- Missed or delayed diagnosis
- In the context of SARS-CoV-2 screening/diagnosis, full blood counts are performed only in a minority of symptomatic patients, as they are generally reserved to those with confirmed SARS-CoV-2 infection with associated signs of severity. The presenting symptoms of hematologic malignancies can be similar to those of COVID-19 infection; in fact, 50-75% of patients with acute leukemia are febrile at diagnosis. This also applies to other malignancies such as primary mediastinal lymphoma or lung cancer, which may present with a cough. In the setting of the current pandemic, these symptoms are likely to be considered trivial following a negative SARS-CoV-2 test, potentially leading to missed or delayed diagnoses of certain oncological conditions; physicians should imperatively keep the possibility of acute leukemia in mind.
2. Delay, deferral or modification in treatment
- Chemotherapy regimens may be postponed to avoid immunosuppressive treatments, to limit hospital visits or due to an eventual shortage of isolation beds and blood products; delays in initiation of chemotherapy may negatively affect prognosis, especially in young patients with favorable or intermediate risk disease.
- Transplantation societies recommend the deferral of hematopoietic stem cell transplantations (HSCT); the impact of delayed transplant on prognosis remains unclear, but if it results in the reappearance of a significant minimal residual disease (MRD), a negative impact on survival is well established.
- GRAALL-14 investigators instruct physicians to omit prednisone and vincristine in maintenance therapy, whilst continuing methotrexate and 6-mercaptopurine. The impact of dose-reduction and/or drug eviction on patient survival and relapse rate is unknown.
- Targeted therapies could potentially be used, but physicians must be aware of their interactions with drugs are used to treat SARS-CoV-2 and its complications (e.g. QTc prolongation with arsenic trioxide combined with antivirals or antibiotics).
3. Shortfall of blood products
- Blood products shortage has already begun in some affected countries; most transfusion societies call for conservative transfusions policies in line with evidence-based guidelines for patient’s blood management.
4. Investigational therapies and clinical studies
- Ongoing clinical studies are likely to be impacted by modifications in therapy protocol, increased subject withdrawal and excess SARS-CoV-2-related mortality; these factors will impair the strength of the results and complexify their interpretation.
5. Prophylactic measures
- Leukemia patients, especially those with recent or ongoing treatment, are to be protected from COVID-19; they should be isolated at home, and their consultation appointments must be reduced to a vital minimum. They should have up-to-date vaccination status.
This information comes a from a literature review, to be published in May in Leukemia Research, that exposes the potential impacts of the current pandemic on patients with acute leukemia in terms of diagnosis, treatment and supportive measures; it offers clues and recommendations to hematology physicians on how to mitigate these impacts and adapt their practice.
Gavillet M., Carr J., Spertini K.O. and Blum S. (March 26, 2020). Acute leukemia in the time of COVID-19. Leukemia Research. https://doi.org/10.1016/j.leukres.2020.106353