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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 14
| Issue : 1 | Page : 7-11 |
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Impact of COVID-19 Pandemic on Treatment Decisions of Patients Treated by Hematologists in Saudi Arabia
Salem M Bahashwan1, Hatem M Alahwal1, Abdullah T Almohammadi1, Osman O Radhwi1, Shahida A Khan2, Ahmed S Barefah1
1 Department of Hematology, Faculty of Medicine; Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
2 Hematology Research Unit, King Fahd Medical Research Center; Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
| Date of Submission | 01-Oct-2022 |
| Date of Decision | 02-Oct-2022 |
| Date of Acceptance | 02-Oct-2022 |
| Date of Web Publication | 17-Feb-2023 |
Correspondence Address:
Dr. Ahmed S Barefah
Department of Hematology, Faculty of Medicine, King Abdulaziz University, Jeddah
Kingdom of Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/joah.joah_85_22
BACKGROUND: As on March 12, 2020, the WHO declared COVID-19 as a global pandemic. Its rapid spread has posed major challenges to the management of health-care systems. Patients with hematological disorders, being immunocompromised in more ways than one, face a lot of challenges. Most of these patients require frequent visits to health-care facilities for transfusion support, infusions, surveillance, and follow-ups, which increase the risk of exposure and hence infection with severe acute respiratory syndrome coronavirus 2.
AIM: We assessed the impact of the pandemic on the decisions of hematologists in Saudi Arabia.
Method: An online survey was done through questionnaires, to understand the decisions and course of clinical treatments taken. 45 hematologist answered 20-questions structured questionnaires through online link.
RESULTS: The majority of hematologist have used virtual clinics in managing patients and have delayed or canceled well visits. Although some hematologist delayed treatment in stable patients like autologous stem cell transplantation for myeloma patients, the majority did not delay induction or consolidation therapies for patients with leukemia with curative intent plans.
CONCLUSION: The crisis brought along with it challenges and opportunities to improve patient care through research and clinical practice. Telemedicine was sought for supporting outpatients. Malignancies were taken care of, with due precautions. Observations of decisions of hematologists resulted in the patients still being closely followed up and urgent treatments being attended to. The hematologists expressed satisfaction with the use of telemedicine. Online consultations and monitoring of patients could probably be taken as an alternative resource in such situations.
Keywords: COVID-19, hematologists, management decisions
How to cite this article:
Bahashwan SM, Alahwal HM, Almohammadi AT, Radhwi OO, Khan SA, Barefah AS. Impact of COVID-19 Pandemic on Treatment Decisions of Patients Treated by Hematologists in Saudi Arabia. J Appl Hematol 2023;14:7-11 |
How to cite this URL:
Bahashwan SM, Alahwal HM, Almohammadi AT, Radhwi OO, Khan SA, Barefah AS. Impact of COVID-19 Pandemic on Treatment Decisions of Patients Treated by Hematologists in Saudi Arabia. J Appl Hematol [serial online] 2023 [cited 2023 Mar 24];14:7-11. Available from: https://www.jahjournal.org/text.asp?2023/14/1/7/369847 |
| Introduction | |  |
The most challenging pandemic of the century COVID-19 struck the world with a short notice. Since its start in December 2019, it did not take long to spread across the globe with full fury, resulting in huge mortalities. The WHO announced COVID-19 as a global pandemic on March 12, 2020. Since then, infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have affected the delivery of health-care services significantly. The rapid spread of this pandemic resulted in significant crises in health-care systems worldwide.[1]
Through severe respiratory acute illness, COVID-19 infections lead to multi-organ failure, and can be fatal in around 2% of the general population, with percentages rising among the immunocompromised and vulnerable individuals.[2] Patients with hematological diseases are at the prime of this challenge, and concerns about their care during this pandemic were raised.[2] Retrospective studies have shown that hemato-oncology patients with COVID-19 experienced higher mortality and complication rate and at high risk of nosocomial infection.[3] Another study on a large number of patients with hematological malignancies showed that comorbidities, older age, and type of therapy were also associated with higher mortality.[4]
