In Research News

Adult neuro-oncology service provision during COVID-19 outbreak

Like most advice in the current crisis, the following is based on a synthesis of national guidelines, published evidence, expert opinion – and common sense.

Clearly there is a hierarchy of need, and how many of these measures need to be implemented will be dependent upon how severe the pandemic is and what the local capacity is. Solutions will be sought locally and so it will not be a one size fits all. These are guidelines, nothing more.

Sources include NHS England and NHS Improvement, UK Government, the Society of British Neuro-Surgeons, and the General Medical Council. This information applies to England only (although an assumption can be made the service delivery will be similar for all four nations).

Headlines

  • Solutions will be sought locally and so it will not be a one size fits all. These are guidelines, nothing more.
  • All out-patient contact except for new patients with malignant tumours and /or patients that need urgent surgery will be done by phone, teleconsultation, email or letter instead
  • Surgery reserved for urgent cases and length of stay minimised (day case, single night stay)
  • Chemo and radiotherapy minimised and triaged for those most likely to benefit
  • Continue to support all patients even those who may now not get treatment

Pre diagnosis

The key message is that service provision may need to flex as part of infection control. guidance has been issued that modifies the existing cancer waiting times guidance.

The policy remains that providers (e.g. consultants, imaging) receiving referrals may NOT downgrade urgent cancer referrals without the consent of the referring GP.

If a referral is downgraded, then safety netting has to be in place so that if a patient deteriorates or the risk of a cancer diagnosis increases, they can be referred for further investigation.

When a 2 week wait referral is received from the GP, telephone triage will stream patients directly to the test needed.

Nearly 60% of patients who are diagnosed with a brain tumour present via the emergency route.  These patients may have a longer wait at A and E, or they may well be referred to their GP to re-enter the system by the 2ww referral if their situation is not life threatening.

Post diagnosis by an MRI

All referrals will be triaged.

Doctors will only see referrals where there is MRI confirmation of malignant brain tumours, providing there are staff to run clinics. A referral will be a non face-to-face consultation where possible and minimise hospital visits

Anyone diagnosed with a non-malignant brain tumour will have a referral by post or phone.

New Brain Tumour Patients

Surgery – high priority

Surgery reserved for urgent cases and length of stay minimised (day case, single night stay):

  • Resection of malignant glioma in patients suitable for CT and RT
  • Posterior fossa tumours (malignant or non-malignant) causing symptomatic or life-threatening hydrocephalus
  • Meningioma causing major mass effect and neurology (e.g. hemiparesis) or which are life-threatening
  • Supratentorial symptomatic brain metastases
  • Rare brain tumours (e.g. lateral / third ventricle, pineal) causing hydrocephalus – although a temporary fix (e.g. shunt) could be used to delay surgery.

If not a surgical high priority then non-operative approaches in patients least likely to gain significant benefit from treatment e.g. elderly patients with clear diagnosis of high-grade glioma on MRI (e.g. best supportive care).

Surgery low priority – consider postponement

  • Low grade glioma (resection and biopsy) where a period of interval monitoring with MRI is a reasonable management option (in the likely event of 3-6 months delay consider adding in a 3-month interval scan to ensure no tumour progression, if not already done)
  • Skull base tumours (e.g. meningioma, vestibular schwannoma) with minimal symptoms where an elective scheduled procedure was already planned.

Non-malignant brain tumours

No surgery for non-malignant, asymptomatic (or minimally symptomatic) brain tumours to be performed as elective services close.

Oncology – high priority

  • HGG for treatment with radiotherapy and chemotherapy – consider reducing course and fractions of treatment where this will not significantly worsen prognosis. Consider increasing use of oral chemotherapy rather than regimes that require IV administration.
  • Chemotherapy may be omitted in MGMT unmethylated glioblastoma patients
  • Brain metastases for stereotactic radiosurgery or whole brain radiotherapy
  • Radiotherapy for other rare malignant tumour (e.g. anaplastic astrocytoma, pineoblastoma, PNET)

Oncology low priority – consider postponement

  • Radiotherapy and chemotherapy for low grade glioma where an initial period of monitoring is a reasonable option
  • Radiotherapy for atypical meningioma or recurrent meningioma.

Follow up brain tumour patients

  • Continue follow-up for malignant brain tumours but reduce face-to-face reviews where possible – use email, telephone, skype instead
  • Stop patients attending clinics for routine review of non-malignant brain tumours
  • Postpone appointments where appropriate and introduce telephone reviews for those where review is required
  • To reduce the need for patients to attend GP surgery 4-8 weeks of medication may be provided on discharge
  • Absorbable sutures may be used on discharge after surgery.

Patients currently on treatment

It depends on:

  • Local circumstance – resources available (drugs, technology, people).
  • Prioritisation – clinicians will make decisions to prioritise treatment for those most in need and in consultation with the patient.

Generally, there are currently no drug shortages as a result of COVID-19. There is no need for patients to change the way they order their medication. The NHS has tried and tested ways of making sure medicines reach the right people, even under difficult circumstances. A problem may arise if patients begin to stockpile.

MDT Meetings

Maintain weekly MDT; can be done remotely if needed. Senior decision makers only. Limit to 2 surgeons, 2 oncologists, 1 radiologist, 1 pathologist, co-ordinator and 1 specialist nurse maximum.

Research Activity

NIHR CRN advice is that studies addressing the COVID-19 pandemic are being prioritised. It is likely that recruitment into brain tumour trials will be suspended for the foreseeable future.