COVID-19 and Aggressive Lymphoma: Frequently Asked Questions
(Version 2.1; last updated May 4, 2020)
Input from Drs. Ranjana Advani, Nancy Bartlett, Leo Gordon, Peter Johnson, Kerry Savage, Laurie Sehn, Jane Winter
Note: Please review ASH's disclaimer regarding the use of the following information.
Some centers are beginning to screen patients beginning therapy in the out-patient clinic or on admission to the hospital for treatment. Practices differ depending on the prevalence of COVID-19 and the availability of screening.
Are you changing your approach to initial therapy?
R-CHOP continues to be the standard of care for diffuse, large B-cell lymphoma, with DA-EPOCH-R indicated only for double-hit and primary mediastinal B-cell lymphomas. Whereas DA-EPOCH-R targets myelosuppression with dose escalation until there is neutropenia and/or thrombocytopenia, it is of necessity a more toxic regimen, and in most institutions requires hospitalization. Centers with the capacity to deliver this therapy on an outpatient basis are encouraging that approach. Others are weighing benefits and risks for the individual patient with double-hit or primary mediastinal B-cell. R-CHOP (or R-CHOP-14) +/- consolidative radiotherapy for some PMBCL patients is an alternative.1
For older patients, R-mini-CHOP with growth factor support is recommended.
For those who are high-risk for CNS involvement, two cycles of high-dose methotrexate is recommended, the timing of which must be individualized. The optimal number of cycles is unknown. For patients receiving DA-EPOCH-R high-dose methotrexate is not easily integrated into the program, and IT methotrexate is an alternative.
For limited stage disease, R-CHOP X 4 rather than combined modality therapy is recommended.
For those who tolerate the first dose of rituximab given intravenously, subcutaneous administration is an option going forward that reduces time spent in the clinic.
Are you changing therapies for patients who have already started treatment?
None of the experts have yet changed treatment for those already under treatment.
Are you changing therapy to minimize visits? For example, changing to oral or less frequent regimens?
Telemedicine is replacing visits that are not coincident with treatment. Oral regimens – e.g. with lenalidomide- are being utilized by some experts in the relapsed/refractory setting.
Are you changing your treatment recommendations for relapsed/refractory disease?
Most experts are continuing to offer second-line chemotherapy and HDC/autoHSCT for patients with relapsed/refractory disease. Outpatient regimens are preferred when possible and are an alternative for non-transplant eligible patients as well. Clinical trial options are limited or nonexistent. Lenalidomide-based therapy or polatuzamab (approved in the third-line setting in the US) with bendamustine are alternatives for some patients.
Admission for HDC/autoHSCT may be delayed in many instances if another cycle of outpatient chemotherapy can be administered. Blood shortages anticipated to occur in the coming weeks may limit the availability of transplant shortly in the US.
Whereas ICU bed availability at most centers is an issue currently or is expected to be shortly, some CAR T-cell programs are currently delaying patients and prolonging salvage therapy when possible.
Are you changing your approach to supportive care?
Most experts are using growth factor routinely in the current environment. There are some theoretical concerns that filgrastim may exacerbate the respiratory effects of COVID-19 infection, but as of yet there is no contraindication to growth factory support in patients anticipated to become neutropenic.
- ILROG Emergency Guidelines for Radiation Therapy of Hematological Malignancies during the COVID-19 Pandemic. Link: https://doi.org/10.1182/blood2020006028.