Treating Leukemia in the Time of COVID-19

Abstract

The coronavirus disease 2019 (COVID-19) pandemic poses several challenges to the management of patients with leukemia. The biology of each leukemia and its corresponding treatment with conventional intensive chemotherapy, with or without targeted therapies (venetoclax, FLT3 inhibitors, IDH1/2 inhibitors, Bruton's tyrosine kinase inhibitors), introduce additional layers of complexity during COVID-19 highrisk periods. The knowledge about COVID-19 is accumulating rapidly. An important distinction is the prevalence of "exposure" versus "clinical infectivity," which determine the risk versus benefit of modifying potentially highly curative therapies in leukemia. At present, the rate of clinical infection is < 1-2% worldwide. With a mortality rate of 1-5% in CO-VID-19 patients in the general population and potentially of > 30% in patients with cancer, careful consideration should be given to the risk of COVID-19 in leukemia. Instead of reducing patient access to specialized cancer centers and modifying therapies to ones with unproven curative benefit, there is more rationale for less intensive, yet effective therapies that may require fewer clinic visits or hospitalizations. Here, we offer recommendations on the optimization of leukemia management during high-risk COVID-19 periods.

Concurrent Diagnosis of Acute Myeloid Leukemia and COVID-19: A Management Challenge

“…The concurrence of AML and COVID-19 presents an extraordinary challenge of treating two potentially life-threatening diseases at the same time. The National Cancer Research Institute (NCRI) AML working group and other expert reviews recommend screening all the patients with AML for SARS-CoV-2 prior to initiation of therapy regardless of symptoms [3,5]. Although the induction for newly diagnosed AML is often done on an emergent basis, a reasonable delay in order to test a symptomatic patient for COVID-19, or to provide appropriate management for the COVID-19 infection may be a prudent approach [6].…”

“…There is a dearth of data on the prognosis and optimal management of patients with concomitant COVID-19 and hematological malignancies [1,2]. In general, some studies suggest that cancer patients may have a higher rate of COVID-19 infection, severe illness, rapid development of severe symptoms and mortality [1][2][3][4]. While it is of utmost importance to minimize the risk of COVID-19 in the immunocompromised population, patients require intensive monitoring and modified treatment strategies once the infection occurs.…”

ACE2andTMPRSS2expression by clinical, HLA, immune, and microbial correlates across 34 human cancers and matched normal tissues: implications for SARS-CoV-2 COVID-19

“…In hematologic malignancies, increased mortality after infection has been widely observed 23 with some connections to recent chemotherapy. 24 In solid tumors, the risk of recent chemotherapy may also be linked to other high risk factors such as age with the impact of treatment being variable. 22 Particularly, there has been concern that patients being treated with cancer immunotherapy drugs might be at increased risk given the possible overlapping immune-related toxicities for checkpoint blocking antibodies with the pneumonitis and diarrheal syndromes seen in COVID-19.…”

Management of Patients With Hematologic Malignancies During the COVID-19 Pandemic: Practical Considerations and Lessons to Be Learned

“…No significant differences in baseline characteristics were observed between the patients with hematologic malignancies who developed COVID-19 and those who did not. However, COVID-19 appeared to be more severe, and more deaths were reported, in the patients with hematologic malignancies compared to the cohort of healthcare providers who developed Several papers have appeared, by individuals, groups of specialists or under the auspices of scientific societies, to offer an initial description of the clinical presentation of COVID-19 in patients with hematologic malignancies and to advocate for general recommendations of good clinical practice in this pandemic period, for both adult and pediatric patients (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21). One interesting case report involved a SARS-CoV-2 infection in a 39-year-old patient with chronic lymphocytic leukemia (CLL) where the clinical and biochemical manifestations of COVID-19 were partly masked by the coexisting CLL (6).…”

“…Specific guidelines have been proposed for chimeric antigen receptor T-cell (CART) therapy (9), acute myeloid leukemia and myelodysplastic syndromes (10)(11)(12)(13)(14), infections (15), chronic myeloid leukemia (16), chronic lymphocytic leukemia (17), and use of BTK inhibitors (18), which may have the potential benefit of blunting the hyperinflammatory response to SARS-CoV-2, but also potentially increasing the risk of secondary infections or impaired humoral immunity (18).…”