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Is CLL Care Finally Returning to Normal?

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Published on June 10, 2020

Chronic lymphocytic leukemia (CLL) patients and their doctors have been approaching treatment differently in recent months due to the coronavirus pandemic. What’s happening now? And what do patients need to know before resuming in-person visits?
 
In this segment from our recent Answers Now program, host Andrew Schorr talks to Dr. John Allan from Weill Cornell Medicine in New York City. They discuss how the pandemic affected NYC, if attempts to flatten the curve have worked, and why Dr. Allan is now recommending the full range of CLL treatments to his patients. Tune in to hear the latest updates from a CLL expert.  
 
If you missed Parts 1, 3 and 4 of this series, watch them at CLL Retreatment Amidst CoronavirusCLL Clinical Trials and Treatment During COVID-19 and Will a COVID-19 Vaccine Work for CLL Patients?

This program is sponsored by AbbVie, Inc. and Genentech, Inc.  These organizations have no editorial control. It is produced by Patient Power.  Patient Power is solely responsible for program content.

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Transcript | Is CLL Care Finally Returning to Normal?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Recorded on June 4, 2020

Andrew Schorr:

Welcome to the CLL Answers Now program. I'm Andrew Schorr in Southern California. Joining us is a great panel today. Thank you so much for being with us. There's Dr. Phil Thompson at MD Anderson in Houston, Texas; Dr. John Allan, who is at Weill Cornell in New York Presbyterian in New York City; and Jeff Folloder, a CLL patient like me. Jeff joins us from Houston, Texas.

So anybody who's watched the news at all over the last two months knows that New York City, and as they call it, the tri-state area, Connecticut, New Jersey, New York, around there, has been a tremendous hot spot for COVID-19; people being hospitalized on ventilators. And at New York-Presbyterian, the doctors at Weill Cornell know that well.

So first of all, Dr. Allan, you are right there. You've maybe had patients like that. How has it affected CLL patients, and how in your view now, should it affect a decision about whether to proceed with treatment?

Dr. Allan:

Yeah, so that's a great question. I think every day it changes and we get more and more information as the weeks go by. Right now, New York City has a lot of unique problems, obviously, with the population density, the public transportation. And so some of the issues that I have to deal with, many providers may not have to deal with in other areas of the country where patients can take their own private transport in. They can have their very controlled settings, and they know it's clean, all these types of things. With that said, though, we have really done a good job in New York state, as well as in our own hospital, in one, testing patients. And so I think that's something that's very important is being able to get a test. If you have some symptoms, to be able to get a test. If you even have something that's concerning for a symptom, to really know if you're positive or not, so you know how to manage yourself, as well as people around you.     

I also think that we are seeing now that we have gotten through the curve, we have flattened the curve. And, in fact, hospitalizations are down. I think the deaths are way down. The patients in ICUs on ventilators are way down from this. And so we've done a really good job at identifying and understanding that preventative measures go a long, long way.      

And so wearing a mask, good hand hygiene, and really protecting yourself when you're out in the environment, if you have to be out in the environment, is imperative in order to be preventing disease as well as spreading it. We've seen that, and I truly believe in it. And I think in our area here, almost everyone wears masks. You literally cannot go into stores without a mask. And so, basically, everyone carries one around. You may see people walking around outside that can social distance without it, but it is important to follow these practices, because I do truly believe in them. And I think it's going to help our patients, especially our immunosuppressed patients that are facing issues.

Andrew Schorr:

Right. So now people like Jeff, where the indications are for treatment again. And I've been through that. Or our many patients who are in watch and wait, and they have it with confidence. And where you have a broad range of treatments now, some that are just oral therapies, some better infused and oral, and where you can match that with confidence in what you and the patient agree is right for them and proceed.

