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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: Hodgkin lymphoma

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 Hodgkin lymphoma patients

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

 

Priorities for Hodgkin lymphoma patients: Limited stage disease

High Priority

  • Curative systemic treatment:
    • The potentially higher efficacy of myelosuppressive treatment has to be balanced against the infectious risk of COVID-19 which may differ locally
    • Use phone calls/telemedicine visits to reduce clinic visits on days when treatment is not scheduled
    • Consider broader use of G-CSF to reduce risk of neutropaenia
  • Curative radiotherapy
  • Continuation of treatment in clinical routine as well as clinical trials

Medium Priority

  • 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 Hodgkin lymphoma patients: Advanced stage disease

High Priority

  • Curative systemic treatment:
    • The higher efficacy of myelosuppressive treatment has to be balanced against the infectious risk of COVID-19 which may differ locally
    • Use phone calls/telemedicine visits to reduce clinic visits on days when treatment is not scheduled
    • Consider broader use of G-CSF to reduce risk of neutropaenia
  • If ABVD is used, consider PET-guided strategy as per the RATHL trial, as omission of bleomycin may reduce the risk of pulmonary complications
  • Continuation of treatment in clinical routine as well as clinical trials

Medium Priority

  • 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 Hodgkin lymphoma patients: Relapsed disease

High Priority

  • High-dose chemotherapy with autologous stem cell support
  • The high efficacy of palliative systemic treatment has to be balanced against the infectious risk of COVID-19 which may differ locally
  • Palliative radiotherapy

Medium Priority

  • Maintenance brentuximab vedotin post Tx
  • 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: ABVD, doxorubicin/bleomycin/vinblastine/dacarbazine; G-CSF, granulocyte colony-stimulating factor; PET, positron-emission tomography; Tx, treatment.

 

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 Hodgkin lymphoma patients

Priorities for Hodgkin lymphoma patients: Limited stage disease

High Priority

  • Curative systemic treatment:
    • Less myelosuppressive treatment may be preferred (e.g. ABVD)
    • Use phone calls/telemedicine visits to reduce clinic visits on days when treatment is not scheduled
    • Consider use of G-CSF to reduce risk of neutropaenia
  • Curative radiotherapy
  • Continuation of treatment in the context of a clinical trial

Medium Priority

-

 Low Priority

-

Priorities for Hodgkin lymphoma patients: Advanced stage disease

High Priority

  • Curative systemic treatment:
    • Less myelosuppressive treatment may be preferred (e.g. ABVD)
    • Use phone calls/telemedicine visits to reduce clinic visits on days when treatment is not scheduled
  • PET-guided strategy as per the RATHL trial may be preferred, as omission of bleomycin allows for G-CSF support to be given
  • Continuation of treatment in the context of a clinical trial

Medium Priority

-

 Low Priority

-

Priorities for Hodgkin lymphoma patients: Relapsed disease

High Priority

  • High-dose chemotherapy with autologous stem cell support

Medium Priority

  • Palliative radiotherapy
  • Maintenance brentuximab vedotin post-treatment
  • Palliative systemic therapy

 Low Priority

-

 

List of abbreviations: ABVD, doxorubicin/bleomycin/vinblastine/dacarbazine; G-CSF, granulocyte colony-stimulating factor; PET, positron-emission tomography.

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