When the Seattle area saw the nation’s first surge of COVID-19 diagnoses starting in February 2020, the team at Seattle Cancer Care Alliance (SCCA) faced a critical question for patients with hematologic malignancies: How should SCCA balance the risk of the underlying cancer with the risks of COVID-19 infection and mortality? SCCA quickly developed — and published — guidelines for nine hematologic malignancies that can inform care nationwide.
COVID-19 is believed to increase the risk of complications among cancer patients. This is especially true for patients who traditionally require highly specialized inpatient care and/or a hematopoietic stem cell transplant. That’s why SCCA was among the first centers to quickly develop guidelines on how to limit COVID-19 exposure among staff, patients and caregivers, and on how to modify patient care for a broad range of situations for those treating patients with hematologic malignancies.
By emphasizing outpatient care and innovative treatment regimens, these guidelines — which were recently published in the Journal of Clinical Oncology, Oncology Practice — ensure SCCA patients get the best possible care throughout the pandemic, and could be informative to other centers. Here are a few examples of how our care has evolved to meet the current crisis.
Minimizing exposure to COVID-19
One of our first priorities was to minimize community spread of COVID-19 while decreasing the risk to providers, staff, patients and caregivers. SCCA quickly moved to educate patients and caregivers about the importance of social distancing, hand hygiene and masking. SCCA started funneling all patients, caregivers and staff through a single entrance where everyone is screened for COVID-19 symptoms; those with symptoms are automatically masked and tested. And we placed strict limits on both outpatient and inpatient visitation. Telemedicine visits are encouraged when possible.
Patients have been understandably concerned about COVID-19, and SCCA has made it part of every discussion about care goals — SCCA openly talks about the risks of COVID-19 and how it could impact the patient and their treatment. These conversations include frank discussions about palliative care, and we advise patients to identify a power of attorney and complete living wills.
SCCA also looked for ways to limit inpatient admission for conditions and complications that are relatively common among our patient population. For instance, SCCA now recommends increased use of granulocyte colony-stimulating factor (G-CSF) and antibiotic prophylaxis to reduce admission for febrile neutropenia. This and other steps minimize patients’ time in the hospital and maximize available beds.
Acute myeloid leukemia: is it appropriate to delay treatment?
As SCCA evaluated how to help patients with acute myeloid leukemia (AML) during the pandemic, our approach led by Mary-Beth M. Percival, MD, Assistant Professor, Division of Hematology, University of Washington School of Medicine, was based on a key insight: AML treatment is often considered an emergency, but retrospective analyses suggest that delaying treatment does not worsen outcomes. With this in mind, SCCA’s new guidelines include:
- Delaying induction to await COVID-19 testing in symptomatic patients or to let patients with confirmed infection recover from COVID-19.
- Considering outpatient induction when feasible.
- If chemotherapy is administered inpatient, considering early discharge.
- Whenever possible, emphasizing outpatient care for patients with AML who are in remission and undergoing consolidation chemotherapy. In some cases, the number of consolidation cycles can be decreased from four to three.
- Continuing to recommend consolidative allogeneic hematopoietic stem cell treatment for patients with intermediate or adverse-risk genomic characteristics.
Outpatient options for aggressive non-Hodgkin lymphoma
Whenever feasible, SCCA has shifted treatment of newly diagnosed aggressive non-Hodgkin lymphoma (NHL) to the outpatient realm. SCCA's new guidelines include:
- Creating outpatient treatment plans that typically include infusional regimens such as dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin plus rituximab [EPOCH-R]).
- Offering abbreviated chemotherapy without the need for consolidative radiotherapy (RT) to certain patients with early-stage diffuse large B-cell lymphoma (DLBCL). Patients with the lowest risk of a negative PET scan after three cycles require only 4 cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) without RT. For older patients, SCCA prefers abbreviated chemo (R-CHOP x 3) 1 consolidative RT. This regimen has similar efficacy and carries lower risk of febrile neutropenia.
- Advising patients with relapsed DLBCL who are eligible for potentially curative therapies to consider less intensive and/or outpatient approaches that produce similar outcomes.
- Autologous hematopoietic stem cell transplant remains an option for those with complete metabolic response after salvage, but less intensive therapies should otherwise be offered to patients with relapsed DLBCL.
When watchful waiting is feasible for indolent lymphomas
While patients with aggressive NHL typically need immediate treatment, watchful waiting can be a sensible approach for many patients with indolent lymphomas. This minimizes their clinic time and thus makes it easier to manage their COVID-19 risk. Whenever appropriate, we implement a wait-and-watch approach for these patients, educating them on symptoms to look for and conducting surveillance imaging as needed.
If patients with indolent B-cell NHL have a strong indication for treatment, such as bulky adenopathy, organ compromise, cytopenias or symptoms, SCCA prefers regimens with the least immunocompromise and the fewest inpatient appointments. For example, if patients have limited-stage disease and are seeking localized symptom control, we may pursue one or two fractions of palliative RT. This approach carries minimal toxicity and has shown high response rates.
Evolving care at a critical time
The guidelines above provide a glimpse of what’s covered in our recent paper, which includes an easy-to-use table outlining treatment recommendations for nine malignancies during COVID-19. These recommendations will continue to evolve as SCCA learns more about COVID-19’s cancer implications, and as it becomes clearer how the pandemic will affect our communities in the coming months. SCCA will continue to share insights, and we look forward to helping cancer centers nationwide adapt in ways that keep patients with hematologic malignancies as safe and healthy as possible.