Working together to overcome the difficulties Professor Zhang Jun| Professor Zhang Jun: In case of "yang" in bowel cancer patients, the guideline consensus recommends what we do?

The new crown virus is impossible to prevent, and domestic and foreign guidelines and consensus recommend treatment recommendations
for people with small "yang" tumors.

Colorectal cancer (CRC) is the second most common malignant tumor in China ^[1], and the patient base is huge
.
The original novel coronavirus pneumonia has been officially renamed as the new coronavirus (hereinafter referred to as the new coronavirus) infection on December 26, 2022, and will implement "Class B tube"
from January 8, 2023.
CRC patients are older, have lower immunity than ordinary people, repeated hospital admissions during treatment, and bone marrow suppression after chemotherapy such as leukopenia and neutropenia, which make CRC patients more susceptible to infection with the new coronavirus and a higher
risk of severe disease.

In view of how to prevent the new coronavirus and how to deal with it after unfortunate infection, the "Medical Tumor Channel" specially invited Professor Zhang Jun of Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, combined with the Chinese Anti-Cancer Association (CACA) "Chinese Expert Consensus on Issues Related to the Protection and Diagnosis and Treatment Management of Solid Tumor Patients during the Novel Coronavirus Pneumonia Epidemic (2022 Edition)" [^2] (hereinafter referred to as "China Expert Consensus"), which he participated in compiling and publishing.
At the same time, please refer to the "Guidelines for Home Treatment of People with New Coronavirus Infection" issued by the National Health Commission of the People's Republic of China[3], the "Guidelines for the Prevention and Treatment of Cancer-Related Infections by the National Cancer Network (NCCN) of the United States 2022.
3 Edition" [4] (hereinafter referred to as the "NCCN Guidelines"), and the Implementation Plan for the Second Dose of Booster Immunization of the New Coronavirus Vaccine^[5] (hereinafter referred to as the ^"Plan") ) to share their valuable experience and views
on the hot issues related to bowel cancer patients in the current new crown situation.

Can cancer patients be vaccinated against the new crown?

Yes, and COVID vaccination
is recommended.
The Chinese expert consensus recommends that patients with solid malignant tumors have a higher risk of new coronavirus infection, severe disease and death after infection than the normal population, and need vaccine protection
.

When do tumor patients receive the new crown vaccine and how many shots do they need?

Chinese expert consensus recommends: it is recommended that tumor patients complete the new crown vaccination
in sufficient amounts, with sufficient treatment courses and according to the recommended doses.
The target population includes high-risk groups, elderly people over 60 years old, people with more serious underlying diseases and immunocompromised people, combined with the above expert consensus and plan, it is recommended that tumor patients complete the new crown vaccination
throughout the process.

Chinese expert consensus points out that patients will have different degrees of immune impairment after receiving chemotherapy, so it is difficult for the body to produce enough protective antibodies
after normal immune response after new crown vaccination.
At present, the optimal time for new crown vaccination related to chemotherapy cycles is not clear, but the most obvious time points
of bone marrow suppression should be avoided as much as possible.
Vaccination of patients undergoing targeted therapy may have a protective response, and vaccination can be given at any time, and vaccination should be completed as soon as possible
.

Fig.
1 Timing of vaccination in different treatment stages of cancer patients

How to get a booster shot of the new crown vaccine?

China has 13 approved new crown vaccines, including 5 inactivated vaccines, 5 recombinant protein vaccines, 3 vector vaccines (adenovirus vector, influenza virus vector), the plan recommends the second dose of the technical route vaccine different from the first dose, that is, sequential booster immunization, or the use of Omicron-containing vaccines or vaccines with good cross-immunity to the Omicron strain for the second booster immunization
.

How to scientifically prevent the new crown virus?

Common protective measures include: frequent hand washing; scientific wearing of masks; Pay attention to cough etiquette; reduce gatherings and outings; civilized dining; Maintain 1 metre social distancing; normally open window ventilation; Do a good job of cleaning and disinfection; Maintain toilet hygiene; Develop a healthy lifestyle; Complete vaccination, etc
.

In case of "Yang", do tumor patients need to postpone treatment?

NCCN guidelines recommend: Patients with tumors who are positive for new coronavirus surveillance are recommended to postpone anti-tumor therapy
.

After the new coronavirus infection, what should I pay attention to in the treatment of CRC patients?

On December 8, 2022, the joint prevention and control mechanism of the State Council issued the "Guidelines for Home Treatment of Persons Infected with New Coronavirus Infection", which is applicable to: 1.
Asymptomatic or mildly symptomatic infected persons
who do not have serious underlying diseases.
2.
Infected people whose underlying diseases are in a stable period and do not have severe heart, liver, lung, kidney, brain and other important organ insufficiency that require hospitalization
.

