Table 4.

Approach to curative intent therapy by tumour sites: summary of the published recommendations during COVID-19 crisis.

Disease	Criteria for delay	Fractionation			Boost		Systemic therapy	References	LMIC applicability
Head and neck
Head and neck cancer: all tumour sites	Head and neck cancer treatment break or deferral may lead to reduced tumour control	Consider mitigatinsbg with additional radiation dose after treatment or addition of chemotherapy.						[[30], [31]]	Applicable
	Patients < 70 y, with non resectable tumours: Standard time for treatment ≤ 4 weeks since diagnosis should be respected	SIB should be considered: -69,96Gy/54.45 in 33 fractions -69Gy/55 in 30 fractions Consider published hypofractionated schemes: 50–52.5 Gy in 16 fractions for larynx T1N0				Concomitant chemotherapy for locally advanced forms should be offered according to the usual indications			Applicable only if IMRT is available. Beside small volumes (such as larynx T1 N0), hypofractionation using 3D RT = risk of high toxicity To favour chemotherapy during the first 2 months before combined chemoradiation
	Patients <70 y, eligible for adjuvant RT: A period of 6–8 weeks between surgery and RT should be respected.	-R1 and/or extra-capsular rupture: 66 Gy/54 Gy in conventional fractionation, -otherwise 60 Gy or 50 Gy depending on the histo-prognostic factors				Concomitant chemotherapy for high risk tumours should be offered according to the usual indications
	Patients >70 years old or unfit (≥PS 2 and/or with significant comorbidities)	Non resectable tumours: -30 Gy in 10 fractions -10–12 days later: 25 Gy in 10 fractions or 24 Gy in 8 fractions Adjuvant: -SIB: 51Gy/42.5 in 17 fractions or any other hypofractionated schedules							Applicable for palliative care
	HPV	no de-escalation for HPV + tumours							Not applicable
Lung cancer
Early NSCLC	No delay of post-op RT No immediate RT for N2 NSCLC	Standard RT					Standard therapy −3 cycles of CT -Carboplatin is preferred over cisplatin -Systematic administration of GCSF	[[32], [33]]	Applicable
Locally advanced NSCLC	No delay of CRT	Standard RT		Standard therapy -Carboplatin is preferred over cisplatin -DURVALUMAB: double dose/4 weeks					Not applicable
Metastatic NSCLC	PS 1, Fit patients PS 2, elderly patients	Palliative strategy		Oncogenic alteration: standard therapy No oncogenic alteration: −4 cycles of CT/Immunotherapy -Maintenance CT: spacing or arrest -Pembrolizumab: Arrest of treatment for responding patients or double dose/6 weeks for non-responding.					According to availability of immunotherapy Applicable
SCLC	No delay of CRT	Standard RT		-Standard therapy -Carboplatin is preferred over cisplatin -Systematic administration of G-CSF					Applicable If G-CSF available
Breast
DCIS	Delete RT 3–6 months	40Gy in 15f					TAM “standby” therapy possible	[3,35]	Applicable
Invasive BC
HR + post M stages I II	Delete RT 3–6 months	Preferred scheme 40Gy in 15f			Not systematic boost in low risk		ET standby therapy systematic
Other BC subtypes and patients profiles including young and high- risk patients	No delay of RT	Standard or hypofractionation			Hypofractionation boost: 10–15Gy OR Integrated boost		Standard therapy
GU – Prostate
Low risk	Active surveillance or delay treatment	–					–	[12,38]	Applicable
Intermediate risk	Delay RT 3 months	In case of RT indication use hypofractionation (60Gy in 20fr)					3–6 months of ADT before RT	[39]	Hypofractionation only if IMRT is available and no indication of nodal RT
	Delay surgery by 3–6 months						No ADT	[12, 39]	Applicable Using standard fractionation No dose escalation if IMRT-IGRT no available
High risk	Delay RT by 3–6 months						3–6 months of ADT before RT	[38, 39]
	Surgery should be switched to RT
Post-operative or “rising PSA” RT indication	Delay RT by 3 months						3 months of ADT before RT
