Many MyLeukemiaTeam members have concerns about their risk for contracting and experiencing serious complications from the new coronavirus (COVID-19). We asked Dr. David Blumenthal, a medical oncologist with Kaiser Permanente, to help us better understand how blood cancers such as leukemia and treatments for leukemia might influence risk relating to COVID-19.
The first question many people with leukemia want answered is whether they are at increased risk. Dr. Blumenthal said, “The short answer to that is yes. But everybody's situation is going to be unique and different.”
He continued, “Every individual patient has their own set of risk factors that will both impact their risk of getting COVID-19 and their risk of getting seriously ill from it. [Medical oncologists try to determine] who is in the highest risk categories and what we should do to mitigate those risks, from suspending some patients’ treatments to trying to keep our infusion centers as safe as possible for patients.”
“Every oncologist around the country is engaging right now to try to figure out what the safest thing is to do for our patients,” he said.
Dr. Blumenthal noted that each individual should be evaluated by their oncologist. “Leukemia is a very broad disease with a lot of different types,” he said.
However, on a very general level, oncologists perceive different degrees of COVID-19 risk for the major types of leukemia. The table below shows general risk levels people with leukemia may have for contracting or having complications from COVID-19.
|Type of Leukemia||Risk of contracting COVID-19||Risk of complications from COVID-19|
|Acute lymphocytic leukemia (ALL) undergoing chemotherapy||Highest risk||Highest risk|
|Acute lymphocytic leukemia (ALL) in remission||Low additional risk||Low additional risk|
|Acute myeloid leukemia (AML) undergoing chemotherapy||Highest risk||Highest risk|
|Acute myeloid leukemia (AML) in remission||Low additional risk||Low additional risk|
|Chronic myeloid leukemia (CML)||No additional risk||No additional risk|
|Chronic lymphocytic leukemia (CLL)||Higher risk||Higher risk|
According to Dr. Blumenthal, people with acute forms of leukemia such as acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) are “probably our highest-risk patients for getting COVID and getting complications from COVID.”
People living with ALL or AML “have markedly diminished immune systems. And the treatments also really make the immune system substantially weakened,” Dr. Blumenthal said. He went on to say they are much more likely to develop complications from COVID-19 than people who do not have acute leukemia.
The challenge people with acute leukemia face in this period of great uncertainty with COVID-19 is that they often still need to be treated for leukemia. That treatment cannot be postponed. “Unfortunately, acute leukemia is a disease that moves too fast [to delay treatment],” Dr. Blumenthal said. “We've had to continue all of our patients with acute leukemia on their treatment as scheduled. And we've really tried to be as careful as we can be with precautions.”
Another risk for people with ALL and AML is hospitalization during leukemia treatments. “Hospitals around the country are really trying to keep those patients physically isolated from the rest of the hospital — with minimal staff interruptions from anyone who’s going to other parts of the hospital — because those are our most vulnerable patients,” Dr. Blumenthal said. “Unfortunately, in terms of treatment protocols, there are just not a lot of realistic modifications we can make to try to make it safer, but we can try to make our hospital system as safe as we can.”
Dr. Blumenthal noted that people with chronic myeloid leukemia (CML) generally have a lower increased risk of contracting COVID-19. People with CML often take tyrosine kinase inhibitors (TKIs), such as Gleevec (Imatinib), Sprycel (Dasatinib), Tasigna (Nilotinib), and Bosulif (Bosutinib).
“Patients who have well-controlled CML on a TKI probably have very minimal, if any, increased risk of getting COVID-19 and getting sick from it,” Dr. Blumenthal said. “Most of those TKIs do not really substantially affect the immune system in a negative way, in particular against viral infections like COVID. We're hopeful that our CML patients who are well controlled on a TKI should be as safe as the general population.”
People who have chronic lymphocytic leukemia (CLL) are at a higher risk of contracting COVID-19 and having COVID-19 complications. “Unfortunately, they are at a pretty increased risk of getting COVID whether they're on treatment or not,” Dr. Blumenthal said. “CLL [is a] cancer of the lymphocytes, which are particularly important for defense against viral infections, and we know those patients tend to get viral infections much more easily, even if they're off treatment.”
Oncologists treating CLL “have some flexibility with treatment because it is not a very fast growing blood cancer,” Dr. Blumenthal explained. Doctors may consider postponing treatments, if appropriate.
