Cancer care

COVID-19: UK cancer clinicians told to use less immunosuppressive chemotherapy

Clinicians in the UK are quickly re-thinking their approach to treating immunocompromised cancer patients during widespread community transmission of the COVID-19 infection.

In correspondence published in the British Journal of Haematology, a team from Oxford warned of the urgent need to “consider the unique impact this [COVID-19] may have on haematology patients and the practical steps that can be taken to reduce their risk”.

This includes cutting outpatients appointments, remote working, deferring treatment and changing chemotherapy regimens.

While there is yet no available data on patients with haematological malignancies with COVID-19, data from a small number of elderly cancer patients in China does show a significantly higher incidence of intensive care admissions, need for ventilation, or death, the authors say.

Other steps that should be considered include greater use of phone, email or text communication to keep patients updated, extending the interval between monitoring blood tests, and establishing off-site phlebotomy, they suggest.

If pressures on hospitals increase, a worst case scenario may be that only immediately life‐saving chemotherapy is considered.

It is also plausible that many bone marrow transplants will have to be deferred, they warn.

Speaking with the limbic, co-author Dr Graham Collins, Lymphoma Lead at Oxford University Hospitals NHS Foundation Trust, said they were having discussions with patients and carrying out careful risk benefit analysis based on their individual needs.

He added that that more advice was now starting to come through from NHS England.

“Where a choice of chemotherapy regimens includes more or less immunosuppressive treatment, we are going more for the less immunosuppressive ones even if they may be less effective.

“This applies in my specialty to follicular and other low grade lymphoma where we are recommending less bendamustine, which suppresses T-cells, and more CVP.

“We are also suggesting less use of maintenance rituximab or obinutuzumab as this has never been shown to cause an overall survival benefit.”

He added that they would very much like to be able to use subcutaneous rituximab with chemotherapy regimens because it reduces the time a patient needs to be on the chemotherapy unit by about three to four hours.

“Currently NHS England only reimburses maintenance subcutaneous rituximab but not when used with chemotherapy. We are waiting to hear whether they will reimburse this during the coronavirus pandemic.”

Dr Collins said some patients do not need urgent treatment and delaying them for as long as possible makes sense.

“Low grade lymphoma patients and patients with chronic lymphocytic leukaemia are examples where a significant delay maybe possible. We are prioritising patients who have curable disease such as high grade non-Hodgkin lymphoma and Hodgkin lymphoma. Again though decisions have to be in consultation with the patient and on a case by case basis.”

He added that haematology departments need to be explaining the risks of treatments in light of COVID-19 and that needed to be reflected in the consent process.

“I am advising immunosuppressed patients that they should consider themselves ‘high risk’. This will almost certainly involve self-isolating for the duration of treatment and potentially beyond.”

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