Mary-Beth Percival, MD, provides insight into precautionary measures put into place to ensure patient safety, some of the considerations included in the paper, and the different ways in which she is overcoming challenges faced in practice in light of the pandemic.
Mary-Beth Percival, MD, associate professor of oncology and urology at Johns Hopkins Medicine
Mary-Beth Percival, MD
The COVID-19 pandemic presents unique challenges for optimal management of patients with hematologic malignancies, according to Mary-Beth Percival, MD. To this end, faculty from Seattle Cancer Care Alliance have come together to generate guidelines geared toward balancing the risk of underlying malignancy with those of the virus infection and mortality.
“We’re treating these patients with curative intent chemotherapy. The chemotherapy can be very toxic to the normal immune system—that's a given, even in non-pandemic times,” said Percival. “As such, when patients are being treated with these really toxic therapies during a pandemic, it raises many questions regarding the best ways to manage patients and to decrease their risk of exposure to the virus. Also, other complications that may land them in the hospital through no fault of their own.”
In January 2020, the first documented patient in the United States who was infected with the virus was diagnosed in Washington State. Since then, cancer care has completely changed. At the Seattle Cancer Care Alliance, oncologists specializing in hematologic malignancies have channeled their efforts into adjusting clinical practices to mitigate COVID-related risks.
In an effort to improve outcomes by sharing experiences, Percival and her colleagues came together to draft recommendations based on best available data from clinical trials and collective knowledge of the different disease states. This guidance, which has been dubbed “The Seattle Strategy,” was compiled into a paper that was published in the Journal of Oncology Practice.
In our exclusive interview, Percival, a hematology/oncology physician at Seattle Cancer Care Alliance; assistant professor in the Division of Hematology at the University of Washington School of Medicine; and assistant member in the Clinical Research Division at Fred Hutchinson Cancer Center, provided insight into precautionary measures put into place to ensure patient safety, some of the considerations included in the paper, and the different ways in which she is overcoming challenges faced in practice in light of the pandemic.
OncLive: What does the situation with COVID-19 look like in Seattle right now?
Percival: Thankfully, the situation is stable to improving by almost all the measures that are being used. We get frequent updates from the inpatient side, which, for us, is the University of Washington Medical Center, at our institution. We also [get updates] from the outpatient side at the Seattle Cancer Care Alliance. [This data includes] updated case counts, the number of people being discharged from the hospital, as well as the statewide information that gets published frequently and updated by the Department of Health.
It looks like the overall number of cases has decreased, but hundreds of cases are still being diagnosed every day, and on the order of 1 to 2 dozen deaths are being reported daily. Everyone is breathing a sigh of relief that things didn't reach the absolute worst that they could have in terms of what was predicted for the potential surge and what was seen in other parts of the country. We, in Seattle, escaped some of that; however, at the same time, it doesn't feel like we are out of the woods.
What were some of the precautionary measures that were put into place at your institution to ensure the prevention of the virus within the community?
We have done many things; it has been a little bit of an evolving response. I will say that what I tell you should be up to date right now, but that's not to say that it won't shortly become less current. One of the big changes has been universal masking. Everyone—healthcare providers, patients, visitors, anyone—who comes through the Seattle Cancer Alliance doors is expected to wear a mask and they're provided with one if they don't have one.
Regarding entry, there is 1 site where everyone enters the cancer center, and everyone is screened with a questionnaire and then able to get their mask. If any symptoms are reported by a patient, a family member who is accompanying that patient, or even a staff member, they can be appropriately triaged to get tested for the COVID-19 virus. We also have a COVID-19 nurse hotline.
Patients who have symptoms are encouraged to call the hot line before they come in to avoid potentially exposing others in the clinic. Drive-thru testing sites [are also available], where patients can undergo testing if necessary, to reduce the exposure and risk to those around them. Those are some examples of efforts that have been made to decrease exposure for symptomatic patients.
