Tumours of the brain and central nervous system (CNS) though relatively rare, comprising less than 2% of the overall cancer burden, are a substantial source of cancer-related morbidity and mortality worldwide. Diagnosing a brain tumour can be a complicated process and involve a number of specialists. A brain scan, most often an MRI, is the first step, post which a biopsy may be necessary. A Histopathologist then helps to identify the tumour type.
However, in these Covid times, it’s important to exercise caution. Some general recommendations that hospitals and physicians can follow include:
- Patients may visit hospitals/clinics for routine inescapable checkups and follow-up assessments when clinically indicated.
- Physicians should reduce the frequency of surveillance neuroimaging, which may be done only to guide clinical decision-making
- Physicians may adopt remote consultation (telephonic, video, or online) to avoid unnecessary overcrowding by applicable local/national laws and telemedicine guidelines
- Hospitals should recommend high levels of caution in patients and staff (personal hygiene and social distancing) including the use of personal protective equipment and covid appropriate behaviour.
- Hospitals and departments should devise and review contingency plans periodically to deal with the ongoing crisis
- Physicians and hospitals should ensure the continuation of ongoing therapy with appropriate modifications as desirable
- Physicians should liaise and coordinate with colleagues within the city/region to ensure uninterrupted and timely completion of active ongoing therapy in the likely event of partial or complete shut-down of services at their institute.
- Physicians and hospitals should create a graded and tiered priority-list based on the type of tumor, recommended therapies, expected prognosis, risks, and current resources, which may vary dynamically over time.
- A multidisciplinary team (MDT) should discuss “standard advice” as well as “Covid-context advice” with patients and caregivers clearly explaining the differences between the two with appropriate documentation. Physical attendance at such MDT meetings should be avoided or restricted to key decision-makers only. Hospitals should strongly consider conducting virtual tumor boards through online resources
- Covid-19-context regimens need not necessarily be based on high-quality (level I) evidence from randomized controlled trials, but could be supported by prospective phase II data, retrospective studies, or even personal/institutional experience.
These recommendations should be used for prioritising the various aspects of cancer care in order to mitigate the negative effects of the Covid-19 pandemic on the management of cancer patients. In OPD patients the following groups need to be considered as high priority over others:
- Newly diagnosed brain tumour patients
- New onset or worsening of symptoms indicative of tumour- or treatment-related complications (e.g., neurological symptoms, dyspnoea, chest pain)
- Clinical or radiological evidence for tumour recurrence
- Application of intravenous or intrathecal anticancer treatment
- Wound-healing problems after neurosurgical intervention
The following groups should be considered as medium priority:
- Evaluation of clinical status, laboratory or neuroradiological results in known brain tumour patients without new or worsening symptoms and with active therapy (convert to telemedicine visits whenever possible)
- Prescription of oral anticancer treatment (convert to telemedicine visits whenever possible)
- Post-operative patients without need for active therapy and no complications
The low priority groups include:
- Evaluation of clinical status, laboratory or neuroradiological results in known brain tumour patients without new or worsening symptoms and without active therapy (convert to telemedicine visits whenever possible)
- Visits of patients on a best supportive care regimen
- Visits of psychological support (convert to telemedicine)
The following procedures too can be categorized on the severity of symptoms:
- High priority in patients who have worsening of neurological symptoms or new onset symptoms
- Medium priority in patients who have no new or worsening neurological symptoms with ongoing anticancer treatment
- Low priority in patients who have a follow-up with no new or worsening neurological symptoms without ongoing anticancer treatment
- High Priority in patients presented with progressive neurological deficit or altered sensorium with need for acute decompression; maximal safe resection in suspected malignant glioma and diagnostic biopsy in suspected primary central nervous system lymphoma (PCNSL)
- Medium Priority in patient with stable neurological status considered for resection or biopsy of non-contrast enhancing primary brain tumour and patients with recurrent lower WHO grade glioma considered for resection.
- Low Priority in partial resection of recurrent malignant glioma
- High priority in patients newly diagnosed with glioblastoma, IDH (isocitrate dehydrogenase) wild-type lower WHO grade gliomas, IDH-mutant with relevant clinical manifestations, adult medulloblastoma radiotherapy
- Medium to low priority in patients diagnosed with lower WHO grade gliomas, IDH-mutants
- High priority for patients requiring high-dose chemotherapy (with methotrexate) for newly diagnosed PCNSL; temozolomide concurrent with and adjuvant to radiotherapy for newly diagnosed glioblastoma with MGMT promoter methylation; temozolomide after radiotherapy for IDH-mutant 1p19q-intact anaplastic astrocytoma; alkylating chemotherapy after radiotherapy in newly diagnosed 1p19q-codeleted anaplastic oligodendroglioma; alkylating chemotherapy for recurrent glioma with MGMT promoter methylation and those on strict control of steroid prescription (as little as possible, as much as needed)
- Medium priority to temozolomide concurrent with and adjuvant to radiotherapy for newly diagnosed glioblastoma without MGMT promoter methylation; progressive brain tumours without evidence, e.g., meningioma or ependymoma in adults; alkylating chemotherapy after radiotherapy in IDH-mutant WHO grade II astrocytoma and adjuvant chemotherapy after radiotherapy for adult medulloblastoma
- Low Priority to alkylating chemotherapy in patients with recurrent gliomas lacking MGMT promoter methylation, patients with second or higher recurrence of glioma, a nd patients with reduced performance status or in advanced age
In conclusion, patients with brain tumours are more at risk at developing neurological complications like stroke seizure and focal neurological deficit. They should be categorised between high to low priority groups so that management can be changed as per recommendation.
Dr. (Col) Joy Dev Mukherji, Principal Director and Head, Neurology, Max Super Speciality Hospital, Saket.
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