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ESMO-EHA clinical practice guidelines for the management of malignant lymphoma – recommendations for the second phase of the COVID-19 pandemic: Aggressive lymphoma (Diffuse large B-cell lymphoma, Mantle cell and T-cell lymphomas)

The tiered approach of ESMO in delivering a guidance for cancer patients during the COVID-19 pandemic is designed across three levels of priorities, namely: tier 1 (high priority intervention), 2 (medium priority) and 3 (low priority) – defined according to the criteria of the Cancer Care Ontario, Huntsman Cancer Institute and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS), incorporating the information on the value-based prioritisation and clinical cogency of the interventions

  • High priority: Patient's condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g. significant overall survival [OS] gain and/or substantial improvement in quality of life [QoL]);
  • Medium priority: Patient's situation is non-critical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority;
  • Low priority: Patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is non-priority based on the magnitude of benefit (e.g. no survival gain with no change nor reduced QoL).

Priorities for diffuse large B-cell lymphoma (DLBCL) patients

In general, the high efficacy favours curative standard-of-care approaches despite the infectious risk of COVID-19.

High Priority

  • Curative treatment for aggressive lymphomas:
    • Chemotherapy schedules may be modified so as to reduce clinical visits without compromising the curative potential of the treatment
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
    • The potentially higher efficacy of intensified treatment has to be balanced against the infectious risk of COVID-19 which may differ locally
    • The addition of high-dose methotrexate, high-dose cytarabine and/or intrathecal methotrexate because of the risk of CNS involvement has to be balanced against the infectious risk of COVID-19 which may differ locally
  • High-dose chemotherapy with autologous stem cell support in relapse of DLBCL
  • Continuation of treatment in clinical routine as well as clinical trials
  • CAR-T cell therapy in refractory DLBCL

Medium Priority

  • Non-curative treatment (e.g. systemic therapy for relapsed aggressive lymphoma, not eligible for autologous stem cell transplant) may be modified to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
  • Consolidation radiotherapy (e.g. due to initial bulk or extranodal disease) may be delayed
  • In the case of COVID-19 infection, treatment should be delayed until viral clearance whenever possible. Patients on treatment who develop COVID-19 infection but without symptoms should be carefully watched and pausing of treatment should be considered depending on the individual patient situation. When patients develop COVID-19 symptoms, treatment should be stopped

 Low Priority

-

Priorities for for Mantle cell lymphoma (MCL) patients

In general, the high efficacy favours curative standard-of-care approaches despite the infectious risk of COVID-19.

High Priority

  • First-line treatment for MCL:
    • Chemotherapy schedules may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
  • Continuation of treatment in clinical routine as well as clinical trials

Medium Priority

  • Systemic therapy for relapsed MCL may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
  • The potential long-term benefit of high-dose chemotherapy with autologous stem cell support has to be balanced against the infectious risk of COVID-19 which may differ locally
  • The overall survival benefit of maintenance therapy with rituximab has to be balanced against the infectious risk of COVID-19 which may differ locally
  • Palliative radiotherapy may be delayed
  • In the case of COVID-19 infection, treatment should be delayed until viral clearance whenever possible. Patients on treatment who develop COVID-19 infection but without symptoms should be carefully watched and pausing of treatment should be considered depending on the individual patient situation. When patients develop COVID-19 symptoms, treatment should be stopped

 Low Priority

-

Priorities for (Aggressive) T-cell lymphoma patients

In general, the high response rates favours standard-of-care approaches despite the infectious risk of COVID-19.

