AML and COVID-19: Chemotherapy Delay May Be the Best Approach

Patients undergoing treatment for acute myeloid leukemia (AML) are severely immunocompromised due to both their disease and the intensive chemotherapy regimens typically used to treat AML. This puts them at increased risk of infection, including during seasonal epidemics and throughout the COVID-19 pandemic.

A study published in Haematologica used data from the European Hematology Association (EHA) EPICOVIDEHA survey to characterize the clinical features of COVID-19 in patients with AML and long-term outcomes.

COVID-19 is already known to present severely in AML patients, with estimated mortality higher than 40% in this population before vaccines were available. However, there has been a lack of studies on large cohorts with long-term follow-ups, and there are no clinical guidelines for optimal management of COVID-19 and AML concurrently.

A total of 388 AML patients with a concurrent COVID-19 diagnosis were identified in the registry and included in the study. Of those patients, 196 patients (50.5%) had controlled AML, while 192 (49.5 %) had active AML. The majority of patients (64.6%) were either currently on intensive treatment or had received intensive chemotherapy or transplantation in the 3 months before COVID-19 diagnosis.

As far as treatment management, 174 patients had their chemotherapeutic schedules modified due to COVID-19 diagnosis, 106 patients permanently discontinued treatment, and 68 patients had delayed treatment due to COVID-19 that was resumed after a median of 1 month post-COVID-19 diagnosis.

A total of 82 patients (21.1%) had critical COVID-19, 160 (41.2%) were classified as severe, 69 (17.9%) had mild COVID-19, and the remaining 19.8% were asymptomatic. Overall, 293 patients (75.5%) were hospitalized and 82 (21.1%) were admitted to an intensive care unit. At a median 325-day follow-up, 180 patients (46.4%) had died, with 78 deaths (43.3%) attributed primarily to COVID-19. Forty-seven deaths (26.1%) were attributed to AML, and 48 deaths (26.7%) were attributed to a combination of COVID-19 and AML.

Patients whose chemotherapy was delayed had a lower overall mortality rate than patients whose chemotherapy was not delayed (18.4% and 37.5%, respectively). Treatment discontinuation was also associated with higher mortality rates, as was age and having active AML.

“The data presented in our manuscript confirm that AML patients frequently have a severe clinical presentation of COVID-19, mainly with respiratory symptoms, and a high rate of ICU admission, even in patients with low-risk AML,” study authors wrote.

Of the treatment approached for concurrent AML and COVID-19, delaying treatment was associated with the lowest mortality rate when compared with therapy discontinuation or no delay of AML treatment. This is in line with findings from a univariable analysis within another study.

Despite study limitations, including a lack of information on COVID-19 vaccinated patients and patient selection bias, considering patients with the ability to delay treatment may have less severe AML.

“Our study shows that COVID-19 in AML patients poses a serious challenge, as it adds a layer of complication which can lead to modified therapeutic algorithms,” the authors concluded. “The mortality rate in this patient group was very high, even when the significant reduction over the pandemic course was considered. According to our results, the best approach to improve the survival of AML patients with COVID-19 seems to delay AML treatment, whenever possible.”

Reference

Marchesi F, Salmanton-García J, Emarah Z, et al. COVID-19 in adult acute myeloid leukemia patients: a long-term follow-up study from the European Hematology Association survey (EPICOVIDEHA). Haematologica. Published online May 12, 2022. doi:10.3324/haematol.2022.280847