3-5 years of scheduled CEA and CT follow-up to detect recurrence of colorectal cancer: FACS randomized controlled trial

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Background: Intensive long-term follow-up after surgery for colorectal cancer is common practice but neither the actual benefit nor the optimal methodology is known. Methods: Pragmatic factorial randomised controlled trial in 39 UK hospitals, comparing minimum follow-up (which included a single CT scan at 12-18 months) with 3-6 monthly blood carcinoembryonic antigen (CEA) testing and 6-12 monthly computerised tomography (CT) imaging of the chest, abdomen and pelvis following 1202 participants for 3-5 (mean 3.7) years. Results: The proportion of participants with recurrence treated surgically with curative intent was lower than predicted (6.0% overall) but was about 3x higher in the more intensive than minimum follow-up arms (p=0.019). The adjusted odds were 2.7 for CEA only (p=0.035) and 3.4 for CT only (p=0.007); the absolute differences in detection rate in the more intensive arms compared to minimum follow-up were 4.3-5.7% (5.8-8.0% per protocol). Combining CEA and CT provided no additional benefit (adjusted odds for CT+CEA arm = 2.9). The absolute difference in the proportion of participants with recurrence treated surgically with curative intent in the factorial comparison was 1.4% for CEA (p=0.28) and 2.8% for CT (p=0.04). There was no statistical difference in colorectal cancer deaths nor overall deaths in the minimum compared to the intensive follow-up arms. Conclusions: Both regular CEA measurement and CT scanning result in significantly higher rates of diagnosis of operable recurrent colorectal cancer compared to minimal follow up. There is no benefit in monitoring with both CEA and CT. To date no difference in the overall mortality has been demonstrated. CEA monitoring combined with a single CT scan at 12-18 months seems likely to be cost effective. Clinical trial information: 41458548.