High Priority

  • First-line treatment:
    • Chemotherapy schedules may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
  • Continuation of treatment in the context of a clinical trial

Medium Priority

  • Systemic therapy for relapsed disease may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
  • The potential long-term benefit of high-dose chemotherapy with autologous stem cell support has to be balanced against the infectious risk of COVID-19 which may differ locally
  • Palliative radiotherapy may be delayed
  • In the case of COVID-19 infection, treatment should be delayed until viral clearance whenever possible. Patients on treatment who develop COVID-19 infection but without symptoms should be carefully watched and pausing of treatment should be considered depending on the individual patient situation. When patients develop COVID-19 symptoms, treatment should be stopped

 Low Priority

-

 

List of abbreviations: ACVBP, doxorubicin/cyclophosphamide/vindesine/bleomycin/prednisone; CAR-T cell, chimeric antigen receptor T cell; CHOEP, cyclophosphamide/doxorubicin/vincristine/etoposide/prednisolone; CHOP, cyclophosphamide/doxorubicin/vincristine/prednisolone; CNS, central nervous system; DLBCL, diffuse large B-cell lymphoma; G-CSF, granulocyte colony-stimulating factor; MCL, mantle cell lymphoma.

 

Literature

  1. www.esmo.org/guidelines/cancer-patient-management-during-the-covid-19-pandemic
  2. www.ehalyg.org
  3. Loblaw DA, Prestrud AA, Somerfield MR, et al. American Society of Clinical Oncology Clinical Practice Guidelines: Formal Systematic Review–Based Consensus Methodology. J Clin Oncol. 2012;30(25):3136-3140.
  4. Murphy M, Black N, Lamping D, et al. Consensus development methods, and their use in clinical guideline development: a review. In: Health Technol Assess. Vol 2.; 1998:88.

Priorities for diffuse large B-cell lymphoma (DLBCL) patients 

High Priority

  • Curative treatment for aggressive lymphomas:
    • Chemotherapy schedules may be modified so as to reduce clinical visits without compromising the curative potential of the treatment
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
    • Less myelosuppressive regimens may be preferred (e.g. CHOP-21 instead of CHOEP-14 or ACVBP)
  • High-dose chemotherapy with autologous stem cell support in relapse of DLBCL
  • Continuation of treatment in the context of a clinical trial
  • CAR T-cell therapy in refractory DLBCL

Medium Priority

  • Non-curative treatment (e.g. systemic therapy for relapsed aggressive lymphoma, not eligible for autologous stem cell transplant) may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
    • Avoid T-cell suppressive agents (bendamustine)
  • CNS prophylaxis with high-dose methotrexate, high-dose cytarabine and/or intrathecal methotrexate may be omitted
  • Palliative radiotherapy may be delayed
  • Consolidation radiotherapy (e.g. due to initial bulk or extranodal disease) may be delayed

 Low Priority

-

Priorities for for Mantle cell lymphoma (MCL) patients

High Priority

  • First-line treatment for MCL:
    • Chemotherapy schedules may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
  • Continuation of treatment in the context of a clinical trial

Medium Priority

  • Systemic therapy for relapsed MCL may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
    • Avoid T-cell suppressive agents (bendamustine)
  • High-dose chemotherapy with autologous stem cell support as consolidation therapy may be delayed
  • Maintenance therapy with rituximab may be delayed
  • Palliative radiotherapy may be delayed

 Low Priority

-

Priorities for Aggressive T-cell lymphoma patients

High Priority

  • First-line treatment:
    • Chemotherapy schedules may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
  • Continuation of treatment in the context of a clinical trial

Medium Priority

  • Systemic therapy for relapsed disease may be modified so as to reduce clinical visits
    • Patients should receive G-CSF growth factor support so as to minimise neutropaenia
    • Avoid T-cell suppressive agents (bendamustine)
  • High-dose chemotherapy with autologous stem cell support as consolidation therapy may be delayed
  • Palliative radiotherapy may be delayed

 Low Priority

-

 

List of abbreviations: ACVBP, doxorubicin/cyclophosphamide/vindesine/bleomycin/prednisone; CAR, chimeric antigen receptor; CHOEP, cyclophosphamide/doxorubicin/vincristine/etoposide/prednisolone; CHOP, cyclophosphamide/doxorubicin/vincristine/prednisolone; COVID-19, severe acute respiratory syndrome coronavirus 2-related disease; CNS, central nervous system; G-CSF, granulocyte colony-stimulating factor.

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