Dr. Allan:

Yeah. So I wanted to get to that point as well. And I just wanted to get that importance on the preventative measures. But now that we are talking about having to treat patients, this pendulum has swung, at least in New York City. When it was on its uptick, there was absolutely deferral of patients coming in. We shut down, basically, our clinics. We were moved to video visits. Patients that could hold off, we held off, and we completely stopped initiating treatment for most of our CLL patients, essentially. The only patients I was treating were patients with curative illnesses, like the diffuse large B-cell lymphoma and people that where the true stopping of their treatment would be a life-threatening problem. And we had to bite the bullet, so to speak, in this really exponential phase that we're in.           

Now, that we are out of that, and we are really flattening this curve, as you hear this term, I do believe that the pendulum is swinging back to where deferring care and deferring initiation of treatments is going to be detrimental. I've seen it outside of some of my CLL patients to where they've had maybe different diseases, more aggressive diseases. But even my CLL patients, it's getting to a point where I need to see the patient in-person. I need to feel those lymph nodes, because our patients aren't always the best at feeling them, or they don't want to, and they don't know how to find and get really deep into the lymph node. And maybe we don't know what that white count has done in the past three to four months where, really, we would have had that information now. So I am encouraging, we have opened our clinical trials back up just this week. This is new for us. And so, we are opening back up.          

I'm encouraging my patients to come back in and see me. With telemedicine, we have been able to get local labs. I can see what labs are. I can check in on a patient, but there's still something meaningful about a face-to-face person. Telemedicine is not going anywhere. It may be an every other visit for some of our watch-and-wait type of patients, where they come in, and then they go instead of every single time coming in. But I am wanting to get my patients back in to it. We see them, now that we have flattened this, it's getting safe. And why I feel safe is because one, we are doing preventative measures with masks, good hand hygiene. Two, we have the ability to test and identify patients; and now when they're coming into our center, they're being isolated. We know who's positive. They go to a completely separate center. They don't even come into the entrance of the general population of our oncology patients.     

And so I think all of the centers around the U.S. are doing the same things, but I encourage, and talk with your doctors to make sure those policies are in place. And so that's why I feel comfortable in my center to be bringing people in. Let's test you, let's find out, let's see where we're at. And if we call you the night before and If you're asymptomatic, you can come on in and so on and so forth. So these policies are there. I feel very safe, and with good, good hand hygiene, masks and preventative measures, I think the risk of catching the illness is low.

Andrew Schorr:

Okay. And just to tie this together, before we go to Dr. Thompson, you have a range of treatments, some include infused therapies as well and the tests you described. You're not hesitating to offer the full range of treatments now?

Dr. Allan:

Right. At this point, since we're to a point where I do feel comfortable and if people truly need it and they are sick from their illness, I am feeling comfortable initiating them on treatment. There are still a lot of what-ifs. And I think Dr. Thompson has brought this up in previous discussions when we're talking; anti-CD20 use does give me a little potential hesitation. I think venetoclax (Venclexta)-based regimens, where patients are having to come in on a weekly basis and frequently, at least in New York City, where its public transportation for many of these patients still might be problematic and gives me a little bit of pause, but I do think these things can be done safely if for whatever reason that strategy and that treatment approach VG or a BTK inhibitor approach is best for that patient, for whatever reason, I think they can all be administrated safely.          

I have actually had patients on clinical trials that we had started, that get the anti-CD20 therapies and can continue on their treatment and with the proper protocols got through safely, never contracted the disease, and this is the epicenter where they were coming in and all these things.      

So again, I think it's patient-specific how much risk aversion does the doctor and the patient have, which approach makes sense for them. But I think either way you want to go, we can do it safely. And we have yet to show any data that anti-CD20 use puts you at a higher risk for severe complications or anything along these lines. And I think that will come out with time. But, but I do think now it's probably safe, as long as you're in a center and area and a region that has gotten in front of the virus instead of in an exponential state.

Andrew Schorr:

Okay. Thank you for all that. And by the way, when he says anti-CD20, if you don't know, those are drugs like rituximab (Rituxan), or obinutuzumab (Gazyva), typically.           

Okay. So let's go to Houston, Texas. So, Dr. Phil Thompson.

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