• Users Online: 1446
  • Print this page
  • Email this page

Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 5  |  Page : 54-58

Management of hematological malignancies during the COVID-19 pandemic

1 Department of Medical Oncology, S.L. Raheja (Fortis) Hospital and HCG Hospital, Mumbai, Maharashtra, India
2 Department of Pediatrics, Mumbai and Aarya Clinic, Sterling Hospital, Mumbai, Maharashtra, India

Date of Submission05-Apr-2020
Date of Decision06-Apr-2020
Date of Acceptance08-Apr-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Ashay Karpe
Aarya Clinic, Shop No 1, Ganjawala CHS, Near Pai Nagar Garden, Off SVP Road, Borivali (West), Mumbai - 400 092, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_123_20

Get Permissions


Coronavirus disease 2019 (COVID-19) caused by novel coronavirus, which is structurally related to the virus causing severe acute respiratory syndrome, has emerged as a global health problem. During this pandemic, treatment of oncology patients especially patients with hematological malignancies has many challenges. In the absence of definite guidelines for the management of hematological cancers, we should follow certain principles for better treatment delivery with precautions to prevent COVID-19 infection in this vulnerable population with the least compromise in patient outcome

Keywords: Coronavirus disease 2019, leukemia, lymphoma, myeloma, treatment, COVID, SARS-CoV-2, India

How to cite this article:
Karpe A, Nagvekar-Karpe S. Management of hematological malignancies during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3, Suppl S1:54-8

How to cite this URL:
Karpe A, Nagvekar-Karpe S. Management of hematological malignancies during the COVID-19 pandemic. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Mar 1];3, Suppl S1:54-8. Available from: https://www.crstonline.com/text.asp?2020/3/5/54/283293

  Introduction Top

Coronavirus disease 2019 (COVID-19) which predominantly affects the respiratory system has emerged as a global health problem.[1],[2] Studies have revealed that novel coronavirus is structurally related to the virus causing severe acute respiratory syndrome. The COVID-19 pandemic is a serious threat to public health and the health-care personnel.

Patients diagnosed to have malignancies usually have impaired immunity as compared to the general population, especially those affected with hematological malignancies. Chemotherapy regimens used in hematological malignancies are more likely to cause neutropenia, as compared to those given for solid tumors.[3] In many instances, these adverse effects/toxicities warrant hospitalization, where patients are vulnerable to various infections.

During the current COVID pandemic, which is highly infectious, continuing chemotherapy involves many challenges, as patients with hematological malignancies are at higher risk of getting opportunistic infections and can have a dismal outcome owing to low immunity.

All due precautions are to be followed for indoor as well as outdoor patients for screening, prevention, and treatment of COVID-19 as in the general population. Cancer patients who get infected with COVID-19 have to be managed as other patients, based on their own merit as per guidelines. In this article, we will be reviewing the optimal management of hematological cancers during the present health crisis.

We cannot have clear guidelines about the management of hematological malignancies during this pandemic. We must be able to deliver prompt treatment without much compromise in cancer outcomes for which we should follow certain principles when treating oncology patients to avoid exposure to probable or proven COVID-19 cases.