Chemotherapy and immunotherapy, such as Rituxan (Rituximab) or Blincyto (Blinatumomab), are common types of treatments for people with leukemia, as are stem cell treatments.
People with acute leukemia often have chemotherapy administered by infusions at a clinic or an infusion center. These individuals may be on chemotherapy regimens such as CHOP or EPOCH.
Dr. Blumenthal warned that these individuals probably have increased risk for getting COVID-19. “Some of those patients are patients who we could consider deferring,” he said, “but most of the time they need to be treated now and can't realistically wait.”
No one knows how long it will be before the risks decrease from COVID-19. As Dr. Blumenthal explained, “If it’s just a couple weeks, that's not such a big deal. But the COVID situation is rapidly evolving and a big unknown. It could be worse in two weeks; it could be worse in two months. So it's hard for us to defer patients who we think will need treatment in the next few months.”
According to doctors affiliated with the Dana-Farber Cancer Institute, people who are taking steroids or other treatments for leukemia or lymphoma may not experience a high fever (or even a fever at all) if they contract COVID-19 — although it is a typical symptom of the new coronavirus.
“There aren't really any issues so far as we know, with [our] infusion centers being vectors,” Dr. Blumenthal said. “I think it's because we have really tried to take a lot of precautions.”
Dr. Blumenthal described several measures clinics use to keep the infusion centers safe for people with leukemia, including:
“Through that combination of efforts, we're hoping that infusion centers will stay safe. But it's a risk,” Dr. Blumenthal said. “There's no guarantee, and is it possible that in the future, someone will get COVID-19 from coming to an infusion center? We can't 100 percent eliminate that risk.”
During the COVID-19 pandemic, many doctors are considering delaying stem cell transplants for people with leukemia by at least two months, if that is an option. “It's going to be patient-specific, and it's going to be center-specific,” explained Dr. Blumenthal. “In general, we are thinking about [for whom] can we safely defer the transplant.”
Where you live may impact this decision too. “If you're in a city or part of the world where there is a really high incidence [of COVID-19] right now, you really want to be thoughtful about who you're sending into the hospital for a transplant,” Dr. Blumenthal said. “If you're in a part of the country where there hasn't been as much, you could think about things a little differently.”
Dr. Blumenthal described chimeric antigen receptor (CAR) T-cell therapies as “a reprogramming of white blood cells, most commonly the patient's own white blood cells. They are harvested from a patient, then programmed to fight that patient's cancer, and then given back to the patient. We're really modifying the patient's own immune system to fight their cancer.”
Given that CAR T-cell therapy is newer, its risks are less well known. “This means that we really don’t know the impact of COVID-19 on people going through these treatments,” Dr. Blumenthal said. “We presume that those patients are going to be at increased risk. … For patients who have been on CAR T-cell therapy in their lifetime, they're potentially at increased risk [for infections] for the rest of their lives.”
Read more about CAR T-cell therapy.
Dr. Blumenthal suggests reaching out by phone or email to ask your doctor questions about your treatment and COVID-19.
“Now more than ever, I would encourage people to reach out to your doctor if you have questions,” said Dr. Blumenthal. Providers are available mostly through telemedicine appointments. He said his organization, Kaiser Permanente, is seeing nearly 100 percent of visits via telemedicine right now.
Dr. Blumenthal explained that oncologists everywhere are thinking through key questions about whether the benefits of continuing a treatment outweigh the risks. These include the risk of:
Dr. Blumenthal reassured members of MyLeukemiaTeam that oncologists are mindful of all of these factors. He said, “Nobody is getting treated right now without their oncologist reviewing that decision.”
This is a period of anxiety, with many unknowns. Dr. Blumenthal stressed the importance of asking for help with your emotions, if needed. “I encourage people to reach out to their primary care doctors if they're really having mental health problems with this,” he said.
Dr. Blumenthal also emphasized the importance of staying socially connected while physically distancing. “I think that it’s important for people to call and check in on loved ones more often than you otherwise would, particularly people who are ill and very homebound right now,” he said. “It can be very isolating. I think there's a lot of benefit in communities trying to come together digitally or just by telephone. Picking up the phone and calling somebody is a meaningful social interaction.”