Australian clinicians have developed a consensus statement giving specific advice on how to manage patients with lymphoma, chronic lymphocytic leukaemia and myeloma during the COVID-19 pandemic.
The position paper, published in the Internal Medicine Journal, provides supportive guidance to clinicians making individual patient decisions during the COVID-19 pandemic, as well as general recommendations on how to minimise patient exposure to COVID-19, such as by avoidance of non-essential visits and minimising time spent by patients in infusion suites.
As with other recent guidance statements for managing patients with blood cancers, the position paper says that there may be a need to reduce the potential for therapy-associated immunosuppression in patients infected with COVID-19. However in the context of low circulating levels of COVID-19 disease the guidance recommends against deferring or omitting treatment options with a clear established benefit in terms of survival outcomes.
For example, in patients with newly diagnosed diffuse large B-cell lymphoma and high-grade B-cell non-HL, the guidance does not recommend delay of therapy “in circumstances where the delay itself is likely to be deleterious to patient outcome as dose intensity and timeliness are important.”
“However in high-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements (’double-hit’ or ’triple-hit’), it is recommended to weigh up the resources needed and the immunosuppression risks associated with intensified regimens, such as dose-adjusted R-EPOCH, “particularly in those with low IPI and older patients who may experience increased toxicity. It may be reasonable to treat such patients with R-CHOP.”
The consensus statement notes that patients with chronic lymphocytic leukaemia are likely to be at increased risk of severe disease and mortality with COVID-19 as many patients are immunocompromised, even with early stage disease, and have additional risk factors, such as age and comorbidities.
“Consideration should be given to the delay of planned initiation of therapy where possible,” it suggests.
Guidance is also provided on mitigating potential risks of agents such as Btk inhibitors and venetoclax and the cardiac toxicity associated with ibrutinib for patients who acquire COVID-19.
In the treatment of people with multiple myeloma it is suggested that consideration be given to stopping immunosuppressive agents such as ongoing dexamethasone in patients with stable disease, as it may not be essential for immediate disease control.
Specific advice is given on how to manage otherwise well patients with slow biochemical progression of MM but without end-organ damage and on decision making for autologous stem-cell transplants.
“Careful consideration, informed consent and a multidisciplinary approach are now more important than ever to tailor therapy to at-risk individuals, and thus, hopefully, reducing the impact of COVID-19 in our vulnerable patients,” the statement authors conclude.