Patients with hematological diseases are immunocompromised and receive therapies that are lymphodepleting that could further lower the immunity and put them at higher risk of complications related to COVID-19.[5]
In addition, most of these patients require frequent visits to health-care facilities for transfusion support, infusions, surveillance, and follow-ups, which increase the risk of exposure and hence infection with SARS-CoV-2. This calls for practical steps to be addressed.[4],[5] Moreover, COVID-19 vaccination hesitancy was noticed among patients with hemoglobinopathy locally despite the efficacy and the free availability of the vaccine which increase the risk of potential COVID-19-related complications in this vulnerable group.[6] This also calls for assessing the risks of reducing the frequency or intensity of chemotherapy or delaying the treatment, as health-care facilities are compromised during a pandemic.[7]
Recommendations may evolve when looking into varied experiences, and decisions taken to update the strategies in improving patients' care. Telemedicine as a solution has promptly been implemented by the medical authorities, especially for patients with hematological diseases. This would provide the proper safety measures of social distancing which are required to be implemented.[8],[9]
With health-care dynamics changing rapidly, it is difficult to establish universal protocols as guidelines for treatment of these patients. With the limited available evidence regarding the management of patients with hematological disease during COVID-19 pandemic, we assessed the impact of the pandemic on the decisions of hematologists in Saudi Arabia using an online survey.
Thereby, we evaluated the decisions of hematologists during the pandemic in patients with hematological complications and assessed the implementation.
| Methods | | |
Study design
Ethical approval was obtained from the Unit of Biomedical Ethics in King Abdulaziz University (reference number: 20-181) to conduct an online survey during the pandemic. All participants were briefed about the research prior to participation, and appropriate consent was taken.
Contact details like official telephone numbers as well as mobile numbers were confirmed. A total of 257 participants, all clinical staff, were contacted through the WhatsApp group of hematologists practicing in KSA. The survey questionnaire was distributed to 100 of them treating adult patients with malignant hematological disease in Saudi Arabia during the COVID-19 pandemic. These hematologists had given their consent to participate. Finally, 45 of them replied to the participation request, and Google link forms were sent to them. Anonymity of the hematologists was maintained, and hence, the region they belonged to, their ethnicity as well as gender were not noted.
Each participant received a 20-question structured questionnaire. All the questions will have an answer scale (Likert scale). The survey commenced online through Google™ forms on April 1, 2020, and ended on April 15, 2020. Data were documented to a secure, anonymous central database for further analysis. Results of the questions have been reported as proportion of answers chosen by the participants on the Likert scale.
| Results | | |
Of the total 45 physicians who responded, one physician does not treat malignant hematology patients regularly and was therefore omitted from the survey. 43.5% of the physicians specialized in treating malignant hematology, while 54.3% of them treat both benign and malignant hematology patients. Fifteen respondents (33.33%) have more than 10 years of clinical experience and 30 (66.67%) have <10 years of clinical experience. Participants received at least two reminders to complete the surveys.
Management of outpatient care/supportive care
The decisions of hematologists on outpatient and supportive treatment are represented in [Table 1]. The median respondents were 41 (range: 38–44). Thirty-three respondents (76.74%) have at least a subset of their patients managed through virtual clinics. All respondents have delayed or canceled well visits, with 30 participants (69.77%) delaying or canceling the majority or all of the well visits. Despite this, 25 (56.82%) respondents have noted that the pandemic has reduced the amount of time spent with patients for the majority of patients. Eighteen respondents (47.37%) have treated a minority of patients through satellite clinics, whereas 9 (23.68%) have not. Twenty-seven (62.79%) respondents have changed the transfusion threshold for most or all their patients.
