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Infection Preventative Strategies: How Does CLL Impact the Immune System?

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Published on January 7, 2019

At a recent town meeting in Atlanta, Patient Power host Jeff Folloder was joined by a panel of chronic lymphocytic leukemia (CLL) experts, including Dr. Jean Koff and Dr. Jonathon Cohen, both from the Emory University School of Medicine, to discuss CLL and its impact on the immune system. Dr. Koff explains the connection between disease burden and decreased immunity, ways to monitor and treat immunity levels and vaccine recommendations for CLL patients. Dr. Cohen also gives an important update on the shingles vaccine. Watch now to find out more.

This town meeting was produced in partnership with Winship Cancer Institute of Emory University and sponsored by AbbVie, Inc., Pharmacyclics, LLC and TG Therapeutics.

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Transcript | Infection Preventative Strategies: How Does CLL Impact the Immune System?

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.

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.

Jeff Folloder:

Jean, is it fair to say that anyone with CLL has a compromised immune system?

Dr. Koff:                     

I think that’s probably fair to say. I think there’s a spectrum of decreased immunity within patients with CLL. Jonathan mentioned disease burden. I think if your CLL is at the point where you have what we would call a higher disease burden, meaning that you have more of the abnormal cells circulating in your blood stream, or larger lymph nodes, there’s a higher probability that those cells may be crowding out your normal immune cells, your normal lymphocytes and other immune cells that are less able to do their job of targeting foreign entities such as infections like viruses, bacteria, things like that; and less able to do the job of targeting them and destroying them.

Now, we’re still doing a lot of research as to how CLL impacts the immune system; and how we can detect what your level of immunity actually is if you have CLL. And one of the ways that we monitor that, because we can intervene and potentially help you is by checking immunoglobulin level. So, your doctor may have checked an IgG level, and often, again, because the CLL kind of crowds out the normal immune cells ability to produce antibodies that target infections, sometimes your IgG level will be low. And what that tells us is that your normal immunity may not be able to function as well and your body may not be able to fight off infections that if your IgG level was normal, that your body would be able to take care of.

And sometimes in that case, if your IgG level is low we can give you an infusion of IVIG which is pooled immunoglobulin from donors. And that way we give you that antibody back and give your native immune system some tools to fight off possible infections. And so, in my practice I usually check an IgG level in any new CLL patient to me, so any new patient visit. And then also in my review of systems, as Dr. Rogers mentioned, we’re asking about your history of infections, we’re asking about whether or not you have more colds than the average person, whether you’ve been hospitalized with pneumonia In that case I would also have a low threshold to check the IgG to see if maybe there’s an intervention that I can do in giving the IVIG and helping your immune system even if I’m not necessarily treating your CLL directly at that time.

Jeff Folloder:               

What about vaccinations? If we have a compromised immune system, if our immune response isn’t necessarily as good as a healthy, normal person, should we be getting vaccines? Should we be getting the flu shot?

Dr. Koff:                     

That’s a great question. I’ve actually been researching that a lot lately because we have a colleague in our group who’s very interested in that question of is vaccination, does it work in patient with lymphoid malignancies who may have a compromised immune system? An immune system that may not be able to mount the appropriate response to vaccination that gives you immunity to whatever pathogen you’re being immunized against. In addition, a lot of the therapies that we give, such as ibrutinib (Imbruvica), they may target those CLL cells, but they may also take out some innocent bystander immune cells, your normal B cells who are the cells that help to mount that immune response.

There have been a lot of studies recently looking at this very question, especially in the seasonal flu vaccine, because that’s something that you are supposed to get every year. And looking at the immune responses both scientifically, by looking at the immune cells themselves and looking at whether they’re targeted against the flu, but also looking at the rate of flu infections in patients, especially taking ibrutinib, who have gotten the flu vaccine. And we do see some signal that one, if you have a lymphoid malignancy, but two if you’re on a B-cell targeted therapy like ibrutinib, and especially if you’ve gotten chemotherapy in the past that your immune system may not be strong enough to mount the same response that somebody who hasn’t been on those drugs or doesn’t have CLL has.

