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Aggressive Supportive Treatment for COVID-19 May Be Needed in Patients With Hematologic Cancers


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New research underscores the need for aggressive support of patients hospitalized with blood cancer and COVID-19, according to data presented at the 2021 American Society of Hematology (ASH) Annual Meeting & Exposition.

Two studies of one of the largest data sets of patients with blood cancer and COVID-19—the ASH Research Collaborative (RC) COVID-19 Registry for Hematology—showed significantly higher mortality among those with hematologic malignancies who are infected with SARS–CoV-2 compared with patients without cancer.1,2 The studies also confirmed the negative impact of age older than 60, male sex, pre–COVID-19 prognosis of fewer than 6 months, and deferral of intensive care unit (ICU) care on mortality among patients with hematologic malignancies and COVID-19.

Pinkal Desai, MD

Pinkal Desai, MD

“We conclude that, if desired by patients, aggressive support for hospitalized patients with COVID-19 is appropriate regardless of remission status, given the results of our study,” said the lead author of one of the studies, Pinkal Desai, MD, Assistant Professor of Medicine at Weill Cornell Medical College and Assistant Attending Physician at the NewYork-Presbyterian Hospital.

ASH Research Collaborative COVID-19 Registry

Lisa Hicks, MD, MSc, a hematologist and Associate Professor of Medicine at the University of Toronto and Co-Chair of the ASH RC COVID-19 Registry Malignant Task Force, was lead author of another study based on the ASH RC database. Dr. Hicks explained the rationale behind the formation of the registry during a press briefing focused on COVID-19–related risks for patients with blood disorders.

Lisa Hicks, MD, MSc

Lisa Hicks, MD, MSc

“Patients with blood cancer are uniquely vulnerable to infections,” said Dr. Hicks. “This is partially because of the strong immunosuppressive treatments they receive, but it’s also because of the unique nature of their cancers, which affect the immune system. When COVID began to spread around the world, there was thus widespread fear in the hematology community about how it would impact people with blood cancer.”

According to Dr. Hicks, the registry was born of a desire to provide practitioners and patients with near real-time information of COVID-19 outcomes among patients with blood diseases. The first analysis of the registry, conducted by Dr. Hicks and colleagues, explored the independent impact of cancer treatment, disease status, type of blood cancer, and other key variables on COVID-19 mortality and hospitalization among patients with blood cancer. The second analysis, conducted by Dr. Desai and colleagues, explored predictors of outcomes from COVID-19 infections in patients with acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), and myelodysplastic syndromes (MDS).

Risks for Hospitalization and Death

In the first study,analysis of 1,029 patients with blood cancer and COVID-19 collected between April 2020 and July 2021 showed an overall mortality rate of 17%.

Multivariable analysis found four variables to be associated with an increased risk of mortality among patients with blood cancer and COVID-19: age older than 60, male sex, an estimated pre–COVID-19 prognosis of fewer than 6 months, and a decision to defer ICU care in favor of palliation. According to Dr. Hicks, these variables were also independently associated with an increased risk of hospitalization with COVID-19, as were the presence of major comorbidities, having active blood cancer, having received systemic treatment in the previous year, and an estimated pre–COVID-19 prognosis of up to 6 months.

“It does appear that patients with blood cancer are likely at higher risk of dying from COVID-19 than are members of the general population,” said Dr. Hicks. “Of course, we can’t compare these numbers, but the mortality reported in the general population does appear to be substantially different.”

Acute Leukemia and MDS: Clinical Predictors of Outcome

According to Dr. Desai, COVID-19 infection has been associated with increased mortality in patients who have advanced age and cytopenia at diagnosis in global populations. Because patients with acute leukemia and MDS are generally older and have disease- or treatment-related cytopenias, this might impact severity and mortality.

Dr. Desai and colleagues utilized the registry to analyze 257 patients with acute leukemia or MDS who developed COVID-19. Multivariable analysis showed that having neutropenia at diagnosis and having active MDS or leukemia were both independently associated with severe COVID-19 illness, defined as ICU admission because of COVID-19. Once patients are hospitalized, however, active disease by itself was not associated with great odds of dying from COVID-19, nor was receiving ongoing cancer treatment.

The researchers found only two variables to be significantly associated with COVID-19 mortality in this cohort: having an estimated pre–COVID-19 prognosis of fewer than 6 months from primary disease and deferral of ICU care when this was recommended to patients. In fact, patients for whom ICU-level care was recommended and declined had five times higher odds of dying compared with patients who opted to go to the ICU.

“Patients who went to the ICU did better regardless of disease status,” said Dr. Desai. “Just having acute leukemia or MDS puts these patients at high risk of severe COVID-19, and they need to be hospitalized and receive treatments. However, decisions about the ICU should be individualized, a patient’s prognosis should be discussed, and if a patient wants aggressive care for COVID-19, that should be offered.”

KEY POINTS

  • Patients with hematologic malignancies are uniquely vulnerable to infections, because of the immunosuppressive treatments they receive, as well as due to the unique nature of their cancers, which impact the immune system.
  • Analysis of the ASH RC COVID-19 Registry for Hematology confirms the negative impact of age > 60, male sex, pre–COVID-19 prognosis of < 6 months, and deferral of ICU care on mortality among patients with hematologic malignancies and COVID-19.

Overall, the mortality in this cohort was 21%. Mortality among hospitalized patients was 34%, and mortality among patients who went to the ICU was 68%.

“Mortality in patients with AML, ALL, and MDS was higher than what was expected for our noncancer population,” said Dr. Desai. She noted, however, the data are limited because they were collected prior to the availability of COVID-19 vaccines.

“Future data should inform about mortality rates among vaccinated patients,” she added. 

DISCLOSURE: Dr. Desai reported financial relationships with Janssen R&D, Astex, Agios, Kura Oncology, Bristol Myers Squibb, and Takeda. Dr. Hicks reported no conflicts of interest.

REFERENCES

1. Hicks LK, Redd RA, Anderson K, et al: Risks for hospitalization and death among patients with blood disorders from the ASH RC COVID-19 Registry for Hematology. 2021 ASH Annual Meeting & Exposition. Abstract 3040. Presented December 12, 2021.

2. Desai P, Goldberg AD, Anderson KC, et al: Clinical predictors of outcome in adult patients with acute leukemias and myelodysplastic syndrome and COVID-19 infection: Report from the American Society of Hematology Research Collaborative (ASH RC) data hub. 2021 ASH Annual Meeting & Exposition. Abstract 280. Presented December 11, 2021.


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