Table 2.

Cancer care consideration during COVID-19 pandemic by leukemia subtype

	Acute myeloid leukemia (AML)	Acute lymphoblastic leukemia (ALL)	Chronic myeloid leukemia (CML)	Chronic lymphocytic leukemia (CLL)
Risk for severe COVID-19	Greater than general population: Myelosuppression secondary to induction therapy	Greater than general population: Myelosuppression secondary to induction therapy	Similar to general population: Risk stratify by considering standard COVID-19-related factors, including age, underlying comorbidities, living conditions, and vaccination status	Greater than general population: Due to underlying immunodeficiency and inadequate immune response to infections, patients with CLL are at elevated risk for infections.
Minimization of Interactions for COVID exposure	Minimize in-person healthcare interaction through promotion of telehealth, minimization of routine bloodwork, minimize aggressive treatment that may require prolonged inpatient care (promote outpatient cancer treatment as appropriate)
Cancer treatment (COVID-19 negative)	COVID-19 community burden: For all types of leukemias, the incidence of COVID-19 and hospital capacity should be considered when considering treatments of choice. If incidence of COVID-19 is low, then abiding by disease-based guidelines should be adhered to. However, as the local incidence of COVID-19 rises, greater caution with regards to the use of high-risk therapies should be applied.
	Induction therapy: Continue to offer 7+3 (or similar regimen); may consider lower intensity therapy as may allow for less healthcare utilization needs (e.g., clinic visitations, transfusions) Consolidation therapy: If candidate for high-dose cytarabine, can continue to offer but may consider decreasing the number of cycles from four to three Salvage therapy: While re-induction may be considered, should also weigh against prolonged hospitalization with greater restriction on visitations.	Induction therapy for ALL Ph-: Continue with current care but may consider dose reducing daunorubicin (50%) or pegasparagase (e.g., 1,000 IU/m2), if patient considered at high risk for complications from myelosuppression. Induction therapy for ALL PH+: Preference for less aggressive measures (e.g., TKI with steroids), rather than aggressive induction chemotherapy; goal to avoid prolonged hospitalization during the pandemic Consolidation therapy: In order to reduce hospitalization stay, may use inotuzumab outpatient or quickly transition to blinatumomab outpatient treatment	Tyrosine kinase inhibitors (TKI): Can continue standard TKI treatment as there is no evidence to suggest TKIs elevate or lower the risk of COVID19 Treatment-free remission: In order to minimize healthcare interaction, it can more readily consider initiation of treatment-free remission (but with continuation of PCR every 3 months).	B-cell receptor (BCR) signaling inhibitors: Continue with standard treatment as there is no evidence to suggest BCR signaling inhibitors elevate the risk of COVID-19. CD20 targeting monoclonal antibodies: Due to the specific immunosuppressive effects of CD20 monoclonal antibodies, some physicians may avoid or skip treatment with these therapies, especially if being used in combination with other targeted agents. Venetoclax: Initiation of venetoclax requires inpatient setting or multiple extended clinic visits with lab testing initially; if able, can consider deferring initiation until later period
Cancer treatment (COVID-19 positive)	During periods of COVID-19 surge, test patients for COVID-19 prior to hospitalization; if COVID-19 positive, withhold cancer-directed therapy for 14 days following COVID-19 diagnosis. Then, even if PCR-positive, can start or restart cancer-directed therapy as viral fragments can be present for extended duration	During periods of COVID-19 surge, test patients for COVID-19 prior to hospitalization; if COVID-19 positive, withhold cancer-directed therapy for 14 days following COVID-19 diagnosis. Then, even if PCR-positive, can start or restart cancer-directed therapy as viral fragments can be present for extended duration	TKI: For non-severe COVID-19 infection, can continue TKI. However, if respiratory symptoms are worsening, TKI interruption should be considered due to the potential for overlapping cardiopulmonary complications.	BTK signaling inhibitors: There is no evidence to support stopping BTK signaling inhibitors. In fact, there are some studies to support potential benefit from BTKis; also potential for CLL flare and cytokine release following BTKi discontinuation, potentially mimicking symptoms of COVID-19 CD20 targeting monoclonal antibodies: Due to the specific immunosuppressive effects by CD20 targeting antibodies, it is recommended to stop therapy during COVID-19 infection
Vaccination	Vaccination is strongly recommended for all leukemia subtypes. Studies have demonstrated reduced antibody response to vaccination, notably for patients receiving B-cell depleting therapies. However, there is no current evidence to support concern regarding COVID-19 vaccination from reducing cancer treatment effectiveness or increasing risk of underlying treatment.

Comments for each of the leukemia subtypes are adapted from the American Society of Hematology expert opinion: AML (https://www.hematology.org/covid-19/covid-19-and-acute-myeloid-leukemia), ALL (https://www.hematology.org/covid-19/covid-19-and-all), CML (https://www.hematology.org/covid-19/covid-19-and-cll), and CLL (https://www.hematology.org/covid-19/covid-19-and-cll).