The International Lymphoma Radiation Oncology Group (ILROG) laid out a set of emergency recommendations for patients with hematologic malignancies to manage increased demand during the coronavirus disease 2019 (COVID-19) pandemic.1
The focus of the recommendations is for alternative radiation treatment schemes, with an emphasis on maintaining clinical efficacy and safety by increasing the dose per fraction while reducing the number of daily treatments. Moreover, the guidance was informed by adherence to acceptable radiobiological parameters and clinical tolerability.
“This important paper by ILROG provides an excellent example of how the medical community is coming together to create cohesive strategies to adapt treatment in the setting of COVID-19 in order to maintain quality care, while lowering toxicity, minimizing viral exposure risk, and decreasing resource utilization,” Laurie Sehn, MD, MPH, of the British Columbia Cancer Centre for Lymphoid Cancer, said in a press release.2
Overall, the researchers indicated that there are 3 possible strategies for reducing the demand of radiation treatments during the pandemic, including omitting, delaying, and shortening the radiotherapy course. Additionally, they suggested that there are clinical situations where radiotherapy may be used as a bridging measure for delaying the need to initiate systemic therapy.
Omitting radiotherapy should be considered when the risk of severe outcomes from COVID-19 infections outweigh the benefit of radiotherapy, according to the researchers, such as in patients aged ≥60 years and/or those with a presence of serious underlying health conditions. Specific situations where this should be considered include:
- The palliative setting, where alternatives can be offered
- In localized low-grade lymphomas if completely excised
- In localized nodular lymphocyte predominant Hodgkin lymphoma if completely excised
- Consolidation of radiotherapy for diffuse large B-cell lymphoma or aggressive non-Hodgkin lymphoma in patients who completed chemotherapy course and achieved a complete remission
However, if additional chemotherapy must be administered in order to omit radiotherapy, this might induce prolonged immunosuppression which may not be the best decision during the pandemic. Multidisciplinary discussion of each patient case is therefore warranted.
The researchers suggested that the delaying of radiotherapy should be considered when there is little or no expected adverse effect on outcome from the delay. This should be considered in certain situations, such as:
- In asymptomatic localized low-grade lymphomas
- In localized nodular lymphocyte predominant Hodgkin lymphoma
- In the palliative setting for low-grade lymphomas in stable patients
- In patients who develop COVID-19 infection prior to commencing radiotherapy, until the infection is clear, if the malignancy is not progressing
Should the shortening of radiotherapy course be deemed necessary, the researchers recommended using alternative hypofractionation radiotherapy regimens. Notably, this should be considered though with the aim of maintain high cure and/or palliation rates without undue toxicity. However, hypofractionation will always influence the effective dose for late effects, so the risks should be weighed carefully.
“The emergency guidelines provide COVID-19 pandemic-relevant considerations for modifying radiotherapy indications and treatment schedules for patients with hematological malignancies,” lead author Joachim Yahamlom, MD, of Memorial Sloan Kettering Cancer Center, said in a press release. “This is an effort to reduce patient and staff exposure by minimizing daily visits and still maintain equivalent efficacy and safety profile. The alternative schedules may be individually adjusted within the suggested boundaries.”
1.Yahalom J, Dabaja B, Ricard U, et al. ILROG Emergency Guidelines for Radiation Therapy of Hematological Malignancies During the COVID-19 Pandemic. Blood. doi:10.1182/blood.2020006028.
2. International Task Force Provides Emergency Guidance for Radiation Therapy to Continue Treating Patients with Hematologic Malignancies During Pandemic [news release]. Washington. Published April 15, 2020. hematology.org/newsroom/press-releases/2020/emergency-guidance-for-radiation-therapy-during-pandemic. Accessed April 16, 2020.