Many MyMyelomaTeam members have concerns about their risk for contracting — and experiencing serious complications from — the new coronavirus (COVID-19). We asked Dr. David Blumenthal, a medical oncologist with Kaiser Permanente, about how blood cancers such as myeloma and treatments for myeloma might influence risk relating to COVID-19.
The first question many people with myeloma want answered is whether they are at increased risk. Dr. Blumenthal said, “The short answer to that is yes. But everybody's situation is going to be unique and different.”
He continued, “Every individual patient has their own set of risk factors that will both impact their risk of getting COVID-19 and their risk of getting seriously ill from it. [Medical oncologists try to determine] who is in the highest risk categories and what we should do to mitigate those risks, from suspending some patients’ treatments to trying to keep our infusion centers as safe as possible for patients.”
Since multiple myeloma is a cancer of the plasma cells and damages the immune system, it can have a different risk profile than other blood cancers. “We think our myeloma patients are at increased risk both of getting COVID-19 and getting sicker from it if they get it,” Dr. Blumenthal said.
This impacts the treatment decisions doctors make for myeloma patients amidst the COVID-19 pandemic. “Does treatment make [people with myeloma] more immune-suppressed or less immune-suppressed?” Dr. Blumenthal asked. “In theory, if we treat the cancer, we may improve their immune system a little bit because the bone marrow is healthier and is able to mount a better response against infection.”
Some myeloma treatments suppress the immune system more than others, and may put myeloma patients at higher risk. “Steroids in particular, which a lot of our myeloma patients are on, are probably more immune-suppressive [than desired with COVID-19],” Dr. Blumenthal explained. “And some of the other mainstay treatments of myeloma might also be a little bit immune-suppressive. But most are only modestly immune-suppressant at worst.”
Corticosteroids, or simply steroids, include Prednisone, Dexamethasone, and Methylprednisolone.
According to doctors affiliated with the Dana-Farber Cancer Institute, people who are taking steroids or other treatments for cancers such as leukemia or lymphoma may not experience a high fever (or even a fever at all) if they contract COVID-19 — although it is a typical symptom of the new coronavirus.
With new information about COVID-19 emerging every day, medical oncologists and hematologists are quickly adapting their treatment practices. Dr. Blumenthal described the case-by-case decisions doctors are making each day.
“Does the benefit of continuing this treatment outweigh all the risks?” he said. “And that includes the risk of coming to the infusion center, the risk of coming to the lab the day before to get your blood checked, and all the risks inherent in the treatment — because the treatments might also further immune-suppress in some ways.”
The goal is to keep treating people with myeloma, while also minimizing their risk from COVID-19. “For most of our myeloma patients, we're probably going to continue treatment as is, at least for right now,” Dr. Blumenthal said. “If the situation changes, and we find that patients are at higher risk than we think just from coming into the infusion center [that may change].”
“Right now, for most of the myeloma treatments, [treatment] probably doesn't increase the risk that much.”
“There aren't really any issues so far as we know, with [our] infusion centers being vectors,” Dr. Blumenthal said. “I think it's because we have really tried to take a lot of precautions.”
Dr. Blumenthal described several measures clinics use to keep infusion centers safe for myeloma patients, including:
Still, this can be challenging. “As everyone knows, there's a real worldwide shortage of masks right now, and we are trying to be thoughtful stewards,” explained Dr. Blumenthal.
“Centers are screening their staff daily and trying to make sure that the staff doesn't become a vector for infection,” he said. “Through that combination of efforts, we're hoping that infusion centers will stay safe. But it's a risk. There's no guarantee, and is it possible that in the future, someone will get COVID-19 from coming to an infusion center? We can't 100 percent eliminate that risk.”
Immunotherapy is a broad term for a variety of anti-cancer treatments that work by interacting with the immune system in some way. One of the most commonly used immunotherapy treatments now for myeloma patients is Darzalex (daratumumab).
“We are hopeful, in general, that immunotherapy probably doesn't really increase a patient's risk very much,” Dr. Blumenthal said. “Immunotherapies, in general, boost the immune system. There is risk, as patients can get a variety of side effects. Some of those side effects could make the patient more susceptible. But if patients are getting immunotherapy, we think probably, in general, those are safe to continue,” Dr. Blumenthal said.