  1. Identifying patients as curative versus palliative
  2. Reducing the number of hospital visits for treatment (possibility of using telemedicine or video conferencing[4])
  3. Avoiding unnecessary hospital admissions
  4. Modifying the treatment intensity or supportive care (granulocyte colony-stimulating factor [GCSF] support, if indicated) to minimize the possibility of neutropenia[5] and infective complications
  5. In most cases, it is wiser to use escalation policy (start with a lower effective dose and then increase the dose as per tolerance) rather than de-escalation (starting with a higher dose and reducing the dose based on the toxicities) in select population, including older patients, patients with a borderline performance status, multiple comorbidities, and organ dysfunction
  6. Intensive treatments must be carried out in institutions where separate facilities are available for treatment of oncology patients as well as for management of complications (like febrile neutropenia). These facilities (outpatient department [OPD] or inpatient department) should not be overlapping with hospital sections where suspected or proven COVID-19 cases are screened or treated
  7. When treating these patients with chemotherapy, we also have to consider that traveling for treatment as well as for complications arising due to therapies can be difficult in the present scenario. In case of certain toxicities (like febrile neutropenia), if the patient is unable to reach the hospital, it can have a detrimental outcome[6]
  8. Another concern during treatment of acute leukemias, intensive chemotherapy in high-grade lymphomas, and stem cell transplant is the availability of blood products. Due to travel restrictions during the pandemic and unavailability of voluntary donors, many blood banks and hospitals are facing a paucity of blood products. We should have institutional blood product transfusion policies to optimize the use of blood products.

The following points can be considered when treating individual hematological malignancies, though not as guidelines or recommendations.


Hodgkin's lymphoma

  1. Hodgkin's lymphoma is one of the most chemosensitive malignancies with improved survival[7]
  2. Patients fit for intensive chemotherapy regimens should be counseled about the potential risks in the present pandemic
  3. Thorough evaluation of the respiratory system prior to starting therapy must be done (especially as bleomycin, which can cause lung toxicity, is part of standard chemotherapy regimen, ABVD, consisting of doxorubicin, bleomycin, vinblastine, and dexamethasone)
  4. In patients who have a history of prior lung disease, alternative regimens containing etoposide,[8] instead of bleomycin, can be considered with GCSF support to avoid neutropenia. In affording patients, brentuximab vedotin[9] can be considered
  5. In case of relapsed refractory cases with borderline Eastern Cooperative Oncology Group performance status (ECOG PS) (≥2) or uncontrolled comorbidities or compromised organ function, rather than intensive chemotherapy, oral chemotherapy protocols such as DECC[10],[11] (lomustine [CCNU], etoposide, chlorambucil, and dexamethasone), CEP[10],[11] (lomustine [CCNU], etoposide, chlorambucil, and prednisolone), and PEP-C[12] (cyclophosphamide, etoposide, procarbazine, and prednisolone) should be considered. Intensive salvage chemotherapies must be planned in young fit patients with no or controlled comorbidities and good organ functions after detailed counseling
  6. Intensive salvage chemotherapy and autologous peripheral blood stem cell transplant (PBSCT) should be deferred, if possible (detailed discussion in the transplant section below).

Non-Hodgkin's lymphoma

High-grade non-Hodgkin's lymphoma

  1. Patients diagnosed with high-grade non-Hodgkin's lymphomas (NHLs) such as diffuse large B cell lymphoma, anaplastic large cell lymphoma, and Burkitt's lymphoma should be treated with high-dose chemotherapy on their own merits
  2. Patients need to be evaluated for organ dysfunction to reduce toxicities and any comorbidity must be strictly controlled. Patients and their relatives should be counseled in detail about toxicities and possibilities of infective complications
  3. In patients with poor PS status or uncontrolled comorbidities, less intensive regimens such as cyclophosphamide, vincristine, and prednisolone or oral chemotherapy regimens such as DECC, CEP,[10],[11] oral metronomic chemotherapy (cyclophosphamide, etoposide, and prednisolone),[13] methotrexate, and lenalidomide[14] can be considered
  4. Relapsed refractory cases can be treated with oral chemotherapy or oral targeted agents, while salvage chemotherapy and auto-PBSCT should be considered only in a select group of patients.

Low-grade non-Hodgkin's lymphomas

  1. Patients with low-grade NHL are noted, especially in the older population. These usually require treatment in specific situations such as the presence of B symptoms, bulky disease, pancytopenia, and repeated infections[15]
  2. Rather than administering high-dose chemotherapy, oral chemotherapeutic agents such as chlorambucil, cyclophosphamide, and prednisolone can be given
  3. Even though intravenous chemotherapy regimens such as BR (rituximab and bendamustine) cause cytopenias less frequently,[16] they should still be given in patients with good ECOG PS only after detailed counseling
  4. Monoclonal antibodies such as rituximab (anti-CD20) are the standard of care in B-cell NHLs, which cause prolonged immunosuppression,[17] and should be administered only after discussing the pros and cons with patients.