CRC patients have exceeded the scope of underlying diseases, their immunity is relatively low, especially after radiotherapy and chemotherapy patients are prone to bone marrow suppression, digestive tract reactions and other adverse reactions, it is recommended that patients can go to the nearest medical institution if necessary, when unable to visit offline, you can consult the doctor in charge by phone or use drugs at home after Internet consultation in regular medical institutions
.
For the use of home drugs, the Health Commission has issued guidelines for home treatment of people infected with the new coronavirus, recommending common drugs for fever, cough and sputum and other symptoms, paying special attention to the need for CRC patients to use drugs
rationally under the guidance of doctors.

Figure 2 Common symptoms of new coronavirus infection recommend common drugs

Choice of antineoplastic drugs in the current context of CRC patients?

Multidisciplinary combination therapy (MDT) is the mainstream mode
of treatment for intermediate and advanced colorectal cancer.
For patients receiving medical anti-tumor therapy, combined with the guidelines and the current situation, it is necessary to optimize the management process to maintain the overall efficacy and reduce the risk of
new coronavirus infection.

• For CRC patients receiving neoadjuvant therapy, conversion therapy, and participating in clinical trials, antitumor therapy
  is prioritized.
  

• For patients with CRC who receive postoperative adjuvant therapy, oral drugs and longer cycle regimens are preferred under the premise of equal efficacy
  .
  

• For patients with metastatic colorectal cancer (mCRC) who are receiving first-line and second-line periodic chemotherapy ± macromolecular targeted drugs, if there are cross-provincial and municipal visits, it is recommended that patients be treated according to the original plan on schedule, and local patients can arrange outpatient chemotherapy
  .
  

• Antineoplastic therapy after the second or second line is scheduled
  for a limited period of time when medical resources permit.
  Try to choose targeted therapy and immunotherapy
  with low toxicity.
  Avoid adverse reactions such as bone marrow suppression caused by high-intensity chemotherapy, and further avoid poor clinical outcomes
  after infection with the new coronavirus.
  

• Patients with CRC who use oral drugs (oral chemotherapy drugs, oral targeted drugs, etc.
  ) or subcutaneous injection drugs are given priority to outpatient treatment
  .
  

The Chinese expert consensus recommends that patients with new coronavirus infected tumors can consider restarting anti-tumor therapy
when the relevant symptoms are completely relieved, and the new coronavirus nucleic acid test is negative for 2 consecutive times, with an interval of 24 hours.
Individualized discussion
is required based on the indications, goals, and tolerability of the patient.

Fig.
3 Timing and indications for restarting anti-tumor therapy for new coronavirus infection

The resumption of anti-tumor therapy for tumor patients after recovery from new coronavirus infection should adjust the treatment strategy according to the patient's status, disease stage, and treatment goals, aiming to reduce complications related to antitumor therapy, reduce treatment-related organ adverse reactions, shorten hospital stay and avoid unexpected hospitalization
.

• Avoid potential treatment-related immunosuppression, reduce hospitalizations, avoid intravenous administration, and avoid other adverse effects
  .
  

• Prefer oral drugs and long-term regimens, and make full use of outpatient methods and day diagnosis and treatment modes to reduce patients' stay time and number of
  hospital visits.
  

The optimization and selection of the backline treatment regimen for patients with advanced CRC need to consider the current epidemic prevention and control situation
.
At present, there is no consensus on guidelines for the selection of late-line therapy for patients with advanced CRC during the epidemic, and in an Italian recommendation for systemic treatment of patients with gastrointestinal tumors during the outbreak ^[6], it is pointed out that third-line oral therapy during the epidemic should try to avoid the selection of myelosuppressive oral chemotherapy drugs such as neutropenia, and oral targeted drugs
can be selected as appropriate.
A multicenter real-world study based on mCRC patients in China was presented at the 2022 ASCO Annual Meeting ^[7], in which 21 cases were unable to go to the hospital for second-line chemotherapy due to the epidemic, and "regorafenib plus capecitabine" was selected for second-line treatment
.
The results showed that the median progression-free survival (PFS) reached 8 months and the median OS reached 26.
9 months
.
The above drugs can be taken orally at home, which is easy to manage, and the way of outpatient drug collection or Internet drug collection provides certain convenience
for these patients with advanced CRC.

summary

The choice of antineoplastic drug treatment for CRC patients needs to be carried out under the guidance of specialist oncologists and the full informed consent of patients, and under the current situation, for most CRC patients who have been diagnosed with new coronavirus infection and need chemotherapy, it is recommended to suspend chemotherapy and ensure that patients clear the virus in time or start other types of anti-tumor therapy, and then chemotherapy
after the disease recovers.
For patients with advanced CRC, third-line treatment can be based on physician evaluation, and oral targeted drugs that are effective and can be treated at home with adverse reactions can be selected at home to avoid the risk of
infection.
Even if you are unfortunately infected with the new crown virus, you should treat it with optimism, treat it carefully under the guidance of professional doctors, and continue to carry anti-tumor treatment after recovery, so as to overcome the disease
as soon as possible.
Finally, I would like to pay tribute to all the medical workers who are fighting on the front line of the fight against the epidemic!