COVID-19 has now taken hold in over one hundred eighty countries. According to a recent article in The Lancet, in May of 2020, the United States reported the highest number of cases in the world. The infection has spread to all fifty states.
The number of fatalities is uncertain but estimated to be about one percent worldwide. However, the elderly and immunocompromised seem to be at a higher risk with fatalities in this population possibly as high as fifteen percent in patients eighty years and older.
Of particular concern are patients with blood cancers such as acute myeloid leukemia, myeloproliferative neoplasms, and myelodysplastic syndromes, where the average patients are between sixty-five and seventy years of age.
Early Chinese data suggests COVID-19 fatalities average about five percent in cancer patients.
As yet the exact incidence of leukemia patients with COVID-19 has yet to be determined.
Pandemic Causing Disruptions in Cancer Care
Due to the pandemic, many leukemia patients have witnessed the disruption of cancer therapies. Moreover, the risk of SAR-CoV-2 infection has affected healthcare personnel in diagnostic specialties.
Therefore, adapting oncology treatment to the pandemic requires planning by local health officials, policymakers, oncology, and hematology representatives. An international panel of oncology and hematology experts specializing in myeloid neoplasms, leukemia, and transplants have offered recommendations.
Although COVID-19 has become a global health concern, it has been noted that more severe post-infection results occur in cancer patients.
In order to adhere to recommended safety guidelines, in-person hospital visits should be kept to a minimum and physical distancing must be mandatory. This applies to hospital staff and patients.
It is highly recommended that hospital personnel, especially the staff assigned to the care of patients who have hematological malignancies, be continuously tested for COVID-19. The frequency of testing should conform to local patterns. This precaution would be in addition to the staff being appropriately outfitted with protective equipment and using stringent procedures to prevent infections.
A strong recommendation from the panel involves the strict separation of oncology departments and COVID-19 areas. The panel emphasized that the clinics and cancer wards must be free of COVID-19 patients. It went further by suggesting three separate areas with nursing staff following a protocol designed to avoid transmission.
One area would treat positive SARS-CoV-2 patients. Another section would involve hematological patients who tested negative for the virus. A third area would be a holding area that isolates patients until their virus status is determined.
The panel suggests prioritizing patients based on the urgency of their disease. It may be possible to delay treatment and in-person visits by using remote and telehealth communication. But in some urgent cases that require life-sustaining therapies, in-person oncology visits cannot be delayed.
In these situations, if possible, therapy should be administered locally to avoid major academic centers.
Changes in Supportive Care
Supportive care for patients with hematological malignancies who require ongoing therapy may be compromised due to the pandemic.
Well thought out plans may suffer due to increased illness of the hospital staff, their fear of exposure, or their concerns about the safety of their family. Many facilities are already functioning at maximum capacity.
For patients with hematological malignancies, the decrease in available staff translates into interruptions in the administration of chemotherapy, radiation, and surgical procedures. It also means a decrease in laboratory tests and in-person oncologist visits.
The motivation to donate blood products can be affected by fear of the virus. Here again, the result is a potential shortage of platelets, red blood cells, and plasma factors.
One solution may be the implementation of restrictive transfusion guidelines. Adhering to these guidelines plus more liberal use of growth factors may decrease the need for transfusions.
Virtual Doctor Appointments During Pandemic
The first step would be for physicians to determine whether patients can be “seen” in a virtual setting and for how long. But then there are specific procedures such as blood tests and therapies that require in-person visits.
Services such as telehealth are widely available and have proven to be invaluable platforms when following distancing guidelines. They may be used as venues for patient/provider sessions in situations that do not require transfusions or laboratory tests.
Therefore, choosing clinical appointments over telemedicine should be individualized in accordance with the demands of the illness. Physicians must always be on the lookout for potential complications.
COVID-19 and Management of Transfusions
It is assumed that during the pandemic there will occasionally be shortages of blood products. It is recommended that physicians consider increasing the time between transfusions as well as increased units of red blood cells per transfusion for patients with serious comorbidities.
With respect to platelet transfusions, a phased response is recommended based on an estimation of the volume of resources in the blood bank. In the event of a severe shortage, it may be possible to substitute antifibrinolytics, which prevent the breakdown of fibrin, the main protein in a blood clot.
A Catch 22
Neutropenia is associated with a low neutrophil count. Neupogen is one of the growth factors used to increase neutrophils.
However, consideration should be given to the risks involved for a patient who also has COVID-19. This is due to the fact that using growth factors to increase neutrophils in the presence of COVID-19 may also increase pulmonary inflammation.
The Pandemic’s Impact on Clinical Trials
It is highly recommended that patients continue to participate in clinical trials that are studying drugs with promising therapeutic benefits. Many of these trials, when and if available, may be the only option available to some cancer patients.
On the other hand, weighing the risk of being randomly assigned to certain standard-of-care treatments in other trials suggests that this type of clinical trial should be carefully evaluated.
It should be noted that onsite monitoring during the trials is difficult due to the distancing requirements caused by the pandemic. The FDA and health organizations in other countries have published guidances in this regard.
The medical community is now coping with the burden of the pandemic in addition to its struggle to contain and eventually cure cancer.