  1. When treating these patients, it is important to distinguish patients as transplant eligible and transplant ineligible
  2. Instead of parenteral regimens, including proteasome inhibitors (bortezomib and carfilzomib)[18] which require patients to visit the daycare frequently, oral regimens such as IMiDs (thalidomide, lenalidomide, and pomalidomide) with steroid (prednisolone/dexamethasone) can be given
  3. If proteasome inhibitors are to be used, subcutaneous bortezomib can be used as home therapy, rather than the intravenous formulation[19]
  4. In patients in whom IMiDs are contraindicated, some of the oldest regimens such as melphalan–prednisolone[20] can be given
  5. Prolonged lenalidomide or melphalan are to be avoided in case of patients who are planned for auto-PBSCT
  6. Intensive treatments such as high-dose melphalan followed by auto-PBSCT should be deferred, and patients should be put on maintenance therapy (bortezomib or lenalidomide). In patients planned for autologous PBSCT, long-term lenalidomide can be a problem and may need to be tackled with plerixafor. Subcutaneous bortezomib at home can be given
  7. In relapsed refractory cases, oral therapy such as IMiDs, melphalan, steroids, and targeted agents (panobinostat)[21] should be considered rather than intensive salvage therapies.

When oral therapies are substituted for intravenous therapies, monitoring as suggested earlier with tele- or videoconferencing should be done and questionnaire can be prepared to assess toxicities and efficacy.


Acute myeloid leukemia

  1. Acute myeloid leukemia (AML) patients have a relatively high early mortality rate of 37.5% at 8 weeks[22] and also a high overall mortality rate of about 76% at 3 years.[23] In patients aged 65 years and older, these rates are higher than in the younger patients
  2. Except low-risk patients and a subset of low intermediate risk, majority of AML patients require allogeneic stem cell transplant in complete remission[24]
  3. Considering the high morbidity and mortality during induction, patients are to be selected carefully: young patients, good risk, no comorbidities or controlled comorbidities, and no underlying infections
  4. These intensive treatments should be performed only in institutional settings and after ensuring adequate support of blood products
  5. Those patients with intermediate high risk or high risk, complex or monosomal karyotype, secondary AML (underlying myelodysplastic syndome [MDS]), induction failure, etc., should be treated with less intense therapies such as hypomethylating agents (decitabine and azacytidine)[25] or targeted agents (e.g., for FLT3-ITD, midostaurin, KIT mutation, or BCR-ABL-dasatinib)[26]
  6. Decision for allogeneic stem cell transplant should be made only after detailed counseling of the patient and family members.

Acute lymphoblastic leukemia

  1. The median age of acute lymphoblastic leukemia (ALL) diagnosis is about 15 years, while above the age of 55 years, approximately 20% of patients are diagnosed. However, around 50% of deaths due to ALL are seen in the population above 55 years of age. The 5-year overall survival is approximately 20% in adults diagnosed with ALL[27]
  2. Newly diagnosed patients are to be treated cautiously during induction therapy
  3. Intensive chemotherapy such as hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone should be reserved for young adults
  4. Those with disease in remission can be considered for maintenance oral chemotherapy with methotrexate/6 mercaptopurine (6-MP)
  5. Philadelphia-positive ALL can be treated with oral tyrosine kinase inhibitor (TKI) (dasatinib)[28]
  6. Relapsed refractory cases to be managed with oral chemotherapy.

