The Impact of the COVID-19 Pandemic on the Diagnosis and Management of Patients with Classical Hodgkin Lymphoma: A Single-Center Experience
Authors: Kucukyurt Selin , Şahin Kübra , Yılmaz Umut , Erçalışkan Abdülkadir , Özkan Tekin Tuba , Ortaboz Damla , Elverdi Tuğrul , Salihoğlu Ayşe , Ar Muhlis Cem , Öngören Şeniz , Başlar Zafer , Eskazan Ahmet Emre 
Published: November 2021

Abstract
Background: The coronavirus disease 2019 (COVID-19) pandemic has brought life to a standstill all over the world. Especially in Istanbul, the most populated city in Turkey, many hospitals served as pandemic hospitals and suspended the examination of patients who were not infected with COVID-19. On the other hand, in this period, lockdown was applied frequently to control the pandemic and to reduce the transmission. It is known that the delay in the diagnosis and treatment of cancer can sometimes be fatal. Initial treatment choice in classical Hodgkin lymphoma (cHL) patients is determined by various factors including the stage of the disease. Therefore, detection of the disease at an early stage has prognostic importance. Our aim was to compare the time from symptom onset to diagnosis and period between diagnosis and treatment initiation, as well as the distribution of stages and treatment responses in cHL patients diagnosed and treated during the COVID-19 pandemic and in the pre-pandemic period.
Methods: Patients who were diagnosed within the 2 years before the pandemic (between March 2018 and March 2020) and in a 12-month period during the pandemic (between March 2020 and March 2021) were compared in terms of demographic data, disease related factors, time interval between symptom to diagnosis, and interim treatment response. Clinical data were obtained from manual and electronic medical records retrospectively. PET scans were performed at baseline, after two cycles of chemotherapy, and end of treatment (EOT). The Deauville five-point scale (5-PS) was used in the initial staging and assessment of treatment response. The 5-PS; a score of 1, 2, or 3 was considered negative. The 5-PS score 4 or 5 was positive.
Results: This single-center study included 90 newly diagnosed cHL patients, with a median age of 33.5 years (range, 17 - 70 years) and a male predominance (53.3%). The most common presenting symptom was a lump in the neck (41.1%), and also, 61.1% (n=55) of the cases had at least one B symptom. Patient characteristics were summarized in Table 1. Age and sex distributions were similar in both groups. Also, the number of patients &gt;60 years was comparable (p=0.868). The most common histopathological subtype in both groups was nodular sclerosis (47.7% vs. 48%). In the pre-pandemic period and during the pandemic, the percentages of patients with early unfavorable disease were 66.7% and 77.8%, respectively (p=0.526). Although the percentage of patients with advanced-stage disease was higher during the pandemic than that observed in the pre-pandemic period (64% vs. 53.8%), this difference did not reach statistical significance (p=0.384). The median interval between symptom onset to diagnosis was significantly longer during the pandemic than was observed within the pre-pandemic era (16 weeks vs. 8 weeks, p=0.042). The median durations between diagnosis and treatment initiation were similar in both groups (13 days vs. 15 days, p=0.253). The majority of patients in both groups received ABVD as first-line therapy, and IFRT was performed in some patients with early-stage cHL (Figure 1). Among all patients (n=90), 85% of the cases had negative interim PET scan results, and this percentage was similar for both patient groups (84.6% vs. 88%, p=0.999). In the pre-pandemic period, 80% of the patients had complete response at EOT, on the other hand, no comparison was performed between two groups regarding response level at EOT, since nearly half of patients (48%) treated during the pandemic were not evaluated for the EOT response at the time of the analysis.
Discussion & Conclusion: In our cohort, the time interval between symptom onset to diagnosis was significantly prolonged during the pandemic. Most probably the patients were afraid of admitting to the hospital due to the fear of contagion, or patients might have experienced difficulties in applying to a health facility, and lastly maybe they had tolerable symptoms, which might all have roles in the diagnostic delay during the pandemic. Higher percentage of patients with advanced-stage disease during the pandemic might also be associated with this delay, however, fortunately, this difference did not translate into a significant difference regarding interim treatment response in both groups.
Figure 1 Figure 1.

Disclosures
No relevant conflicts of interest to declare.