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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: Indolent B-NHL (Follicular and Marginal Zone Lymphoma, Waldenström’s Macroglobulinaemia)

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 Indolent B-NHL (Follicular and Marginal Zone Lymphoma, Waldenström’s Macroglobulinaemia) patients

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

High Priority

  • In indolent B-NHL, life threatening situations are rare, but might occur (e.g. compression of a vital organ, hyperviscosity or CNS involvement in Waldenström’s Macroglobulinaemia (Bing-Neel Syndrome). Under these circumstances, the pros and cons of an immediate versus delayed treatment should be evaluated thoroughly and decisions have to take into account the individual patient situation
    • Chemotherapy schedules may be modified to reduce immunosuppression or to minimise the necessity of clinical visits
    • Consider G-CSF support to minimise risk of neutropaenia
  • Radiotherapy with curative intent

Medium Priority

  • In advanced stage indolent B-NHL patients should follow a watch & wait strategy whenever possible
    • Patients in need of treatment should generally receive treatment following standard guidelines
    • Less immunosuppressive treatments should be preferred as treatments requiring fewer clinical visits
    • The improved long-term outcome of anti-CD20 antibody-based maintenance has to be balanced against the infectious risk of COVID-19 which may differ locally
    • 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, with the exception of BTK-inhibitors, given the risk of IgM rebound and constitutional symptoms upon withdrawal (Treon, Blood 2020)

 Low Priority

  • Watch & wait strategies should be followed strictly in all patients not clearly in need of treatment

 

List of abbreviations: BTK, Bruton's tyrosine kinase; CNS, central nervous system; G-CSF, granulocyte colony-stimulating factor; IgM, immunoglobulin M; NHL, non-Hodgkin 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 Indolent B-NHL (Follicular Lymphoma, Marginal Zone Lymphoma, Waldenström’s Macroglobulinaemia) patients

High Priority

  • In indolent B-NHL, life threatening situations are rare, but might occur (e.g. compression of a vital organ, CNS involvement in Waldenström’s macroglobulinaemia (Bing-Neel). Under these circumstances, the pros and cons of an immediate versus delayed treatment should be evaluated thoroughly and decisions have to take into account the individual patient situation
    • Chemotherapy schedules may be modified to reduce immunosuppression or to minimise the necessity of clinical visits
    • Consider G-CSF support to minimise risk of neutropaenia
  • Radiotherapy with curative intent

Medium Priority

  • In advanced stage indolent B-NHL, patients should follow a watch & wait strategy whenever possible
    • Patients in need of treatment should generally receive treatment following standard guidelines
    • Less immunosuppressive treatments should be preferred as treatments requiring fewer clinical visits
    • In the case of seropositivity for COVID-19, treatment should be delayed until seronegativity whenever possible. Patients on treatment with conversion to seropositivity for COVID-19 but without symptoms should be carefully watched, and pausing or stopping of treatment should be considered, depending on the individual patient situation. When patients develop COVID-19 symptoms, treatment should be stopped
    • Optional treatments such as anti-CD20 antibody-based maintenance should be avoided during the COVID-19 pandemic to avoid long-standing immunosuppression, minimise the need of clinical visits and to spare critical resources in the hospital needed for COVID-19

 Low Priority

  • Watch & wait strategies should be followed strictly in all patients not urgently in need of treatment

 

List of abbreviations: CNS, central nervous system; COVID-19, SARS-cov-2-related disease; G-CSF, granulocyte colony-stimulating factor; NHL, non-Hodgkin lymphoma.

 

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