Chronic myeloid leukemia

  1. Chronic myeloid leukemia in the chronic phase and accelerated phase can be continued with oral TKIs (imatinib, dasatinib, and nilotinib)
  2. Follow-up visits can be scheduled less frequently and can be done via tele- or videoconferencing[4]
  3. Patients in blast crisis can be managed with second -generation TKI (dasatinib or nilotinib), or in case of T315I mutation ponatinib, as a bridge to transplant[29],[30],[31]
  4. Candidates for allogeneic transplant must be carefully evaluated.

Chronic lymphoid leukemia

  1. Many of chronic lymphoid leukemia patients are under surveillance unless there are indications to start treatment (B-Symptoms, bulky lymphadenopathy, progressive marrow failure, massive or symptomatic splenomegaly, autoimmune complications, etc.)[32]
  2. Regular follow-up can be done telephonically or by videoconferencing
  3. Those who require treatment can be started appropriately based on risk stratification after detailed discussion
  4. Chemotherapy regimens such as BR should be considered after detailed evaluation and counseling
  5. Oral agents such as chlorambucil[33] and ibrutinib[34] can be considered to treat patients on OPD basis.

Autologous and allogeneic transplants

Stem cell transplant is one of the most intensive treatments and infective complications are much higher. Another concern is requirement of blood products.

  1. For transplant, whether autologous or allogeneic, candidates should be selected considering ECOG PS, comorbidities, organ function, etc.
  2. When doing such intensive treatment, risk must be weighed against outcome
  3. These must be done in institutions with good blood bank when ensuring availability of voluntary donors and facility of irradiating blood products in house
  4. Patients must be properly isolated to avoid exposure to COVID-19 positive or suspected cases
  5. In allogeneic transplant, if the family donor is available, pretransplant isolation of both patient and donor should be done to avoid exposure to COVID-19 cases; as if the donor gets infected and the patient has already received conditioning regimen, it can result in major complications
  6. Matched unrelated donor transplants can be problematic in the present pandemic, where a distant donor might get infected with COVID-19 or might deny stem cell donation due to other logistic issues, especially if the donor is from another country. In this case, transportation of stem cells can be another issue. It is prudent to obtain stem cells at the transplant center prior to starting conditioning regimen and these must be appropriately cryopreserved to maintain viability.