There's also a growing body of evidence suggesting that there is asymptomatic transmission and that anyone who has the virus is not always aware that they have it and may be shedding the virus in that circumstance. Keeping that in mind, there has been a lot of encouragement to work from home for people who are able to. For a large clinical trial center like ours, we have a rotating system for the clinical trial coordinators so that they only come in if necessary. We’ve been playing around with the thought that maybe they can use Zoom to join in on some of the telemedicine visits; we're working on trying to figure out what that's going to look like. Again, we’re operating with this [mentality] that we're not completely out of the woods yet, even though things weren't as bad as they absolutely could have been.
I alluded to this move toward telemedicine. While many of my patients with hematologic malignancies still need to get their labs drawn, they maybe don't always need to have a physical exam. As such, whenever possible, we have been moving many of those visits to telemedicine. Patients will come in at a quiet time, such as on the weekends when it's usually very quiet in the lab and there is minimal exposure to other patients in the waiting room, staff, or family members of patients, and we'll get their blood drawn. Then, maybe 1 or 2 days later, we'll be able to conduct a telemedicine visit; that decreases exposure [to the virus] and the person-to-person transmission risk significantly.
Testing is a critical component of care right now. How are you approaching testing in practice? Are you experiencing any challenges or shortages?
We have been very lucky that the University of Washington Department of Virology lab managed to develop an in-house test that reached the clinical certification levels and was able to be ramped up pretty quickly with the capacity to perform thousands of tests a day. [Because of this], thankfully, we haven't experienced too many shortages in terms of testing, and we've been able to test everyone for whom it seems appropriate to do so.
Determining who is appropriate to test remains a little bit of a moving target. For example, right now, I'm the inpatient leukemia attending at the University of Washington Medical Center and when patients come in, if they are admitted with a complication like neutropenic fever, even if they don't have any chest x-ray findings, they undergo at least 2 different tests for COVID-19. Every patient who gets admitted to the hospital gets swabbed for COVID-19; they're not necessarily put into respiratory isolation and precautions unless the tests were to come back positive, which would be unusual but possible. The fact that patients have a fever when they have neutropenic fever is sufficient [reason] to get a second swab 12 to 24 hours later, to ensure that they are negative and that we weren't catching the virus right at the beginning of its replication. [If that was happening], the sensitivity of the first test wouldn't be sufficient to detect the virus.
We are lucky to be able to have enough testing at our center and I think that is true at a number of the hospitals in our region; it's more of an issue to be able to get adequate testing at other facilities like long-term care facilities where sometimes our patients may need to go for rehab after a hospital stay. I know that there has been a push, in the state of Washington at least, to devote separate spaces to patients who have COVID-19 infection, who are recovering from infection, and are being discharged from the hospital after having had an infection. [By having] a separate wing [dedicated to these patients in] a nursing facility, they’ll still be able to care for those patients and treat them appropriately if they are found to have any symptoms.
What are some unique challenges that the pandemic presents with regard to providing optimal management of patients with hematologic malignancies specifically?
Patients with hematologic malignancies are a unique subset within cancer more broadly. Many times, even for patients with relapsed or refractory disease, but certainly for patients who are newly diagnosed, we’re treating these patients with curative intent chemotherapy.
For example, one issue that we deal with a lot is neutropenia, having a low white blood cell count, and an inability to fight off typical bacterial and fungal infections with the same capability as someone who is nonneutropenic. For neutropenic patients, we are more liberally using growth factors to try to decrease that duration of neutropenia and the amount of time that patients need to spend in the hospital and hospital-like setting because of the potential of spread of the virus in that setting. Hospital capacity constraint issues [must also be considered]. Although that hasn't been as much of an issue, if there is a surge, questions regarding adequacy of the number of ventilators or other supportive care measures available for patients [will be raised]. We're trying to decrease the burden that our patients would need to put on the system if it were stressed.
