COVID-19 diagnosis results in frequent treatment delays among younger patients with ALL
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Key takeaways:
- Severe cases of COVID-19 rarely occurred among younger patients with ALL/lymphoblastic lymphoma.
- Potential racial and ethnic disparities warrant further research, according to researchers.
A COVID-19 diagnosis led to a delay in receiving chemotherapy among younger patients with acute lymphoblastic leukemia or lymphoblastic lymphoma, results from a retrospective analysis published in JAMA Network Open showed.
Despite the delay in treatment, severe reactions to COVID-19 rarely occurred, according to researchers.
“During our observation period, SARS-CoV-2 infections occurred in 110 of 308 patients (36%), a rate substantially higher than the cumulative incidence of 18% in our general pediatric population; this is probably reflective of routine screening (at least weekly) in the patients in this study. Severe COVID-19 occurred in only seven of 110 patients (6%), a low incidence consistent with findings in European countries,” Saman K. Hashmi, MD, a hospitalist in the department of global pediatric medicine at St. Jude Children’s Research Hospital, and researchers wrote.
Background and methodology
Little published data exist on the impact of COVID-19 in younger patients with ALL or lymphoblastic lymphoma, according to background information provided by study investigators. Evidence about how diagnosis and treatment of the disease impacts subsequent cancer therapy is particularly lacking, they added.
Hashmi and colleagues conducted a retrospective case series study to determine the scope of treatment delays, the effect on the administration of chemotherapy or any impact on long-term patient outcomes after a diagnosis of COVID-19 among younger patients with ALL or lymphoblastic lymphoma.
The single-center study included patients aged 1 to 18 treated on the Total XVII protocol who received protocol chemotherapy at St. Jude Children’s Research Hospital and its affiliate sites between March 30, 2020, and June 20, 2022.
Researchers analyzed acute symptoms and potential chemotherapy modifications for 60 days after a COVID-19 diagnosis, and followed up on viral clearance, adverse events and second COVID-19 infections throughout the 27-month study period.
The clinical characteristics of COVID-19 cases and modifications to chemotherapy after diagnosis served as the study’s main outcome measurements.
Results, next steps
Of the 308 patients included in the case series, 110 (36%) developed COVID-19 (median age, 8.2 years; 62% male) — most cases (n = 101; 92%) occurred in the continuation/maintenance phase of chemotherapy.
Eighty-seven percent of study patients diagnosed with COVID-19 had their chemotherapy withheld until they showed evidence of clinical improvement or completed a course of antiviral therapy. Chemotherapy delays lasted a median of 8 days (interquartile range, 7-14 days).
Researchers reported infrequent severe disease, with only seven patients (6%) being classified as having a rare case. Common characteristics among severe cases included older age and those with higher white blood cell counts at ALL or lymphoblastic lymphoma diagnosis, lower absolute lymphocyte counts at COVID-19 diagnosis, abnormal chest imaging findings and SARS-CoV-2 reinfection.
A single case each of pulmonary embolism and cerebral venous sinus thrombosis occurred; researchers noted no multisystem inflammatory syndrome in children or death.
COVID-19 reinfection occurred in 11 patients (10%), associated with older children and those receiving standard or high-risk vs. low-risk ALL or lymphoblastic lymphoma therapy.
Chemotherapy interruptions occurred in 96 patients (87%), with those enduring longer COVID-19 cases also enduring longer chemotherapy interruptions.
The researchers recognized several potential study limitations, including a small sample size and the study period covering a large time span with several different SARS-CoV-2 variants.
In an accompanying editorial by Jenny Ruiz, MD, MSCE, and colleagues agreed with the researchers’ conclusion that treatment delays among younger patients with ALL or lymphoblastic lymphoma should not impact OS, but that potential racial and ethnic disparities exist, warranting further studies.
“Much has been written about the disproportionate impact of COVID-19 on racial and ethnic minority groups and how social determinants of health (SDOH) — like gaps in wealth, housing and employment — contributed to this disparity,” Ruiz and colleagues wrote. “St Jude Children’s Research Hospital is known for covering the cost of treatment, travel, housing and food for all their patients, which in theory may help mitigate adverse SDOH. However, the higher risk for SARS-CoV-2 infection in Hispanic children in this cohort suggests an unmeasured influence of SDOH.
“Applying an SDOH lens on pediatric oncology outcomes, including COVID-19 outcomes, is especially needed because we already know that Hispanic children with ALL experience inferior overall survival compared with non-Hispanic white children. Reporting racial and ethnic disparities in outcomes is a needed first step that must be followed by efforts to understand the cause of these disparities and to work toward the design and implementation of targeted interventions for SDOH subdomains,” they added. “We do not expect delays in chemotherapy due to SARS-CoV-2 infection in children with ALL or [lymphoblastic lymphoma] to impact overall survival in isolation. However, combined with other delays, as well as the potential of added risk factors like adverse SDOH, these delays have the potential to lead to worse outcomes.”
References:
- Hashmi SK, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2023.55727.
- Ruiz J, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2023.55679.
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Hashmi SK, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2023.55727.
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