Patients with haematologic malignancies, including diffuse large B cell lymphoma (DLBCL), have the highest COVID-19 severity and mortality. It is thus important to balance minimising nosocomial COVID-19 transmission with treatment of aggressive DLBCL. At the National Cancer Centre Singapore (NCCS), we implemented these changes: 1. Reduce outpatient visits for patients on surveillance through telemedicine consultations 2. Low threshold for prophylactic granulocyte stimulating factors (GCSF) to reduce febrile neutropenia 3. Low threshold for antimicrobial prophylaxis 4. Subcutaneous instead of intravenous rituximab to reduce “chair time” in suitable patients 5. Outpatient chemotherapy where possible (including for rituximab with dose-adjusted etoposide, prednisone, vincristine, doxorubicin and cyclophosphamide; DA R-EPOCH for double/triple hit lymphomas) 6. Central Nervous System International Prognostic Index (CNS-IPI) to determine high risk patients requiring CNS prophylaxis; delay CNS prophylaxis with intravenous methotrexate (MTX) to later cycles We then reviewed the data to see if these outcomes had been achieved.
Data from DLBCL patients between 1 March to 30 April 2019 and the same period in 2020 were reviewed retrospectively and compared. Statistical analysis was performed using the chi-square test (Stata version 16.0, StataCorp, Texas, USA).
There was no nosocomial COVID-19 infection. Inpatient admissions and outpatient visits showed numerical decrease, with significant reduction in surveillance visits (p<0.001). Patients still received appropriate curative treatment. CNS prophylaxis was given when indicated; MTX was given intrathecally during staging lumbar puncture and intravenously later. Most on treatment received GCSF as primary prophylaxis. All who received R-EPOCH also received antimicrobial prophylaxis. There was no difference in number of patients receiving radiation or palliative care.
In- and outpatient visits were successfully reduced with no compromise to treatment and supportive care, with no nosocomial transmission of COVID-19. With no end from the pandemic in sight, this strategy for the management of DLBCL is useful in the “new normal” and for future pandemics of similar nature.
The authors.
Has not received any funding.
All authors have declared no conflicts of interest.