High morbidity and mortality among COVID-19 patients with haematologic malignancies
Patients with coronavirus disease 2019 (COVID-19) who have haematologic malignancies have a 28 percent mortality rate, according to data collected from 250 patients by the ASH Research Collaborative COVID-19 presented at the 62nd American Society of Hematology Annual Meeting and Exposition (ASH 2020).
“Early in the COVID-19 pandemic, reports emerged that patients with active or resolved cancers may be at particularly high risk of adverse outcomes from COVID-19. This was especially concerning to patients with haematologic malignancies as many of them have an underlying immune dysfunction and are uniquely vulnerable to viral and other infections. Additionally, blood cancer treatments, including cytotoxic agents, immunomodulators, haematopoietic stem cell transplantation, and chimeric antigen receptor T-cell therapy, are profoundly immunosuppressive,” wrote the study authors. [Lancet Oncol 2020;21:e181; Infect Dis Clin North Am 2019;33:523-544]
The ASH Research Collaborative COVID-19 Registry for Hematology opened for data collection on 1 April 2020, and data reported at ASH 2020 were collected through 8 July 2020. Data from 250 patients with blood cancers from 74 sites around the world (including 35 patients from Asia) had been entered into the registry. The most common malignancies were acute leukaemia (33 percent), non-Hodgkin lymphoma (27 percent), and myeloma or amyloidosis (16 percent). Physician-estimated prognosis for survival before COVID-19 diagnosis was >12 months for 62 percent of patients. [Wood W, et al, ASH 2020, abstract 215; Blood Adv 2020;4:5966-5975]
At COVID-19 diagnosis, 78 percent of patients were >40 years of age, and 36 percent were aged >70 years. “Older age was associated with moderate or severe disease [p<0.001], a decision to forgo ICU care in favour of a palliative approach [p<0.001], and mortality [p=0.01],” noted the researchers. The mortality rate was 11–13 percent in patients <40 years of age, 27 percent in those 40–70 years of age, and 39 percent in those aged >70 years.
Among patients with moderate (n=96; 38 percent) or severe (n=72; 29 percent) COVID-19, mortality rate was 42 percent. Of those with at least moderately severe COVID-19 for whom ICU admission was forgone in favour of palliative care (n=37), 33 died (89 percent). “Of those with at least moderate-severity infection who did not forgo ICU admission [n=131], 35 died [27 percent; p<0.001 for those who did vs did not forgo ICU admission],” noted the researchers. “Male sex was associated with more frequent preference for a palliative approach [p=0.03] and mortality [p=0.008].”
“Patients with haematologic malignancies and COVID-19 presented with a myriad of symptoms, the most common being fever [73 percent], cough [67 percent], dyspnoea [50 percent], and fatigue [40 percent]. A high index of suspicion for COVID-19 is needed during periods of high disease prevalence in the overall population,” suggested the researchers.
The most common COVID-19–specific therapies for patients with at least moderate-severity disease were hydroxychloroquine and azithromycin, used in 76 (64 percent) and 59 (50 percent) patients, respectively. “Although we do not know which of these treatments were offered as part of a clinical trial, it is reasonable to assume that this percentage was low, given the historically low rates of enrollment of cancer patients onto clinical trials before the COVID-19 pandemic. Off-label use of COVID-19–directed therapies in patients with haematologic malignancies could be potentially problematic due to unexpected toxicities of these agents, potential drug-drug interactions in cancer patients, and emerging data suggesting ineffectiveness or potential harm from these treatment approaches in COVID-19 and cancer,” warned the authors. [Cancer 2018;124:4601-4609; Cancer Chemother Pharmacol 2005;56:286-290; Cancer Discov 2020, doi: 10.1158/2159-8290.CD-20-0941]