Watchful Waiting Urged for Indolent Lymphoma During COVID-19

Pam Harrison

August 28, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Given that the risk for COVID-19 could be elevated for adults with cancer, the threshold for treatment initiation should be high in patients with indolent lymphomas, including Waldenstrom's macroglobulinemia (WM), two sets of expert recommendations advise.

"Watchful waiting should be the preferred strategy whenever possible," according to the American Society of Hematology (ASH) FAQ on COVID-19 and indolent lymphomas, updated earlier this month.

The strategy applies to both treatment-naïve patients and patients with relapsed or refractory disease.

This recommendation is echoed in the consensus statement on the management of WM patients during the pandemic, released by the International Workshop on Waldenstrom's Macroglobulinemia (IWWM), published online in HemaSphere.

"We used the backbone of the ASH recommendations to create our own for WM patients, so many of our recommendations are going to match" theirs, said Jorge Castillo, MD, from Harvard Medical School in Boston, who presented the updated ASH recommendations at the International Waldenstrom's Macroglobulinemia Foundation's Virtual Educational Forum.

When symptoms do require first-line treatment, single agents are preferred over combination regimens, largely because combination regimens usually carry a higher risk for infection than single agents, he explained.

The ASH also recommends that physicians choose oral agents over parenteral or intravenous (IV) agents, such as rituximab (Rituxan), for additional safety.

In contrast, the IWWM statement says that chemoimmunotherapy with rituximab or a Bruton's tyrosine kinase (BTK) inhibitor, such as ibrutinib (Imbruvica), is a reasonable option.

If a patient is already receiving chemotherapy and has had a good response, then we should consider reducing the number of treatment cycles, said Castillo.

If a patient finds travel difficult during the pandemic, the physician should stick with oral agents to minimize clinic visits, he added. A BCL-2 inhibitor, such as venetoclax (Venclexta), is an option for oral therapy, but it is not yet approved for WM.

The use of proteasome inhibitors, such as bortezomib (Velcade), in combination with steroids and rituximab in WM patients should be minimized because this regimen involves weekly visits to an infusion center.

Both the ASH and IWWM recommendations suggest that rituximab maintenance be avoided because it also increases visits to healthcare centers. However, "if getting subcutaneous rituximab is a possibility in your center, then it should be pursued," said Castillo.

Although the subcutaneous formulation of rituximab plus hyaluronidase human (Rituxan Hycela) has not yet been approved for patients with WM, it was recently approved by the US Food and Drug Administration for other lymphomas and can be administered in 5 to 7 minutes, in contrast to the 90 minutes required for IV rituximab, he explained.

Because many WM patients are encouraged to, and do, participate in clinical trials, the IWWM recommends that physicians contact trial monitors or sponsors to determine how patients should be managed during COVID-19, said Castillo. Some patients might be eligible to receive a 3-month supply of oral medications, which would allow them to minimize their clinic visits.

And telehealth and video consultations should be used, when possible, instead of in-person consultations, said Castillo, although he acknowledged that this is easier said than done for patients who require infusions or injections.

For all patients, "I think we need to be very proactive in using supportive therapy, like medications to boost white blood cells" or hemoglobin levels, and "even intravenous immunoglobulin supplementation, if needed," he noted. For select patients receiving bendamustine, growth-factor support is also recommended to prevent neutropenia.

Routine vaccination against influenza and pneumococcus should be also continued, according to the IWWM consensus statement.

Castillo has served as a consultant to Janssen, Merck, and Pharmacyclics, and has received research funding from AbbVie, Gilead Sciences, Janssen, Millennium Pharmaceuticals, and Beigene.

International Waldenstrom's Macroglobulinemia Foundation (IWMF) 2020. Presented August 27, 2020.

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