You authored a paper on considerations for managing patients with these malignancies during the pandemic. What were the steps that led up to the paper? What was your inspiration for putting it together?
It came out of hallway conversations. Ajay K. Gopal, MD, Andrew J. Cowan, MD, and I realized as we were taking care of our various types of patients who more broadly all have hematologic malignancies but who require many differences in their care, that there were different considerations that other people would benefit from thinking about and learning about. We were trying to consider what we would do differently in the time of the pandemic. Dr. Gopal, for example, primarily cares for patients with lymphoma and Dr. Cowan primarily cares for patients with myeloma. I primarily take care of patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). As such, we decided to approach colleagues we work with who treat different subsets of hematologic malignancies and [record] what particular considerations they were coming up with [to care for their patients during this time].
One example that Dr. Cowan came up with, that we put in the paper that you referred to, is that part of the treatment for patients with relapsed/refractory multiple myeloma often includes an anti-CD38 antibody known as daratumumab (Darzalex). This drug can be a really effective treatment for patients with relapsed/refractory disease. However, something that I was unaware of, because that's not the primary patient population that I care for, is that the rate of upper respiratory tract infections is consistently higher in patients who receive daratumumab; that has been previously published. Given that, if Dr. Cowan has a patient who has stable disease or a low burden of disease, he, and some of his other myeloma colleagues, are considering holding a dose or maybe keeping the patient off for a longer period of time, such as a period of weeks or months, while the pandemic is ongoing to really ensure that he is not predisposing patients to adverse risk outcomes with the COVID-19 virus.
Could you discuss some of the other recommendations you shared for some of the other malignancies in your paper? What is being done for your patients with AML, for example?
For patients with AML, it's often considered an emergency when the diagnosis is made, and thus, treatment is initiated very quickly. However, if you look back, a couple of retrospective analyses that have been published suggest that it's OK to wait a period of time [before beginning treatment], more on the order of days to weeks rather than months. AML is still [a disease] that needs to be treated urgently but that suggests that there would be time to test a patient for COVID-19. We can wait for those results, and possibly be able to support a patient through a diagnosis of COVID-19 without feeling that immediate pressure to initiate treatment, a pressure that often happens when we see a patient with a new diagnosis of AML.
Additionally, at our center, we have done a couple of clinical trials to examine whether it's safe to administer outpatient induction chemotherapy with the goal of trying to decrease the burden of hospitalization for patients. We found that [approach is] safe in a pilot study that was published in Blood Advances earlier in 2020. As such, we have done more of this during the pandemic. Additionally, based on another clinical trial that was published, we often discharge patients after the completion of induction chemotherapy, whereas at other centers they're kept inpatient for a full month while they're waiting for their blood counts to recover after chemotherapy. Those are some interventions that would be reasonable [to consider], that other centers may not be as aware of but may be more willing to adopt during this period of time.
Is there anything that you would like to add?
One thing is to speak a little more generally about cancer because it's hard to know exactly what the interplay is between the virus and other comorbidities that patients may have, cancer being just one of them. Not a whole lot of data are out yet regarding patients with hematologic cancers in particular in terms of their response to the COVID-19 virus; however, some data from China are available because they're a little farther ahead in time in terms of exposure. A little bit of data suggest that outcomes are a lot worse for patients who have a history of cancer who end up getting the COVID-19 virus, and that's both in terms of requiring intensive care unit stay and then also in terms of overall mortality being higher in patients with a history of cancer. Many of the publications have not drilled down on the type of cancer yet. More information will become available, but I think that really underscores the importance of primary prevention and just trying to reduce exposure so that patients with blood cancers, or any other kind of cancer, don't get the virus to begin with.
Percival MM, Lynch RC, Halpern AB, et al. Considerations for managing patients with hematologic malignancy during the COVID-19 pandemic: the Seattle Strategy [published online May 5, 2020]. JCO Oncol Pract. doi:10.1200/OP.20.00241