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More and more "lymphoma" will (or has) encountered the "new crown", how should we deal with it?
With the "liberalization" of epidemic control, the new coronavirus infection (COVID-19) has been adjusted from "Class B tube" to "Class B tube", and the long-lost "fireworks" have returned, and the streets and alleys are full of traffic and people.
.
.
As a special group, lymphoma patients will face if they are unfortunately "recruited"? How to adjust the treatment? Embrace change as you would embrace the New Year! The "CD30 Navigator" column sorted out the relevant response recommendations for "lymphoma" to meet "new crown", come on, let's take a look
.
What are the particularities of lymphoma patients diagnosed with COVID-19?
Patients with hematologic malignancies may be immunocompromised due to their own disease, anticancer therapy, and concomitant immunosuppressive therapy
.
They are more susceptible to the novel coronavirus (SARS-CoV-2) and are at higher risk of developing severe/critical COVID-19 than the general population
.
Even with vaccination, patients with lymphoma may lose protection due to inadequate antiviral immune responses [1].
The data showed that in patients with lymphoma and other hematological tumors, most patients with confirmed COVID-19 were severe/critical COVID-19; Lymphoma patients with confirmed COVID-19 have an increased overall mortality rate (>30%)
compared with the general population with confirmed COVID-19 and lymphoma patients without COVID-19.
In terms of prognostic factors, poor prognostic predictors for patients with lymphoma diagnosed with COVID-19 include older age, presence of associated comorbidities, and active neoplasm [1].
A prospective study compared the clinical features of patients with confirmed COVID-19 before and after vaccination in 365 patients with haematological malignancies who had completed their first dose of SARS-CoV-2 vaccination; The study found that vaccinated patients had a significantly lower incidence of critical illness (10 versus 33 percent) and hospitalization (17 versus 50 percent) and a significantly shorter median duration of disease (16 versus 22 days) compared with unvaccinated patients [1].
A retrospective analysis of OnCovid data showed that the most common COVID-19 sequelae in patients with haematological or solid tumors infected with SARS-CoV-2 included respiratory symptoms, fatigue, weight loss, and neurocognitive symptoms; The incidence of sequelae in the subgroup of hematologic malignancies (13.
3 percent) was similar to that in the general population (15.
0 percent) [1,2].
The Italian expert group recommended that all lymphoma treatment should generally be suspended for lymphoma patients with confirmed COVID-19; For patients with mild-to-moderate COVID-19 (often outpatients), the decision to suspend antineoplastic therapy should be made on a case-by-case basis; For patients receiving chemotherapy + anti-CD20 therapy, discontinuation of the B-cell depletion regimen rather than discontinuation of the entire antitumor regimen may be considered [1].
The Guidelines for the Prevention and Treatment of NCCN Cancer-Associated Infections (2022.
3 Edition) (hereinafter referred to as the "NCCN Guidelines") recommend that patients with tumors with positive SARS-COV-2 tests, including lymphoma patients, postpone anti-tumor therapy; The duration of deferred antineoplastic therapy depends on the severity of clinical SARS-CoV-2 infection, type and state of malignancy, risk of tumor recurrence and progression that may result from delayed treatment, comorbidities, type and intensity of treatment, and possible adverse effects; If antineoplastic therapy is urgently needed because the tumor is uncontrollable, treatment should be administered at the clinician's discretion [3].
How often can anti-tumor therapy be restarted for patients with lymphoma who test positive for SARS-CoV-2? The NCCN guidelines also provide relevant recommendations[3]:
For asymptomatic infected individuals who test positive for SARS-CoV-2, targeted therapy, long-acting biological therapy, immune checkpoint inhibitors, radiation therapy, immunotherapy, or hormone therapy are recommended to be suspended for 10 days, cytotoxic therapy for at least 10 days, and planned hematopoietic stem cell transplantation (HCT) or chimeric antigen receptor T cell (CAR-T) therapy for at least 14 days from the date of the first positive test result, and resumption of treatment
if asymptomatic during this period.For patients with mild-to-medium-sized COVID-19, targeted therapy, long-acting biological therapy, immune checkpoint inhibitors, radiation therapy, immunotherapy, or hormone therapy are recommended to be suspended for at least 10 days, and cytotoxic therapy, planned HCT, or CAR T cell therapy for at least 14 days until symptoms improve and fever is relieved without fever reducers for at least 24 hours, after which the planned antitumor therapy
is started or resumed.For patients with severe-critical COVID-19, regardless of the type of antineoplastic therapy received, it is recommended to suspend or resume the planned antineoplastic therapy
for at least 20 days from the date of the first positive test result until symptoms improve and fever is reduced without the use of antipyretics for at least 24 hours.
According to the "Diagnosis and Treatment Plan for Novel Coronavirus Infection (Trial Version 10)", the new crown treatment methods include: general treatment, antiviral therapy (nematevir tablets/ritonavir tablets combination package, azvudine tablets, monoravir capsules, ambavirumab/romisivimab injection, etc.
), immunotherapy, anticoagulation therapy, prone position therapy, psychological intervention, heavy/critical supportive treatment, traditional Chinese medicine treatment, early rehabilitation, etc.
[4].
NCCN guidelines state that COVID-19 treatment in oncology patients is substantially similar to non-oncology patients; COVID-19 treatment options for oncology patients include antiviral drugs [remdesivir, nirmatrelvir/ritonavir, molnupiravir], monoclonal antibodies (Bebtelovimab, tisagvirumab/sigavirumab), COVID-19 convalescent plasma, immunomodulators, etc.
[3].
