The ongoing Coronavirus Disease 2019 (COVID-19) pandemic from its onset in late December 2019 in Wuhan, China has rapidly progressed to a global health crisis disrupting every aspect of conventional medical care. There is no standard approved, universally accepted, therapy available for the acute respiratory syndrome that is induced by COVID-19. While the overall fatality varies between 2 to 1 percent depending on the case definition that is used1 it is recognized that these figures are much higher in older patients, those with pre-existing co-morbidities and also likely to be even higher in patients with cancer and those on chemotherapy or immunosuppression.
Intervention at this time point is directed at interrupting viral transmission by social distancing with the goal of flattening the incidence curve to a level that the current medical care delivery systems can cope with. India was quick to respond to the challenge with a very early closure of its international border and a nationwide lockdown that was praised by WHO as “tough and timely” (India under COVID-19 lockdown. Lancet April 25, 2020. Pg 1315). While this was the need of the hour, the severe restriction on travel limiting access to medical care and re-directing available and already limited medical resources are likely to have debilitating impact on patients with hematological malignancies2, an otherwise already vulnerable population.
The combination of lack of an effective therapy, late onset of severity of illness (mean 9 to 11.5 days) in those that do become ill, a large proportion of asymptomatic infections and high viral titers in the oropharynx in the early phase of the disease leading to high degree of infectivity suggest that this disease and its effects are unlikely to disappear in the near future. One can anticipate periodic surges of disease incidence among a susceptible population in the future. This could have significant adverse impact on delivery of intensive chemotherapy and immunosuppressive regimens that may be required to treat various hematological malignancies and continued risk to health care workers (HCW).
In the absence of an effective vaccine in the near future, one can also anticipate that going forward there will be a cohort of patients who have previously been infected and are less susceptible and another group that has not been exposed and are at high risk of acquiring this infection, especially within a hospital setting and while on therapy that compromises there immunity. Treatment algorithms, location of medical care delivery within a hospital and even the medical teams involved could potentially be different for these two groups.
The current situation forces us as hemato-oncologists to redefine our goals, strategies and treatment algorithms in various hematological malignancies. Strategies to reduce hospital visits, increased use of tele-medicine, switching therapies to favor oral or subcutaneous medication over long intravenous infusions, hypo-fractionated radiation therapy to reduce treatment duration, decrease use of intensive regimens or intense immunosuppression, reducing or eliminating certain diagnostic or prognostic investigations and avoiding maintenance therapy that may only change progression free survival without impacting overall survival at the expense of prolonged immunosuppression our some changes that may be considered (modified from1). These will have to be individualized and prioritized depending on the hematological malignancy being considered.
Hematology Cancer Consortium through its partnering institutions and members put together teams to address common hematological malignancies to come up with suggestions to address these challenges and recommend some strategies to help prioritize and deal with them. It must be recognized that the situation is labile and may also vary significantly from one part of the country to another, these expert opinions are not guidelines and only meant to stimulate us to think of how each of our centers are going to deal with this situation and work towards a consensus based guideline for the country. The concepts outlined under each disease could be used as a possible template for development of institution specific guidelines for a particular hematological malignancy.
1. Fauci AS, Lane HC, Redfield RR. Covid-19 - Navigating the Uncharted. N Engl J Med. 2020;382(13):1268-1269
2. Saini KS, de Las Heras B, de Castro J, et al. Effect of the COVID-19 pandemic on cancer treatment and research. Lancet Haematol. 2020