COVID-19's Impact on How Patients with CLL, Myeloma Have Received Treatment

CURE® recently invited patients, survivors, caregivers, advocates and health care professionals to attend its first-ever live webinar, “Hear from the Experts: COVID-19 & Cancer Care for Patients.”

Sponsored by Janssen and Pharmacyclics, the webinar was designed to provide those affected by chronic lymphocytic leukemia (CLL) and myeloma with information and updates as it pertained to the current landscape of cancer care during the uncertain times of the new coronavirus (COVID-19).

Dr. Saad Usmani, chief of the Plasma Disorders Program and director of clinical research in hematologic malignancies at the Levine Cancer Institute served as the moderator for the webinar. Panelists included:

• Dr. Zainab Shahid, medical director of bone marrow transplant infectious diseases at the Levine Cancer Institute
• Dr. Farukh Awan, director of the Lymphoid Malignancies Program at the Harold C. Simmons Comprehensive Cancer Center at UT-Southwest
• Dr. Ian Flinn, director of the Lymphoma Research Program at Sarah Cannon Research Institute
• Dr. Lee Greenberger, chief scientific officer at the Leukemia and Lymphoma Society

In the first part of this series, Dr. Farukh Awan addresses how the pandemic has affected his practice, as well as how it has impacted how patients with CLL and myeloma have received care.

Awan: We’re all learning. This is something that none of us have experienced before, so we’re learning more and more about the virus with every passing day. There’s more data coming out. There’s a lot of new clinical trials happening, so everything is happening at the same time we are all trying to do the best we can to decrease the spread of this so we can better manage our patients who do get infected and that would not overwhelm the system.

In line with that, every institution has instituted a policy that suits their needs. Fortunately, in Dallas we started with social distancing early and I think we were able to keep the numbers fairly manageable. And yet, we still had to make a lot of changes to the way we practice.

In terms of outpatient management, we have limited the number of visitors that come in with the patient. We try to keep them outside of the clinic area. We also have tried to make the most of our electronic visits so that the least number of patients get exposed to the staff, and vice versa. We have also started utilizing local labs, which are a lot of times not as busy as the oncology clinics and cancer centers. Those labs then give us the results from the blood work that we need. I think we've utilized all of these approaches on the outpatient side. We've also been fortunate that we have a service for drive-through testing for patients who have active symptoms. We are trying to get them through the drive-through testing and if they are positive, then they're asked to quarantine at home.

For those who do get really sick and need to go to the hospital, the ER has a system where everybody gets quarantined on arrival. They get tested in a timely manner with a rapid test for their COVID-19 and if they are positive, they are then sent to a specific isolation floor meant for those patients. There are mechanisms in place, both on the outpatient and inpatient side, which have tried to minimize exposure to patients, family members, and staff at the same time.

As far as for patients with chronic lymphocytic leukemia (CLL) who are concerned, a lot of our patients can afford to wait a little bit to start their new treatment. For patients who are not actively getting treated, we do plan on delaying their treatment until at least we have some idea of better treatment modalities and if their symptoms can be managed by other approaches. For those who are on active treatment, we are trying to continue those treatments while trying to minimize their return visits and we're trying to do that electronically as much as possible, either via telephone calls or through a video visit. Either option is being utilized so that patients can limit their back and forth to the clinic.

We know that our patients with CLL are especially at a high risk of getting infections. Infection-related complications are one of the leading problems in our patients. We expect that our patients would be at an extremely higher risk and that’s why we are also advising that they socially distance themselves from any known patient or persons who might have the virus. We are now also learning that there is a fairly large group of patients, or people in the community, who would have asymptomatic disease and they can potentially spread the disease to a lot of other people without even knowing that they have the virus, and I think that's very scary for our patients since they are immunocompromised at baseline, even without treatment.

It’s a unique challenge. We are recommending that all our patients with CLL practice social distancing, minimize exposure, and even if they don’t have to go out for groceries they shouldn’t. I think if we can do that over the next few months, hopefully, we can right this and hopefully we will get our patients through it without having any serious complications.

On the other hand, some patients with lymphoma can wait to start treatment, some of them cannot. In some aggressive lymphomas, the treatments need to be started right away. For those patients who need to start treatment right away we are following them very closely for any symptoms. If they exhibit any symptoms, like fevers or a cough or any upper or lower respiratory tract symptoms, we are testing them before we give them any chemotherapy. If somebody is positive for the virus, we are not using chemotherapy for those patients and we are trying to delay chemotherapy as much as possible.

For patients already on treatment and need to be admitted to the hospital we are screening them with a test 48 to 72 hours prior to their admission to the hospital, and once they're negative, they can then start their treatments. We're trying to use all these resources that are available to us to try to minimize the risk, again, to the staff and to patients and to prevent any complications that might happen in the future.

Finally, I’d like to make a point regarding stem cell transplants and CAR T. These can be potentially curative options for our patients. We also realize that a lot of our patients will get extremely sick during that process. So, we have multiple challenges with regards specifically to stem cell transplants and CAR T. We’ve also learned that the Red Cross and blood banks are being stretched and that their resources are limited. The number of donors is limited. Since there aren't a lot of donors like we normally would have, getting access to blood products can be a challenge for our transplant patients, especially if they need blood transfusions and platelets.

We’re trying to very specifically look at all the factors for every patient who is undergoing an autologous transplant, or a CAR T cell treatment and we are trying to select the patient who absolutely needs to proceed with it. We are taking that patient to transplant and are employing a multitude of tests at various time points and making sure there are no visitors during their hospital stay, and as much as possible we are ideally using electronic visits for follow-up to minimize exposure.

Have we done transplants in the last few months? Absolutely. We’ve also done CAR Ts and we have successfully and safely gotten patients through it, but it’s challenging. It can be done but we have to be extremely careful that we minimize exposure to our patients and hopefully we can all get through this.