Metastatic setting hormone sensitive	Delay RT for oligo-metastatic disease						ADT + New generation of ET
Castration-resistant patients	Delay/avoid CT and prednisone						Enzalutamide is to be preferred	[12]	If Enzalutamide is available
GU – Bladder
Muscle infiltrating (MI)	Surgery, no delay						NA Chemotherapy possible	[38]	Applicable
MI when surgery is contraindicated	RT with or without 5Fu/myto		In case of RT indication hypofractionation should be preferred (55Gy in 20fr)					[38, 39]	Hypofractionation only if IMRT is available a
Metastatic 1st line	cisplatin-gemcitabine + G-CSF (No MVAC)							[38]	Applicable If G-CSF is available
Metastatic 2nd line	Delay treatment		Unknown impact of checkpoint inhibitors on covid19						–
GI – oesophagus
Localized cancer	RTCT with Carboplatin-Taxol		Standard					[[40], [41], [42], [43], [44], [45], [46], [47]]	Applicable
Inoperable or advanced			Standard				Or FOLFOX
Complete response to CRT	Follow-up or delay surgery
Incomplete response to CRT	Delay salvage surgery up to 3 months
GI-Pancreas
Operable/bordrline	Patients who does not fit for neo-adjuvant chemotherapy should be considered as high priority for surgery						NA FOLFOX to delay surgery	[40, 47]	Applicable according to drugs availability
Locally advanced	Avoid CRT during COVID-19 outbreack Completion of NA chemotherapy when already started or patients included in clinical trials should be also considered as a high priority						CT with schemes using Capecitabine
Post-operative setting	Delay adjuvant treatments according to the benefit risk						FOLFIRINOX is recommended (depending on benefit in OS)	[40]
GI – Rectum
CRT completed or ongoing	Delay surgery up to 3 months							[40, [42], [43], [44]]	Applicable
All new patients	Pre operative RT	25Gy in 5fr and surgery after 3 months
T4 rectal cancer	Chemoradiation	CAP 50 and surgery after 11weeks
Low rectum with complete response to chemoradiation	Tumour excision or watch and wait (GRECCAR 2 criteria)
GI – Anal canal
Localized	Standard chemo-radiation based on capecitabine or mytomicin C							[40, 47]	Applicable
Recurrence or metastatic setting	Chemotherapy with capecitabine/oxaliplatin or carboplatin/capecitabine
Gynaecological – Cervical cancers
Cervical cancer	-No delay of RT or RCT -Delay of LN staging surgery -No RT in the in case of complete response	Standard RT or RCT						[36, 37]	Applicable
Gynaecological – Endometrium
Low and intermediate risk or stage IA	Delay surgery up to 1–2 months		Total hysterectomy with bilateral annexectomy associated with sentinel node procedure						Applicable
High-risk or stage II	-To favour the MSKCC algorithm (PET CT + sentinel node procedure) in order to omit LN dissection -Delay of RT according to the benefit/		Consider if brachytherapy alone is a reasonable substitute for these patients after weighing risks and benefits						PET-CT availability
Advanced stage III IV	-Primary chemotherapy -Delay RT		6 cycles of Carboplatin - Taxol up-front and then delay the pelvic RT until after chemotherapy completion.						Applicable
Gynaecological – others
Vulvar cancer	Early-stage: surgery could be delayed up to 1–2 months No surgery indication: RTCT without delay								Applicable
Vaginal cancer	To favour imaging for staging in order to omit LN surgery RTCT if no surgery indication without delay
Ovarian	Early-stage: delay surgery up to 1–2 months Advanced stage: to favour primary systemic therapy No intraperitoneal hyperthermia chemotherapy (CHIP).								Not available mainly

RTCT, radiochemotherapy RT, radiotherapy; NA, neoadjuvant; LN, lymph nodes; COVID-19, coronavirus disease 2019; LMICs, low- and middle-income countries; MSKCC: Memorial Sloan Kettering Cancer Center; PET-CT: positron emission tomography-computes tomography; G-CSF: Granulocyte colony-stimulating factor