There’s No Avoiding Difficult Choices

What your doctor is reading on Medscape.com:

APRIL 17, 2020 — I am sitting in Manhattan, in the middle of a nightmare. We are at the epicenter of the COVID-19 outbreak in the United States. The hospitals where I practice—Weill Cornell Medical and NewYork-Presbyterian—have become frontline outposts more or less solely devoted to treating this devastating virus. 

Knowing that I have had an up-close look at this pandemic’s impact, many of my colleagues have asked me if I had any guidelines for how they should adjust their treatment of acute myeloid leukemia (AML). Yet, like them, I have no idea what the situation on the ground will be in a week or two, here or elsewhere in the world. Any such guidelines would also be tremendously influenced by regional variations in the spread of COVID-19 and in how patients are treated. There is simply no way to ensure consistent practice for individual patients across the country or even across the world. This uncertainty would probably render any guidelines substantially outdated, if not outright irrelevant, by the point they reach you.

This is not the time for guidelines, but instead for bespoke, individualized medicine. With that said, what I can offer are my thoughts, based on my ongoing clinical experience rather than the latest data, about how COVID-19 has substantially reframed how we are treating our patients with AML.

Considerations by Disease Status

Of course, the first goal is to keep patients in remission and out of harm’s way. Although we don’t have data yet on the impact of COVID-19 on patients with AML who are in remission, we certainly know that patients with cancer in general are experiencing increased mortality rates as a result of the virus. Therefore, we’re trying to keep people out of the hospital and to not drop their blood counts.

Many of our elderly patients on azacitidine- and venetoclax-based regimens would typically be receiving ongoing therapy on a monthly or every-6-week basis. However, we are now delaying those treatments so they can avoid coming to our center, which is currently overrun with COVID-19-positive patients.

I don’t want older patients who are feeling pretty well to leave their house. I want them to stay home. For how long exactly, I don’t know. But I’m certainly not starting any additional cycles of post-remission therapy right this minute.

For patients with newly diagnosed leukemia coming into the center for necessary treatment, it’s critical, if possible, to get a rapid-turnaround coronavirus test to know at the beginning whether they are or are not positive. Some of these patients decline very rapidly. If you start AML therapy right out of the gate without knowing the COVID status, it will be nearly impossible to determine the source of any complications they may later experience.

If these patients are COVID-19 positive, it is very important to try to hold off treatment for a few days, even if you need hydroxyurea, to monitor how quickly the coronavirus disease is going to evolve. If the patient already has an extremely poor COVID-19 status, unfortunately it’s going to be simply impossible to get intensive chemotherapy going.

Difficult Conversations, Painful Decisions

For newly diagnosed older patients, one has to look carefully at the overall probability of getting them into remission. If you have a much older, frail patient with a complex karyotype or with p53 mutations, you may not even want to try an induction. At this moment, hospitals in my area aren’t allowing any visitors, which means such a patient is going to be separated from their family while also having a poor chance of long-term survival. Unfortunately, these types of horrible conversations are happening every day.

In older patients who are in better shape, for whom remission may be feasible, one still has to be very careful about using regimens with venetoclax and azacitidine. Although these certainly have less problematic side-effect profiles for older patients than does standard chemotherapy, they are still myelosuppressive. You’re going to need to do blood checks and transfusions during a time when the lack of donor drives is leading to critical blood shortages nationwide.

Even for an older patient getting a less intensive regimen, you have to carefully consider how you’re going to follow them. How are they going to get back and forth from home? Could they reasonably stay safely in your hospital, alone, without visitors?

These terrible conversations are currently taking place regarding the care of patients with relapsed and refractory disease. Realistically, these patients are not going to be able to be supported in intensive care units or on ventilators when they have terminal prognosis due to underlying disease.

Before embarking on any type of a salvage therapy, it’s important to be really honest with patients and their families about the chances of success. We need to explain to them how difficult it will be for them to be trapped in the hospital, separated from visitors.

If there are patients whom you believe have a good chance of responding to salvage efforts (eg, they experienced a long first remission), it is again key to establish their COVID status prior to starting therapy. That will give you a sense of the likely trajectory for at least the first couple weeks of their starting treatment.

Keep Patients Home, for Their Own Health

The main message is to keep people at home who can stay at home.

I’ve even started applying this to patients whom I would normally see twice a week for a blood count check. I’m now using telemedicine to check on them at home. If they feel fine and show no signs of oral bleeding or petechiae, I’ll maybe skip that second blood count check and have them stay home. Some of these patients can also obtain blood counts locally or even at home, which would give you a sense of whether they really need to be seen in the office.

For those patients who must be seen in person, most hospitals and offices in my area have implemented prescreening procedures. Rather than just showing up, patients are encouraged to first participate in a telemedicine check. Before they leave their home, they are asked whether they have relevant signs and symptoms, such as coughing or fever. If so, they may be told to use a separate entrance to the building. This allows us to not only try to keep them away from other people, but also to protect the healthcare workers, who can don appropriate personal protective equipment.

Of course, where you practice will factor largely into these decisions. I’ve spoken with colleagues outside of New York City whose patients can drive up to their office and see them without interacting with another person. Many of my patients in New York City don’t have that option. They’re reliant on public transportation and may live in quite close quarters with those who are already COVID-19 positive. Under these circumstances, rapid COVID testing for newly diagnosed patients embarking on therapy is essential.

Regardless of where you practice and how COVID-19 is currently affecting you, there is one set of guidelines that applies across the board. You probably know them by heart at this point, but they are worth restating: Wash your hands, a lot. Don’t touch your face. Stay at home whenever you can. And please be safe.