COVID-19 and Indolent Lymphomas: 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.
Whereas treatment for indolent lymphomas and mantle cell lymphoma is not curative, there is more flexibility in approach with a key focus on safety in the setting of COVID-19. The ILROG has recently published emergency guidelines for radiation therapy of hematological malignancies that may be helpful when considering radiotherapy.
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 indications for therapy?
Given COVID-19, the threshold for initiating treatment should be high and watchful waiting should be the preferred strategy whenever possible. Treatment is recommended in symptomatic patients, but if the indication for therapy is borderline, (e.g. if the patient meets GELF criteria but is asymptomatic) treatment deferral and close monitoring with repeat imaging may be prudent. Treatment for asymptomatic patients with rituximab monotherapy is not recommended (see recently posted ILROG guidelines).
Are you changing your approach to initial therapy?
When treatment is indicated, rituximab monotherapy rather than R-chemotherapy should be given consideration. If a single disease site is of concern, limited radiotherapy is an effective option (see ILROG Emergency Guidelines). Many experts have concerns about the immunosuppressive properties of bendamustine and are recommending R-CVP or R-CHOP with growth factor support as alternatives, without rituximab maintenance. Others, continue to prescribe R-bendamustine followed by maintenance but changes in practice are evolving rapidly.
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.
Ibrutinib continues to be prescribed for CLL/SLL and Waldenstrom’s and is an option for relapsed mantle cell lymphoma and marginal zone lymphoma in the US. Consolidation with high-dose chemotherapy and HSCT in mantle cell is of uncertain value and is not recommended at this time.
Are you changing therapies for patients who have already started treatment?
For patients who have already achieved an excellent response to R-chemotherapy, a reduced number of cycles may be considered or a switch in therapy to less immunosuppressive or myelosuppressive approaches. Maintenance rituximab continues to be prescribed by some of the experts, but not others. Some have discontinued maintenance rituximab, especially in older patients and in younger patients with low immunoglobulin levels.
Are you changing therapy to minimize visits? For example, changing to oral or less frequent regimens?
Some experts are switching patients to oral options – e.g. ibrutinib in CLL/SLL, marginal zone lymphoma or mantle cell lymphoma, rather than continuing intravenous chemotherapy, in an effort to reduce the risk of infection and limit the number of visits to the outpatient clinic. Some patients may be eligible to receive up to a three month supply of their oral medication; this approach, with labs obtained locally and telehealth visits may allow patients to stay at home for the time being. Patients who are on “watchful waiting” may have visits delayed with telemedicine alternatives, with labwork obtained locally or delayed if risk is low.
Are you changing your approach to supportive care?
When choice of therapy is available, options that minimize clinic/chemotherapy outpatient visits are preferred. When feasible, select patients are being reviewed by telehealth to avoid clinic visits. Growth factor support is recommended for patients receiving R-CHOP and may be helpful in select patients who are receiving bendamustine. Patients with comorbidities, recent infections, and low IgG levels, including those who have received rituximab, may benefit from monthly immunoglobulin supplementation if available.
Q5. Are you changing your treatment recommendations for relapsed/refractory disease?
Management of relapsed/refractory indolent lymphoma should be based on symptoms and indications for treatment as for previously untreated patients. When possible, experts recommend delaying treatment. When choice of therapy is available, options that minimize clinic/chemotherapy unit visits are preferred. Use of bendamustine, given its immunosuppressive properties is discouraged by many experts. Oral agents such as ibrutinib and lenalidomide with rituximab are options that should be considered. Radioimmunotherapy, where available, is an underutilized option for relapsed/refractory follicular lymphoma.
- ILROG Emergency Guidelines for Radiation Therapy of Hematological Malignancies during the COVID-19 Pandemic. Link: https://doi.org/10.1182/blood2020006028.