Increase in the severity of acute malignant hemopathies during the COVID-19 pandemia

Dear Editor:

In December 2019, the appearance of the coronavirus disease (COVID-19) was detected in Wuhan, China, and since then it has spread extensively, turning this infection into a pandemic. The healthcare system has mobilised a large amount of healthcare resources to control this pandemic, which has had a major impact on hospital care for patients, especially during the months of March and April 2020.¹ After riding out the pandemic's acute phase, one of the consequences is the great impact it has had on the care of patients afflicted with diseases other than COVID-19 infection, including cancer. Apart from the delays in population screening programmes, rapid diagnostic circuits, and diagnostic and therapeutic surgical interventions, there have also been delays in medical consultations in patients whose eventual diagnosis is cancer.^2,3 This has been due not only to the collapse of the health system, but also because patients shelved or postponed their primary or hospital care visit until their clinical manifestations were intolerable. This has meant that in the case of malignant haemopathies with their frequently acute course, patients are being diagnosed in more advanced stages with the prognostic implications this entails. This fact has been widely commented by professionals but has barely been analysed. The objective of this study was to analyse the characteristics of patients newly diagnosed with acute malignant hemopathies, seen in a Haematology department of a tertiary hospital, in an area with a high incidence of COVID-19 infection.³

In March and April 2020, 17 patients were diagnosed with acute malignant haemopathies (10 acute leukaemias and 7 lymphomas). The main prognostic characteristics are shown in Table 1. Four patients with acute leukaemias presented poor prognostic factors (hyperleukocytosis, disseminated intravascular coagulation, cerebral haemorrhage) and in 5 cases the patients suffered severe infections at the time of diagnosis. Six of the 7 lymphoma patients also had unfavourable prognostic characteristics, such as bulky masses and marked elevation of serum LDH, and two patients had spinal cord compression.

Table 1.

Main characteristics in malignant haemopathies diagnosed during the COVID-19 pandemic.

Disease	Age (years)	Gender	Main characteristics
Acute leukaemias
Mature-B cell ALL (Burkitt-type)	61	Male	Leukocytes 75 ⋅ 10^9/l
			Acute tumour lysis syndrome
			LDH 4,961 U/l
AML	39	Male	Leukocytes 285 ⋅ 10^9/l
APL	34	Male	Leukocytes 102 ⋅ 10^9/l
			Disseminated intravascular coagulation
			CNS hemorrhage
ALL	25	Male	Leukocytes 448 ⋅ 10^9/l
Lymphomas
Diffuse large B-cell lymphoma	26	Male	Bulky mass
			LDH 1,100 U/l
Lymphoma of the marginal zone	70	Male	Spinal cord compression
High-grade B-cell lymphoma, unclassifiable	21	Male	Bulky mass
T-cell-rich B-cell lymphoma	42	Male	Tense ascites
Hodgkin lymphoma	20	Male	Stage IV, B symptoms
Follicular lymphoma	62	Female	Spinal cord compression

ALL: acute lymphoblastic leukaemia; AML: acute myeloblastic leukaemia; APL: acute promyelocytic leukaemia.

The collapse of the healthcare system in regions with a high incidence of COVID-19 infection, such as Barcelona, has led to the hospital system focusing mainly on the care of COVID-19 patients who presented clinical manifestations of varying severity and who required hospital admission or support in intensive care units. This has greatly affected the healthcare of high health impact diseases such as cardiovascular diseases and cancer. This fact, together with the reluctance of patients to go to hospitals practically saturated with COVID-19 patients, has determined that these diseases are frequently diagnosed in more advanced stages, with the prognostic consequences that this entails. In the cases of acute malignant haemopathy analysed in this study, it should be noted that most share characteristics indicative of a delay in diagnosis, such as hyperleukocytosis in acute leukaemias and bulky tumour masses in lymphomas. And for patients with established spinal compression whose chances of functional recovery are extremely low, this is even more disturbing.

The COVID-19 pandemic is posing unprecedented challenges and its trajectory remains uncertain. However, during this time of controlling the expansive phase, we must strive to quickly return to normal in such sensitive areas of health care as cancer diagnosis and treatment.^2,4,5