cancer patient: cancer patientAutologous stem cell transplant (ASCT) remains a mainstay therapy, particularly for young patients (Blood Cancer J 2019; doi: 10.1038/s41408-019-0205-9). But with the COVID-19 pandemic sweeping the world, new guidance urges myeloma doctors and patients to consider postponing these elective procedures. The American Society for Transplant and Cellular Therapy (ASTCT) issued interim guidance recommending delay of elective stem cell harvest and autologous and allogeneic transplants (https://go.aws/3eX5SWD). The guidance states that it is “intended as a guide for diagnosis and management of COVID-19 in adult and pediatric hematopoietic cell transplant and cellular therapy patients. There is currently limited data on the epidemiology and clinical manifestations of COVID-19 in this population. Given the experience with other respiratory viruses, we anticipate patients may develop severe clinical disease and thus provide the following general principles for cancer centers across the nation.” Although the ASTCT interim guidance specifically states that it does “not cover specific infection prevention policies and procedures,” many leading transplant centers have adopted these recommendations in part or whole, according to Hearn Jay Cho, MD, PhD, Associate Professor of Medicine, Hematology and Medical Oncology at Mount Sinai and the Chief Medical Officer at the Multiple Myeloma Research Foundation (MMRF). “Many institutions are following the ASTCT guidance and postponing elective procedures. The decision to proceed with a stem cell harvest or transplant is best determined by the patient in collaboration with his/her myeloma treatment team,” said Cho. Multiple myeloma patients are particularly vulnerable to the virus because these patients are immunosuppressed—from both the condition itself and the treatment regimen, which makes it harder for their bodies to ward off new infections. Second, many patients with myeloma are older and have other comorbid conditions, further increasing their risk of contracting the virus. The good news is that this patient population, for the most part, does well with outpatient care and in-home treatment regimens. Although the usual care plan isn't to wait until relapse to perform the stem cell transplant, the COVID-19 pandemic has clinicians pivoting toward that approach in an abundance of caution. “For myeloma patients, the majority of autologous transplants are for consolidation therapy, which means the patients are already in partial or complete remission, so the transplant procedure is not urgent,” Cho said. “Therefore, the risk of harvesting a contaminated stem cell product or exposure to COVID-19 during the severe immunosuppression during a transplant significantly outweighs the potential benefit and it makes sense to delay these procedures.” Cho addresses patient concerns and questions on a FAQ page on the Multiple Myeloma Research Foundation site (https://themmrf.org/2020/03/multiple-myeloma-and-the-coronavirus/). The International Myeloma Foundation (IMF) also released a FAQ for patients, with Brian G.M. Durie, MD, issuing a specific guidance to ensure safety for multiple myeloma patients (https://www.myeloma.org/cure-blog/coronavirus-crisis-point-america-faq-myeloma-patients-0). Both the IMF and MMRF recommend patients stay home whenever possible, even if it means skipping non-essential doctor appointments. “Patients who recently completed stem cell transplant should be observing strict precautions to avoid exposure risks anyway, but extra care should be taken in this setting. Patients should stay home as much as possible, practice social distancing and good hygiene, and adhere to their post-transplant precautions,” said Cho. Although social distancing is a crucial step in protecting patients from infection, it's not always easy for patients in need of ongoing medical care. Clinicians can schedule essential visits during quieter hours to reduce the risk of contact between patients and should follow up with patients over the phone whenever possible. Clinicians should advocate for immediate COVID-19 testing for any myeloma patients who develop suspicious symptoms such as fever, dry cough, or additional tiredness—and even for those who suspect exposure. If testing is not available, risk should be ascertained based on local epidemiology. The ASTCT issued interim guidance that also outlines diagnostic considerations in HCT and cellular therapy patients, saying that in the setting of known high community prevalence of COVID-19 or exposure to a known case of COVID-19 the following evaluations should be performed: In any patient with upper or lower respiratory symptoms, send PCR testing for SARS-CoV-2 in addition to other respiratory virus PCR testing from any respiratory sample obtained. In patients positive for SARS-CoV-2 in an upper respiratory tract sample, chest imaging should be considered. Patients without SARS-CoV-2 detected in the upper respiratory tract but with clinical symptoms of lower respiratory tract infection, chest imaging to evaluate for lower respiratory tract infection should be considered. Routine bronchoalveolar lavage is not recommended if a patient tests positive for SARS-CoV-2 given risk of transmission amongst health care workers, unless a co-infection is suspected. If chest imaging is abnormal and in patients for whom it is clinically indicated, a lower respiratory tract endotracheal tube aspirate or BAL sample should be collected and tested for SARS-CoV-2. If the virus persists, weighing down the health care system and leaving patients at risk for months, physicians may need to turn to novel treatment approaches to care for multiple myeloma patients during the pandemic. Researchers recently concluded outpatient ASCT is both safe and feasible—with the right patient selection, a multidisciplinary approach and close follow up (Clin Lymphoma Myeloma Leuk 2019; doi: 10.1016/j.clml.2019.09.619). This could potentially reduce the resources necessary to care for these patients and keep them a little further away from inpatient facilities inundated with COVID-19 patients. “If the crisis drags on for several months, however, clinicians will have to re-evaluate the risks and benefits as the ratio will change over time,” Cho said. While no vaccine or antiviral is available, researchers and clinicians have many supportive care options to help patients make it through the resulting illness. The ASTCT guidance also recommended interim treatment options for both adult and pediatric patients in different disease stages, though the guidance emphasized that “lack of conclusive data on clinical efficacy precludes specific recommendations, and patients should be enrolled in clinical trials whenever possible.” Information is continuously evolving as the virus spreads though the population. Clinicians can find timely information from the World Health Organization and the Centers for Disease Control and Prevention (CDC). In addition, the New England Journal of Medicine is updating its resource page as more information becomes available. Rebecca Wilson is a contributing writer. Sarah LaCorte is associate editor.