  Conclusion Top

The current COVID-19 pandemic has affected health-care globally as well as in India. Besides the burden on health-care givers, it is causing multiple problems in delivering treatments in other specialties such as cardiology, oncology, and nephrology. As we are learning to treat cancer patients in the middle of this crisis, we must understand that we should make rational clinical decisions based on our experiences. Our aim is to reduce COVID-19 infection in our patients, but with the least compromise in patient outcome.[35]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fauci AS, Lane HC, Redfield RR. Covid-19-Navigating the uncharted. N Engl J Med 2020;382:1268-9.  Back to cited text no. 1
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648. [Epub ahead of print].  Back to cited text no. 2
Ludwig H, Bokemeyer C, Aapro M, Boccadoro M, Gascón P, Denhaerynck K, et al. Chemotherapy-induced neutropenia/febrile neutropenia prophylaxis with biosimilar filgrastim in solid tumors versus hematological malignancies: MONITOR-GCSF study. Future Oncol 2019;15:897-907.  Back to cited text no. 3
Patil VM, Pande N, Chandrasekharan A, M C, Tonse R, Krishnatry R, et al. Shadow study: Randomized comparison of clinic with video follow-up in glioma undergoing adjuvant temozolomide therapy. CNS Oncol 2018;7:CNS14.  Back to cited text no. 4
Mehta HM, Malandra M, Corey SJ. G-CSF and GM-CSF in neutropenia. J Immunol 2015;195:1341-9.  Back to cited text no. 5
Rosa RG, Goldani LZ. Cohort study of the impact of time to antibiotic administration on mortality in patients with febrile neutropenia. Antimicrob Agents Chemother 2014;58:3799-803.  Back to cited text no. 6
Hohaus S, Di Ruscio A, Di Febo A, Massini G, D'Alo' F, Guidi F, et al. Glutathione S-transferase P1 genotype and prognosis in Hodgkin's lymphoma. Clin Cancer Res 2005;11:2175-9.  Back to cited text no. 7
Canellos G, Gollub J, Neuberg D. Primary systemic treatment of advanced Hodgkin's disease with EVA (etoposide, vinblastine, doxorubicin): 10-year follow-up. Ann Oncol 2003;14:268-72.  Back to cited text no. 8
Connors JM, Jurczak W, Straus DJ, Ansell SM, Kim WS, Gallamini A, et al. Brentuximab Vedotin with Chemotherapy for Stage III or IV Hodgkin's Lymphoma. N Engl J Med 2018;378:331-44.  Back to cited text no. 9
Lennard AL, Carey PJ, Jackson GH, Proctor SJ. An effective oral combination in advanced relapsed Hodgkin's disease prednisolone, etoposide, chlorambucil and CCNU. Cancer Chemother Pharmacol 1990;26:301-5.  Back to cited text no. 10
Proctor SJ, Lennard AL, Jackson GH, Jones GL, Lewis J, Wilkinson J, et al. The role of an all-oral chemotherapy containing lomustine (CCNU) in advanced, fs progressive Hodgkin lymphoma: A patient-friendly palliative option which can result in long-term disease control. Ann Oncol 2010;21:426-8.  Back to cited text no. 11
Coleman M, Martin P, Ruan J, Furman R, Niesvizky R, Elstrom R, et al. Prednisone, etoposide, procarbazine, and cyclophosphamide (PEP-C) oral combination chemotherapy regimen for recurring/refractory lymphoma: Low-dose metronomic, multidrug therapy. Cancer 2008;112:2228-32.  Back to cited text no. 12
Mailankody S, Ganesan P, Joshi A, Ganesan TS, Radhakrishnan V, Dhanushkodi M, et al. outcomes of oral metronomic therapy in patients with lymphomas. Indian J Hematol Blood Transfus 2019;35:50-6.  Back to cited text no. 13
Krawczyk K, Jurczak W, Gałązka K, Gruchała A, Skotnicki AB. Lenalidomide in heavily pretreated refractory diffuse large B-cell lymphoma: A case report. J Med Case Rep 2014;8:325.  Back to cited text no. 14
Nair R, Kakroo A, Bapna A, Gogia A, Vora A, Pathak A, et al. Management of lymphomas: Consensus document 2018 by an Indian expert group. Indian J Hematol Blood Transfus 2018;34:398-421.  Back to cited text no. 15
Rummel MJ, Al-Batran SE, Kim SZ, Welslau M, Hecker R, Kofahl-Krause D, et al. Bendamustine plus rituximab is effective and has a favorable toxicity profile in the treatment of mantle cell and low-grade non-Hodgkin's lymphoma. J Clin Oncol 2005;23:3383-9.  Back to cited text no. 16