Management of acute leukemia/allogeneic stem cell transplantation (SCT)
The median respondents were 38 (range: 24–41). The majority of respondents did not reduce the dose of induction, 29 (76.32%), or consolidation chemotherapy, 23 (56.1%), and did not delay consolidation chemotherapy, 26 (63.41%). Only a minority of respondents, 9 (34.62%), have delayed allogeneic stem cell transplantation for a minority of acute leukemia patients, whereas 12 (46.15%) have not. Mostly, the patients, who already planned to receive transplantation at the beginning of the pandemic, did not have their appointments canceled. Only the precautionary measures were strictly implemented. In addition, 13 (54.17%) respondents have changed their conditioning regimen in allogeneic stem cell transplant [Table 2]. | Table 2: Decisions of clinicians on maintenance and chemotherapy of patients with acute leukemia
Click here to view |
Management of lymphoma
The median number of respondents was 37.5 (range: 32–43). The majority of respondents, 26 (63.41%), did not reduce the dose of chemotherapy in lymphoma patients. Twenty-one (48.84%) respondents did not interrupt or delay chemotherapy cycles for their lymphoma patients where 18 (41.86%) did for the minority of their patients. Most respondents, 32 (74.42%), used granulocyte colony-stimulating factor (G-CSF), in at least minority of the patients and G-CSF was prescribed more than usual during this period. The majority of respondents, 25 (78.12%), would delay autologous stem cell transplantation for at least a minority of their patients.
With regard to chronic lymphocytic leukemia treatment, 22 (66.67%) respondents would delay the initiation of therapy and 23 (76.67%) would change the treatment protocol for at least a minority of their patients [Table 3]. | Table 3: Decisions of clinicians on maintenance and chemotherapy of patients with lymphoma
Click here to view |
Management of multiple myeloma
The median number of respondents was 33.5 (range: 28–35). The majority of respondents 20 (58.82%) reduced the dose of steroids in treating multiple myeloma for at least a minor subset of their patients. in managing patients with multiple myeloma, 19 (57.58%) of respondents have interrupted or delayed chemotherapy cycles, and 21 (60%) have interrupted maintenance therapy for at least a minor subset of their patients. The majority of respondents, 25 (89.29%), have delayed autologous stem cell transplant for at least the majority of their patients [Table 4]. | Table 4: Decisions of clinicians on maintenance and chemotherapy of patients with multiple myeloma
Click here to view |
| Discussion | | |
Patients with hematological malignancies are immunocompromised, and COVID-19 infection in this group of patients is associated with high mortality and morbidity. Several restrictions were implemented during the COVID-19 pandemic, such as restricting hospital admission and clinic visits, to minimize the risk of COVID-19 exposure and infection. Some of these implemented measures affected patients' care directly or indirectly. Most of the patients with hematological diseases require frequent visits to health-care facilities for transfusion, chemotherapy infusion, surveillance, and follow-up, which increased the risk of COVID-19 exposure and infection.
With the limited available evidence regarding the management of patients with hematological malignancies during COVID-19 pandemic and the difficulties to establish universal protocols in a short period of time, it was important to build up local guidelines by experts in the field.
This study demonstrated different measures by a hematologist to overcome the challenges faced in managing the hematological malignancies during COVID-19 pandemic. These include virtual clinics to communicate with patients, delaying or canceling well visits for stable patients, G-CSF support to prevent or minimize the risk of neutropenia and infection, considering stopping the treatment temporarily, increasing the interval between treatments, reducing the doses of chemotherapy, or switching to less toxic agents without compromising the outcomes. Delaying autologous stem cell transplant in special cases like myeloma was also considered.
