Initiation and Implementation of Infusional Chemotherapy As a Base Regimen for Increased Risk Lymphoid Malignancy in an Inner-City Academic Institution

Our institution is a 695-bed facility that serves an inner-city population and the surrounding area which together are largely urban and have withstood longstanding obstacles to care including food insecurity, absence of reliable transportation, lack of insurance coverage, and poor health literacy. Such barriers have historically served to limit for many patients, routine outpatient visits, weekly, or even nadir lab work as well as outpatient-based cancer therapy. Institutional barriers include limited nursing resources.

Given these challenges, with a change in divisional leadership and the establishment of a new fellowship in hematology/oncology, a simplified and streamlined approach to managing and treating high-risk lymphoid malignancies was planned. Infusional chemotherapy has been shown to have activity in a variety of lymphoid cancers (Wilson, 1993; Dobashi, 1998; Cassaday, 2018). To address inconsistent patient follow-up, a program was instituted, utilizing a dedicated Registered Nurse coordinator making routine proactive phone and electronic check-ins to ascertain patient status; a distinct, direct phone number to call to report symptoms; electronic medical record access for communication; dedicated physician/physician assistant availability; and treatment planning assigned to a single, designated faculty physician with fellow support. Additionally, planned treatment needed inpatient administration, no routine dose alterations, no requirement for patient self-medication, and scheduled single-dose growth factor support.

With this in mind, we have utilized an infusional chemotherapy regimen of Hydroxydaunorubicin (Adriamycin) (10 mg/m2), Oncovin^R (Vincristine) (0.4 mg/m2), and Etoposide (50 mg/m2) by continuous infusion daily for 4 days with Prednisolone 125 mg IV daily for 5 days, and Cyclophosphamide 750 mg/m2 IV on day 5. Peg-filgastrim 6 mg subcutaneously was given following completion of therapy. Cycles were repeated every 21 days. Additions of Rituximab and TKI varied by individual malignancy type.

Pt characteristics: 7 males/6 females, median age-45 (range: 19-75), median ECOG status-2, B symptoms-8, LDH elevation-9, no prior therapy-7, disease types: diffuse large B-cell lymphoma-4, large cell unclassifiable, intermediate between DLBCL and classical Hodgkin-2, plasmablastic lymphoma-1, primary effusion lymphoma-1, Burkitt lymphoma-1, lymphoblastic lymphoma-1, acute lymphoblastic leukemia-3.Median number of cycles received = 6 (range: 1-8).Six have had complete responses and four partial responses. One patient with acute lymphoblastic leukemia has undergone transplant and is free of leukemia at 19.9+ months. The median duration of complete response has not been reached at > 6 months. Median survival is ongoing at 11.5+ months. There have been no treatment-related deaths. Three patients required dose modification of Vincristine related to transient paresthesia. There have been no hospitalizations related to toxicity.

This systematic approach including an infusional chemotherapy regimen may produce positive downstream effects such as consistency with nursing, a deeper understanding of side effects by nurses and mid-level providers and a predictable patient flow to improve the patient experience and ultimately outcomes. Given the resource constraints experienced at our institution, and potentially other urban teaching institutions, this approach may prove helpful in terms of patient compliance, satisfaction with care, and outcomes.

Quan:Coastal Blood Foundation: Research Funding; Delta Fly Pharma: Research Funding; Imago BioSciences: Research Funding.