Looney RJ, Renganathan S, Leonard HC. The effects of rituximab on immunocompetency in patients with autoimmune disease. Arthritis Rheum 2008;58:5-14.  Back to cited text no. 17
Bagal B, Bonda A. Induction therapy in newly diagnosed multiple myeloma: Current research scenario and questions for the future. Cancer Res Stat Treat 2019;2:76-82.  Back to cited text no. 18
  [Full text]  
Petrucci MT, Finsinger P, Chisini M, Gentilini F. Subcutaneous bortezomib for multiple myeloma treatment: Patients' benefits. Patient Prefer Adherence 2014;8:939-46.  Back to cited text no. 19
Giovanni C, Ralph LE, Albert S.- Melphalan and Prednisolone: An effective combination for the treatment of multiple myeloma. Clinical Study (1973) Vol 54 (5) 589-599.  Back to cited text no. 20
Eleutherakis-Papaiakovou E, Kanellias N, Kastritis E, Gavriatopoulou M, Terpos E, Dimopoulos MA. Efficacy of panobinostat for the treatment of multiple myeloma. J Oncol 2020;2020:11. Available from: https://doi.org/10.1155/2020/7131802. [Last accessed on 2020 Apr 16].  Back to cited text no. 21
Oran B, Weisdorf DJ. Survival for older patients with acute myeloid leukemia: A population-based study. Haematologica 2012;97:1916-24.  Back to cited text no. 22
Walter RB, Kantarjian HM, Huang X, Pierce SA, Sun Z, Gundacker HM, et al. Effect of complete remission and responses less than complete remission on survival in acute myeloid leukemia: A combined Eastern Cooperative Oncology Group, Southwest Oncology Group, and M. D. Anderson Cancer Center Study. J Clin Oncol 2010;28:1766-71.2.  Back to cited text no. 23
Oran B, Weisdorf DJ. Allogeneic stem cell transplantation in first complete remission. Curr Opin Hematol 2011;18:395-400.  Back to cited text no. 24
Haifa A, Nadja Jl, Dietger N. The role of hypomethylating agents in the treatment of elderly patients with AML. J Geriatr Oncol 2014;5:89-105.  Back to cited text no. 25
Fernandez S, Desplat V, Villacreces A, Guitart AV, Milpied N, Pigneux A, et al. Targeting Tyrosine Kinases in Acute Myeloid Leukemia: Why, Who and How? Int J Mol Sci 2019;20. pii: E3429.  Back to cited text no. 26
Ibrahim A, Stephen F, Vinod P. Acute lymphoblastic leukemia in the older adult. J Oncol Pract 15:67-75.  Back to cited text no. 27
Zhang C, Luo XQ, Zhang X. Dasatinib monotherapy for newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia with pulmonary infection in induction remission: A case report and review of the literature. Medicine (Baltimore) 2018;97:e12308.  Back to cited text no. 28
Ostendorf BN, Nogai H, Baldus CD, Burmeister T, Arnold R. BCR-ABL Mutation-Guided Therapy for CML Blast Crisis: A Case Report. Biomark Insights 2015;10:25-8.  Back to cited text no. 29
Tan FH, Putoczki TL, Stylli SS, Luwor RB. Ponatinib: A novel multi-tyrosine kinase inhibitor against human malignancies. Onco Targets Ther 2019;12:635-45.  Back to cited text no. 30
Jain H, Thorat J, Sengar M, Dubey A. Ponatinib: A drug review. Cancer Res Stat Treat 2019;2:190-6.  Back to cited text no. 31
  [Full text]  
Hallek M, Cheson BD, Catovsky D, Caligaris-Cappio F, Dighiero G, Döhner H, et al. iwCLL guidelines for diagnosis, indications for treatment, response assessment, and supportive management of CLL. Blood 2018;131:2745-60.  Back to cited text no. 32
Vidal L, Gurion R, Ram R, Raanani P, Bairey O, Robak T, et al. Chlorambucil for the treatment of patients with chronic lymphocytic leukemia (CLL)-a systematic review and meta-analysis of randomized trials. Leuk Lymphoma 2016;57:2047-57.  Back to cited text no. 33
Burger JA, Barr PM, Robak T, Owen C, Ghia P, Tedeschi A, et al. Long-term efficacy and safety offirst-line ibrutinib treatment for patients with CLL/SLL: 5 years of follow-up from the phase 3 RESONATE-2 study. Leukemia 2020;34:787-98.  Back to cited text no. 34
Noronha V, Behel V. Catch-22: COVID versus Cancer. Cancer Res Stat Treat 2020;3:1-2.  Back to cited text no. 35
  [Full text]  


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article

 Article Access Statistics
    PDF Downloaded107    
    Comments [Add]    

Recommend this journal