Dear fellow members of the EANO, dear colleagues, dear friends

Our societies are being shocked by a wave of the SARS COVID-19 infection, resulting in large numbers of patients being severely infected, requiring hospital and ICU admission in a sizeable proportion of affected individuals. The end of this wave of infections is not in sight, fundamentally affecting our societies, disrupting our health care systems. That disruption is not limited to the demands this wave of SARS patients requests from our health care system, but also the care of other patients with other diseases: they need to be cared for as well. That care needs to be as good as possible, according to the existing guidelines and treatment standards, but also in consideration of health care limitations that may occur and of new safety issues the wave of COVID-19 infections brings to other patients and their caregivers. For us, as neuro-oncologists, apart from all our other concerns, brain tumor patients are our concern and it is our responsibility to take care of them to the best of our abilities.

The data on the impact the COVID-19 infection on cancer patients are still very limited. Current data on risks come in particular from China, where the pandemic started, and epidemiological data have been collected. A first report on few cancer patients suggests that patients with cancer but also cancer survivors have a higher risk of severe COVID-19 events (1). Because of the limited numbers of cancer patients, the conclusions of that study are questioned. Still, the observations led the authors to a number of possible considerations, including postponing adjuvant chemotherapy or elective surgery for stable cancer in endemic areas, stronger personal protection provisions for patients with cancer or cancer survivors, and more intensive surveillance or treatment should be considered when patients with cancer are infected with SARS-CoV-2, especially in older patients or those with other comorbidities.

Data on brain tumor patients are not available yet, it will take time for those data to emerge. Many of our patients are above 60 years of age, receive or have received chemotherapy and do travel to hospitals – especially in endemic area’s another risk factor. General guidelines for this situation cannot be given, as the situation differs from one region to another, even within countries. Also, while postponing treatments may be wise for certain patients, it may be hazardous in other patients in whom treatment cannot be postponed without jeopardizing outcome. This requires us to take decisions on a patient-by-patient and an institution-by-institution basis, based on tumor risk assessment and the situation at your institution and region. Of course, all such considerations have to be discussed with patients and caregivers; and should not be driven by fear alone but on a careful weighing of all information – in particular also on long term benefit of treatment.

A few recommendations and considerations that come to mind:
• Recommend high levels of carefulness to our patients (hygiene, social distance)
• Develop teleconsultation for patients, lab tests at outside hospital facilities if face to face contact can be safely avoided
• Consider stretching control MRI appointments in asymptomatic, long-term survivors of less malignant brain tumors, e.g., meningiomas, schwannomas.
• Consider hypofractionated radiotherapy schedules limiting the number of visits to the hospital for patients’ tumors in which this is likely to be feasible without affecting outcome
• Consider to postpone treatment if this is considered safe and feasible, e.g. probable or proven WHO grade II IDH mutant glioma
• Reconsider the risk benefit ratio of chemotherapy, e.g. in MGMT promoter unmethylated glioblastoma, notably in the elderly
• Be more strict in who you operate, postpone is safely possible, avoid if clinical benefit is less likely or marginal

It is important to realize we do not know when the situation will become more normal again. That requires us not to interrupt ongoing treatments without solid reasons. Nor should we interrupt follow-up of patients; if we do, we will be facing a bow wave of care later on. Regular care should go on as long this is safely possible. Lastly, our patients face emotional distress and anxiety – they know they are more vulnerable. This may require further support. I wish you all strength and please, take care!

On behalf of the EANO board,
Martin van den Bent
EANO President
REFERENCES: 1. Liang W, Guan W, Chen R, et al.: Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 21:335-337, 2020 DOI: 10.1016/S1470-2045(20)30096-6