Interim Treatment Change Options During the COVID-19 Pandemic, Endorsed by NHS England

The aim of the interim treatment changes is to allow for greater flexibility in the management of cancer during COVID-19 pandemic to ensure clinicians have additional treatment options through this time.

These interim treatment regimens are based on clinical opinion from members of the Chemotherapy Clinical Reference Group and specialised services cancer pharmacists and endorsed by NHS England and NHS Improvement. Each interim treatment changed has been clinically assessed against the following criteria:

a) the treatment is less immunosuppressive and thereby mitigates a patient’s likelihood of contracting COVID-19 or becoming seriously ill from COVID-19 or
b) the treatment can be administered at home or in a setting that reduces the patient’s exposure to COVID-19 or
c) the treatment is less resource intensive and makes better use of clinical capacity and
d) the treatment is feasible; that is, it is not likely to require significant service change or additional training and
e) there is likely to be adequate capacity in the relevant sector (such as home care providers) to deliver the treatment
The responsibility for using these interim treatment regimens lies entirely with the prescribing clinician, who must discuss the risks and benefits of interim treatment regimens with individual patients, their families and carers.

All patients who start on an interim treatment during the COVID-19 pandemic should be allowed to continue the treatment until they and their clinician jointly decide it is appropriate to stop or to switch to a different treatment.

The interim treatment changes are for an initial 3-month period only, starting 23 April 2020, and to address the COVID-19 pandemic. Treatment regimens will revert to the standard commissioned position after this period unless this guideline is updated. Any interim treatment change listed below that is currently subject to an ongoing NICE technology appraisal will be superseded by the appraisal guidance should this be published during the COVID-19 pandemic.

These interim treatment changes do not constitute NICE guidance. When using this table, bear in mind that some regimens may not have a UK marketing authorisation for the use listed (for further information, see the General Medical Council's guidance on prescribing unlicensed medicines).

Indication Treatment changes
General •Give prophylactic daily granulocyte-colony stimulating factor (G-CSF) or a biosimilar PEGylated G-CSF to prevent neutropenic fever and reduce admissions (for example, for patients on chemotherapy regimens with a greater than 10% risk of neutropenic fever)

• After an assessment of the risks and benefits to the patient, consider stopping: - later-line palliative treatment to reduce the need for admission - adjuvant therapy for low-risk patients, for example those with breast, lung or colorectal cancer, to reduce the need for immunesuppressive therapy
Acute myeloid leukaemia (AML) • Allow the use of venetoclax with either low dose cytarabine or azacitidine instead of standard induction chemotherapy for newly diagnosed acute myeloid leukaemia, to reduce need for prolonged in-patient admission and reduce risk of neutropenia.

• Allow the use of gilteritinib for relapsed/refractory Flt3+ acute myeloid leukaemia, to reduce toxicity and number of admissions.
Bladder Cancer •Give atezolizumab as first-line immunotherapy instead of chemotherapy to reduce the number of admissions and reduce the risk of neutropenia
Breast Cancer •Suspend treatment with adjuvant bisphosphonates to reduce inpatient visits

• Reduce the course of adjuvant trastuzumab treatment from 12 months to 6 months

• Give pertuzumab plus trastuzumab for neoadjuvant therapy, adjuvant therapy, locally recurrent or metastatic disease without chemotherapy to reduce the risk of neutropenia

• Switch to oral capecitabine from intravenous taxanes with anti-HER2 therapies for metastatic disease to reduce the risk of neutropenia

• Substitute albumin-bound paclitaxel (Abraxane) for paclitaxel or docetaxel to reduce toxicity and potential for admission

• Give atezolizumab for triple negative metastatic breast cancer instead of chemotherapy to reduce toxicity and delay need for subsequent chemotherapy
Colorectal Cancer •Allow intermittent treatment with chemotherapy regimens that contain cetuximab or panitumumab to reduce the need for immunosuppressive treatment