Hematological malignancies such as acute leukemia, aggressive lymphoma, and allogeneic stem cell transplant, with high cure rate, have a high risk of progression or relapse. They should be treated without delay or dose reduction of chemotherapy alongside measures to minimize the risk of exposure to COVID-19. Delaying treatment if possible or switching to nonmyelosuppressive drugs are alternative options in some hematological diseases that are indolent in nature with indication of treatment or in some conditions where delaying treatment will not probably affect the survival. One such is the transplantation of autologous stem cells in multiple myeloma patients who are in deep remission. Some studies during the pandemic suggest that some initial delays in the chemotherapy cycles, as well as nonmyelosuppressive regimens, could be also considered.[9],[10]
| Conclusion | | |
As COVID-19 pandemic is likely to be around until the near future, research strategies addressing patients with hematological disorders and their treatment protocols need to be updated, revised, and implemented continually. National and international health-care systems for this vulnerable group of patients need to be evolved by designing, redesigning, and balancing their risks for infections. Telemedicine could be upgraded along with newer technological inputs for ease of the clinicians as well as for delivering better services by them to the patients.
Ethical statement
Ethical approval was obtained from the Unit of Biomedical Ethics in King Abdulaziz University (reference number: 20-181) to conduct an online survey during the pandemic. All participants were briefed about the research prior to participation, and appropriate consent was taken.
Author contributions
Concept, design, clinical studies, and data acquisition – Salem Mohammad Bahashwan, Ahmed Salleh Barefah, Hatem Mahmoud Alahwal, Abdullah Talal Almohammadi, and Osman Omer Radhwi; Intellectual content, literature search, data analysis, statistical analysis, manuscript preparation, manuscript editing, and manuscript review – Salem Mohammad Bahashwan, Shahida Khan, Ahmed Salleh Barefah, and Hatem Mahmoud Alahwal. All authors critically read the manuscript and approved the final manuscript ensuring their integrity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Piñana JL, Martino R, García-García I, Parody R, Morales MD, Benzo G, et al. Risk factors and outcome of COVID-19 in patients with hematological malignancies. Exp Hematol Oncol 2020;9:21. |
| 3. | Infante MS, González-Gascón Y Marín I, Muñoz-Novas C, Churruca J, Foncillas MÁ, Landete E, et al. COVID-19 in patients with hematological malignancies: A retrospective case series. Int J Lab Hematol 2020;42:e256-9 . |
| 4. | García-Suárez J, de la Cruz J, Cedillo Á, Llamas P, Duarte R, Jiménez-Yuste V, et al. Impact of hematologic malignancy and type of cancer therapy on COVID-19 severity and mortality: Lessons from a large population-based registry study. J Hematol Oncol 2020;13:133 . |
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| 6. | Jan H, Waheeb A, AlAhwal H, Almohammadi A, Al-Marzouki A, Barefah A, et al. COVID-19 vaccine perception and hesitancy among patients with sickle cell disease in the Western Region of Saudi Arabia. Cureus 2022;14:e21026. |
| 7. | Alzahrani M, Al-Mansour MM, Apostolidis J, Barefah A, Dada R, Alhejazi A, et al. Saudi lymphoma group's clinical practice guidelines for diagnosis, management and follow-up of patients with various types of lymphoma during the coronavirus disease 2019 pandemic. Saudi J Med Med Sci 2020;8:227-38 . [ PUBMED] [Full text] |
| 8. | Pagano L, Salmanton-García J, Marchesi F, Busca A, Corradini P, Hoenigl M, et al. COVID-19 infection in adult patients with hematological malignancies: A European Hematology Association Survey (EPICOVIDEHA). J Hematol Oncol 2021;14:168. |
| 9. | Shah MA, Emlen MF, Shore T, Mayer S, Leonard JP, Rossi A, et al. Hematology and oncology clinical care during the coronavirus disease 2019 pandemic. CA Cancer J Clin 2020;70:349-54. |
| 10. | Sahu KK, Cerny J. A review on how to do hematology consults during COVID-19 pandemic. Blood Rev 2021;47:100777. |
[Table 1], [Table 2], [Table 3], [Table 4]
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