Does that mean you shouldn’t get a flu vaccine? No. Because we still don’t have anything right now that can even offer the chance of protection. And there are some patients who still mount an immune response and that is very protective and prevents you from getting the flu, or complications from the flu such as secondary infections. And so, I am still recommending all my patients get a flu vaccine, but work is ongoing to really see what the difference is in immune response in patients with CLL and especially patients who are receiving CLL-directed therapy.

Jeff Folloder:               

From what I understand, some doctors who specialize in CLL are now even recommending as far as the flu shot goes, not one shot, but two because of that decreased response to the shot. My doctor told me he wanted me to get a flu shot and then four to six weeks later he wanted me to follow-up and get it again, which I’ve never dealt with before. Of course, all I’m thinking to myself is what a lot of people out there, rightly or wrongly think, if I get two flu shots I’m getting the flu aren’t I? Flu shots give you the flu, don’t they?

Dr. Koff:                     

So, I talk with my patients a lot and there’s a common misconception that the flu vaccine either causes the flu or makes the majority of people feel like crap for days and days after they take the vaccine. And they’ve done a lot of studies on this and this is actually a huge barrier to patients getting the flu shot because there is this fear that it is going to make you feel very bad for a significant amount of time after you get the flu shot. The first thing I would say it’s that’s a small percentage of people who actually have very a severe reaction to the flu shot.

Jeff Folloder:               

But it’s not the flu. 

Dr. Koff:                     

No. No. No. It’s not the flu, it is your body reacting and mounting that immune response to the vaccine, but it is not the flu infection. And let me tell you, the flu infection will be a lot worse. Even if you just get a simple uncomplicated flu it’s going to be much worse than the reaction that you get to the vaccine. In addition, if you have a cancer like CLL you are at increased risk not just of getting the flu but of getting a secondary infection that rides on the back of the flu and can take over either in your lungs or just overcome your immune system; and you can get a life-threatening pneumonia, or a staph infection, or things like that. And so, the reason that we recommend the flu vaccine is not just to protect you from the flu and a week of feeling icky, it’s to protect you from getting hospitalized with something that can be much worse than the flu.

Jeff Folloder:               

Dr. Cohen, what about the shingles vaccine, as we get older most of us have experienced chicken pox so I understand this nasty little bug is hiding inside of us. I watched a neighbor of mine go through a shingles episode and I was absolutely horrified and all I had to do was watch. I was told for the past eight or nine years, sorry you can’t have the shingles vaccine. Has something changed? 

Dr. Cohen:                  

Yeah, so shingles is—my dad does not have CLL, but he had shingles, I guess two to three years ago, and still today, from time to time, has discomfort from it. I know there are probably some of you that have had it as well. So, it’s a real problem. And in the best of circumstances it’s very painful and then it resolves. But in the worst of circumstances it can lead to a life-threatening systemic infection. The challenge is that historically the shingles vaccine has been more of what we consider a live virus vaccine which is a problem for patients that have been on treatment or that have impaired immune systems. Even though it’s what we consider and attenuated virus, meaning it’s weakened it still has the potential to actually induce the disease.

One of the exciting things that we’ve seen recently is that there is a newer form of the vaccine that’s been developed that is not live and that is potentially an option for patents that have received treatment. Okay, this is called Shingrix, many of you may have heard about it, and many of my patients have asked about it and it’s something we feel a lot more comfortable offering for patients.

Jeff Folloder:               

Excellent! 

Dr. Cohen:                  

There are also sometimes oral preventive medications that we can use for patients that are on treatment to try to prevent shingles, but it’s not 100 percent. Anyway, something certainly to talk with your physician about because we do have some options now that we didn’t necessarily have in the past.

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.

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