• Give nivolumab (subject to confirmation) as firstline immunotherapy instead of chemotherapy for the treatment of metastatic colorectal cancer with high levels of micro-satellite instability and/or deficient mis-match repair to reduce the number of admissions and reduce the risk of neutropenia
Gestational or placental site trophoblastic tumour •Option to give pembrolizumab first-line or subsequent line instead of combination chemotherapy (change of sequence) to reduce the number of admissions and reduce the risk of neutropenia
Head and neck cancer •Option to give pembrolizumab as first-line immunotherapy instead of chemotherapy to reduce the number of admissions and reduce the risk of neutropenia
Lung cancer (non-small cell) •Stop maintenance pemetrexed in combination with pembrolizumab to reduce treatment toxicity and risk of neutropenia

• Allow pembrolizumab to be given as a single agent as a first-line treatment for squamous or nonsquamous non-small cell lung cancer and a PDL-1 score of less than 50% to reduce treatment toxicity and risk of neutropenia

• Allow durvalumab be given 4 weekly in patients eligible for durvalumab following treatment with chemo-radiotherapy to reduce the number of hospital visits

• Switch to carboplatin and paclitaxel from day 8 treatments such as gemcitabine and carboplatin and cisplatin and vinblastine

• Option to give osimertinib as first-line therapy to delay the need for subsequent chemotherapy
Lung cancer (small cell) •Stop first-line chemotherapy for stage 4 small cell lung cancer after 4 cycles to reduce hospital admission and risk of neutropenia
Lymphoma (Hodgkin) • Option to give brentuximab earlier in treatment pathway to replace salvage chemotherapy, to reduce toxicity of treatment and number of admissions needed for intensive treatment

• Option to give nivolumab earlier in treatment pathway - after brentuximab to replace salvage chemotherapy - to reduce admission time and reduce risk of neutropenia
Lymphoma (non-Hodgkin) • Suspend rituximab maintenance to avoid patients attending hospital • Suspend obinutuzumab maintenance to avoid patients attending hospital

• Allow the use of polatuzumab (in combination with bendamustine and rituximab) for diffuse large Bcell lymphoma as bridging therapy for patients approved for CAR-T therapy, both before and after apheresis

• Switch intravenous rituximab to subcutaneous rituximab in follicular lymphoma patients receiving rituximab with lenalidomide to reduce the time patients spend in hospital

• Allow option to give oral ibrutinib (with or without rituximab) first-line instead of intravenous chemotherapy in patients with mantle cell lymphoma to reduce toxicity of tre
Melanoma •Give oral therapy as first-line treatment for BRAFpositive patients in preference to immunotherapy to reduce admission for intravenous therapy

• Stop immunotherapy doublet (ipilimumab and nivolumab) and switch to single agent nivolumab or pembrolizumab to reduce toxicity
Myeloma •Allow oral pomalidomide with dexamethasone as second- or third-line therapy instead of intravenous treatments in patients previously treated with lenalidomide to reduce the need for chemotherapy and reduce admissions and risk of neutropenia

• Allow first-line lenalidomide and dexamethasone for transplant eligible myeloma patients in preference to regimens that need more hospital attendances and parenteral administrations to reduce toxicity of treatment and number of admissions needed for treatment

• Allow second-line lenalidomide and dexamethasone for patients who have not been previously treated with bortezomib
Neuroendocrine tumours • Give oral temozolomide and capecitabine instead of intravenous streptozocin and 5-fluorouracil to reduce toxicity and admissions for treatment
Ovarian cancer • Give olaparib or other poly-ADP-ribose polymerase (PARP) inhibitors instead of chemotherapy plus maintenance PARP at first relapse for BRCA-positive PARP-naive patients to reduce admissions and risk of neutropenia
Prostate cancer •Option to give enzalutamide (subject to confirmation) with androgen deprivation therapy for patients with newly diagnosed metastatic disease instead of docetaxel to reduce toxicity and potential for admission

• For patients who are intolerant of enzalutamide, give the option of switching treatment to abiraterone
Renal cell cancer • Stop first-line immunotherapy using nivolumab with ipilimumab in intermediate and poor risk groups, and switch to either first-line single agent nivolumab or use oral therapy as first-line and nivolumab with ipilimumab as second-line therapies to reduce toxicity

• Use first- and second-line oral tyrosine kinase inhibitors and switch nivolumab from second to third line to delay use of intravenous immunotherapy (hospital visits)

Interim treatment change options for the COVID-19 pandemic, endorsed by NHS England (27 April 2020)

Source: Targeted Drugs Approved as First-line Alternative for Prostate Cancer. (2020). Retrieved 6 May 2020, from