“I've certainly continued 100 percent of my patients so far with immunotherapy,” Dr. Blumenthal continued. “Again, evaluating every patient case-by-case, but so far I’ve continued my patients because I think it's probably pretty safe. It’s a newer therapy and combined with a new viral pathogen that we don't know everything about makes this an unknown without a lot of data to guide us.”
Read more about immunotherapy.
During the COVID-19 pandemic, many doctors are considering delaying stem cell therapy treatments for people with myeloma by at least two months, if that is an option. “It's going to be patient-specific, and it's going to be center-specific,” explained Dr. Blumenthal. “In general, we are thinking about who can safely defer the transplant, particularly for patients who are getting an autologous transplant [using their own stem cells] for multiple myeloma. You're taking down the immune system, and there is the physical risk that they'll be in the hospital for a prolonged period of time.”
Where you live may impact this decision too. “If you're in a city or part of the world where there is a really high incidence [of COVID-19] right now, you really want to be thoughtful about who you're sending into the hospital for a transplant,” Dr. Blumenthal said. “If you're in a part of the country where there hasn't been as much, you could think about things a little differently.”
Read more about stem cell transplants.
The chimeric antigen receptor (CAR)-T cell therapies are newer, and their risks are less well known. Dr. Blumenthal provided a layman’s explanation of the treatment: “The broad idea of a CAR-T cell treatment is a reprogramming of white blood cells, most commonly the patient's own white blood cells. They are harvested from a patient, then programmed to fight that patient's cancer, and then given back to the patient. We're really modifying the patient's own immune system to fight their cancer. They're exciting, but there are unknowns. It's relatively new — most of these treatments have just been approved over the last couple of years. There are many in development under clinical trials right now for other types of blood cancers and some solid cancers.”
As for the risk posed by CAR-T cell treatments during the COVID-19 pandemic, there is a lack of data on how they affect patients’ long-term immunity. “We don't really know long-term consequences,” Dr. Blumenthal said. “We presume that those patients are going to be at increased risk. Again, these are patients who we will try to keep safe in the infusion center. But they probably are [at increased risk]. For patients who have been on CAR-T cell therapy in their lifetime, they're potentially at increased risk [for infections] for the rest of their lives.”
Read more about CAR-T cell therapy.
Dr. Blumenthal suggests reaching out by phone, telemedicine appointment, or email to ask your doctor questions about your treatment and COVID-19. Kaiser is seeing nearly 100 percent of visits via telemedicine right now.
“Now more than ever, I would encourage people to reach out to your doctor if you have questions,” said Dr. Blumenthal.
Dr. Blumenthal reiterated the importance of physical distancing for you and your family members. “I think that it's important that people really try to be careful about the physical distancing as much as they realistically can,” he said. “I think this even applies to family members. If you have a loved one who has a blood cancer — or really any cancer — it's important for you to try to minimize how much you are interacting with the outside world right now. Because you don't want to bring that home to your loved one. I think that's really important to emphasize.”
“I presume everyone reading this has some sort of connection to the blood cancer world,” Dr. Blumenthal said. “It is important for everybody to [practice physical distancing], even if you are young and healthy. It's important for you to try to physically distance right now as much as you can, because everybody who is out there in the world increases the risk of literally everybody in the world of getting this. Trying to physically distance as much as you can is really helpful. I prefer [the term 'physically distancing' over 'socially distancing'] because we are trying to encourage people to stay socially connected, even as we stay physically apart.”
This is a period of anxiety, with many unknowns. Dr. Blumenthal stressed the importance of asking for help with your emotions, if needed. “I encourage people to reach out to their primary care doctors if they're really having mental health problems with this,” he said.
He also reiterated the importance of staying socially connected while physically distancing. “I think that it’s important for people to call and check in on loved ones more often than you otherwise would, particularly people who are ill and very homebound right now. It can be very isolating. I think there's a lot of benefit in communities trying to come together digitally or just by telephone. Picking up the phone and calling somebody is a meaningful social interaction.”