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Real-world assessment of the clinical impact of symptomatic infection with severe acute respiratory syndrome coronavirus (COVID-19 disease) in patients with multiple myeloma receiving systemic anti-cancer therapy Dear Editor, Infection with the novel coronavirus SARS-CoV-2, resulting in an acute respiratory disease (COVID-19), is the cause of the current pneumonia pandemic, with a rapid rise in cases being reported in the European Union and UK. 1,2 The UK index case was identified on January 31, 2020 and, given the rapid spread and high mortality rate of COVID-19, it is imperative to define the impact on patients with co-existing medical conditions. 3 Multiple myeloma (MM), the second-most common haematological malignancy, is a cancer of the mature B-cell lineage, and is associated with both cellular and humoral immune dysfunction that renders patients susceptible to infections, especially of the respiratory tract. [4][5][6][7] This, coupled with a median age at presentation of 70 years in a population with frequent co-existing medical conditions, means the outcomes of MM patients infected with COVID-19 warrants particular attention. We conducted a fully-anonymised prospective clinical audit where only MM patients with documented symptomatic COVID-19, whether managed in the inpatient or outpatient setting, were reported. All patients were tested within the secondary care setting and were receiving systemic anti-cancer therapy (SACT).At the time of analysis (May 18, 2020), 75 completed proformas from MM patients who tested swab-positive for COVID-19 had been received (Table I). The median age of COVID-19-positive MM patients was 73 years (range, 47-88), with 27Á5% of patients >80 years of age. Where ethnicity details were available (n = 51), most (82%) were Caucasian, with 16% being Afro-Caribbean. 41% of patients were newly-diagnosed MM receiving frontline therapy (NDMM); 24% had relapsed from their frontline therapy and were now receiving second-line therapy (1 st REL); and 35% had relapsed and/or refractory disease (RRMM). The median absolute lymphocyte count at presentation with COVID-19 symptoms was 600 cells/ll (range, 0-2500), with 90% of patients demonstrating hypo-gammaglobulinaemia affecting at least 1 sub-class (IgG> IgM>IgA). The male/female ratio was 1Á5, but varied with age (<75 years ratio 2Á33 vs. >75 years ratio 0Á94) as a consequence of significant age difference between the groups (P = 0Á049).The median time from the UK Index case to COVID-19 symptoms was 54 days (range, 23-88). 20Á5% of patients did not have a temperature on presentation but did have a cough, and 16% reported GI symptoms, with 20Á5% of patients acquiring COVID-19 whilst an inpatient for other reasons. 75% had evidence of pulmonary infiltrates primarily detected by chest radiograph. All but three patients were admitted for clinical care. Systemic anticancer therapy (SACT) was stopped a median of 0Á5 days (range, 5-23) after the onset of COVID-19 symptoms. Only nine of 70 patients received critical care support, with five pati...

SummaryAlthough the incidence rate of acute lymphoblastic leukaemia (ALL) is slightly higher in older than in younger adults, response rates to induction chemotherapy and survival rates are poorer. The contribution of disease‐related versus treatment‐related factors remains unclear. We analysed 100 older patients (aged 55–65 years) treated on the UKALLXII/ECOG2993 trial compared with 1814 younger patients (aged 14–54 years). Baseline characteristics, induction chemotherapy course, infections, drug reductions and survival outcomes were compared. There were more Philadelphia‐positive (Ph+) patients in the older group (28% vs. 17%, P = 0·02), and a trend towards higher combined cytogenetic risk score (46% vs. 35%, P = 0·07). The complete remission rate in older patients was worse (73% vs. 93%, P < 0·0001) as was 5‐year overall survival (21% vs. 41%, P < 0·0001) and event‐free survival (EFS) (19% vs. 37%, P < 0·0001). Older patients had more infections during induction (81% vs. 70%, P = 0·05), and drug reductions (46% vs. 28%, P = 0·0009). Among older patients, Ph+ and cytogenetic risk category as well as infection during induction predicted for worse EFS. Poorer outcomes in these patients are partly due to cytogenetic risk, but there is significant morbidity and mortality during induction chemotherapy with frequent delays and drug reductions. New approaches, including better risk stratification and use of targeted therapies, could improve treatment for these patients.