。
For the treatment of COVID-19 in oncology patients, NCCN guidelines also give stratified recommendations for antiviral therapy [3]:
For outpatients with acute infection, recent onset of symptoms, and high risk of progression, nematevir/ritonavir, remdesivir, and monoclonal antibodies are preferred;
For patients with acute symptomatic COVID-19 who are hospitalized for other (non-COVID-19) indications, monoclonal antibodies, remdesivir, preferred;
remdesivir is preferred in patients hospitalized with acute symptomatic COVID-19;
Patients with persistent symptomatic COVID-19, particularly those with B-cell damage, can be treated
with an antiviral agent (remdesivir or nematevir/ritonavir) combined with passive immunity (plasma or monoclonal antibodies to COVID-19) for investigational use.
Prevention first, how can lymphoma patients prevent COVID-19? 01Active immunization through vaccination
Even with major mutations in SARS-CoV-2, the protective efficacy of existing vaccines may be somewhat weakened, but it still exists and is still highly effective in preventing hospitalization, severe disease and death from variants [5].
Vaccination remains the main effective means of preventing COVID-19 and severe disease [2].
The Chinese Expert Consensus on Vaccination of Adult Patients with Blood Diseases against the Novel Coronavirus (2023 Edition), released in January 2023, recommends that patients with blood diseases who meet the vaccination conditions complete the new crown vaccination
.
Prior to vaccination, the risk of the epidemic and the patient's condition should be comprehensively considered, the risks/benefits of vaccination should be fully assessed, and the principle of
informed and voluntary should be followed.
This consensus has detailed recommendations
for vaccination.
For example: (1) people who should be vaccinated: patients with hematological tumors who have completed treatment and achieved complete remission; Patients with non-malignant hematologic disorders without immune dysfunction or coagulopathy; Those who have not been vaccinated for 6 months after recovering from new crown infection >; (2) People who can be vaccinated: 3 months after the end of hematopoietic stem cell transplantation or cell immunotherapy>, hematopoietic and immune system recovery; Have been vaccinated before transplantation or CAR-T treatment, and re-vaccinated at appropriate times 3 months after the end of treatment; In monotherapy with targeted drugs that have little effect on immune response; Patients in maintenance therapy with non-anti-B cell drugs after remission; (3) Patients who can optimize the vaccination time, such as the interval of chemotherapy, have stable condition, and neutrophil ≥ 1.
0×10 9/L and platelet count ≥ 50×109/L; For new-onset indolent haematological tumors, vaccination may be prioritized before initiation of antineoplastic therapy [6].
In addition, patients with blood diseases who meet the vaccination conditions can be vaccinated with 1 booster dose 3 months after completing the primary immunization of the vaccine, and if more than 6 months have passed since the booster vaccination, another booster dose can be considered
.
Consensus also describes the recommendations for patients who are advised to withhold vaccination and those who are not vaccinated (Figure 1) [6].
For lymphoma patients who are difficult to produce neutralizing antibodies after vaccination, passive immunization with anti-SARS-CoV-2 monoclonal antibodies can be used as a complementary strategy to active immunization with vaccination[1].
The Italian expert group recommended that the monoclonal antibody combination tixagevimab/cilgavimab be used for pre-exposure prophylaxis
both in patients with newly diagnosed lymphoma that have not been exposed to SARS-CoV-2 and in patients with lymphoma who are actively treated.
Currently, tixagevimab-cilgavimab for SARS-CoV-2 pre-exposure prophylaxis has been granted emergency use authorization from the US Food and Drug Administration (FDA) and formal approval by the European Medicines Agency (EMA), respectively [1].
"Everyone is the first responsible person for their own health"
.
Patients with lymphoma should do general prevention by themselves, such as: maintaining good personal and environmental hygiene, balanced nutrition, moderate exercise, adequate rest, avoiding excessive fatigue, and improving health literacy [4].
epilogue
I hope that in 2023, the new year will be better than the old year, the old diseases will be healed, and the years will be as new; Lymphoma patients can withstand the impact of the epidemic and reap the double victory of "epidemic prevention and anti-cancer"!
References
[1] Passamonti F, Nicastri E, Di Rocco A, et al.
Management of patients with lymphoma and COVID-19: Narrative review and evidence-based practical recommendations[J].
Hematol Oncol.
2022; 1-13.
[2] Professional Committee of Tumor Support Treatment of Chinese Anti-Cancer Association, Clinical Chemotherapy Committee of Cancer of Chinese Anti-Cancer Association.
Chinese expert consensus on issues related to the protection and diagnosis and treatment management of patients with solid tumors during the novel coronavirus pneumonia epidemic (2022 edition)[J].
Chinese Journal of Oncology.
2022; 44(10):1083-1090.
[3] NCCN Clinical Practice Guidelines in Oncology: Prevention and Treatment of Cancer-Related Infections（Version 3.
2022）.
[4] Diagnosis and treatment plan for novel coronavirus infection (trial version 10).
YUAN Jing, TAN Xiaohua, WANG Fuxiang, et al.
Expert opinion on new coronavirus vaccination in patients with malignant tumors[J/CD].
Electronic Journal of Emerging Infectious Diseases.
2022; 7(2):1-5.
[6] Hematology Rehabilitation Professional Committee of Chinese Rehabilitation Medical Association, Hematology Branch of Chinese Medical Association.
Chinese expert consensus on vaccination of adult patients with blood diseases against novel coronavirus vaccine (2023 edition)[J].
Chinese Journal of Hematology.
2022; 43(5):359-364.
Material approval number: VV-MEDMAT-80379
Material approval date: 1/2023
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