Many MyLymphomaTeam 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, to help us better understand how blood cancers such as lymphoma and treatments for lymphoma might influence risk relating to COVID-19.
The first question many people with lymphoma 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.”
“Every oncologist around the country is engaging right now to try to figure out what the safest thing is to do for our patients,” he said.
Dr. Blumenthal discussed the risk factors for people who are diagnosed with lymphoma. “Lymphoma is a very broad diagnosis, and there are a lot of different lymphomas,” he said.
“Some of them are a little bit more indolent [slow growing], like a lower grade follicular lymphoma. For those, we might feel that deferring treatment for a couple months might be the safest thing to do,” he said. For slow growing and less aggressive cancers, oncologists may also encourage their patients to continue to practice physical distancing and to take extra precautions to avoid COVID-19 infection.
However, some people with lymphoma need treatment immediately. “[They] probably do have some increased risk of getting [COVID-19],” Dr. Blumenthal said. “We try to take the physical precautions that we can, but a lot of those patients are not going to be able to realistically defer.”
People who have chronic lymphocytic leukemia (CLL) or small-cell lymphocytic lymphoma (SLL) are at a higher risk of contracting COVID-19 and having COVID-19 complications.
“Unfortunately they are at a pretty increased risk of getting COVID whether they're on treatment or not,” Dr. Blumenthal said. “CLL [is a] cancer of the lymphocytes, which are particularly important for defense against viral infections, and we know those patients tend to get viral infections much more easily — even if they're off treatment.”
Oncologists treating CLL “have some flexibility with treatment because it is not a very fast growing blood cancer,” Dr. Blumenthal explained. Doctors may consider postponing treatments, if appropriate.
People with lymphoma may receive chemotherapy, immunotherapy, or radiation treatments. Stem cell treatments are used to treat someone who has a recurrence of lymphoma or people who do not respond to other treatments.
According to doctors affiliated with the Dana-Farber Cancer Institute, people who are taking steroids or other treatments for leukemia or lymphoma may not experience a high fever (or even a fever at all) — although it is a typical symptom of the new coronavirus.
Dr. Blumenthal explained that it’s likely almost all chemotherapy regimens for lymphoma increase the risk of both contracting COVID-19 and having more complications from COVID-19.
“Oncologists around the country are being thoughtful about what can be done to mitigate these risks for our patients, from drug and dosage modifications to postponing treatment when that’s possible,” said Dr. Blumenthal.
Talk to your doctor about the specific risks associated with your treatment regimen and what can be done to mitigate them.
“There aren't really any issues so far as we know, with [our] infusion centers being vectors,” explained Dr. Blumenthal. “I think it's because we have really tried to take a lot of precautions.”
Dr. Blumenthal described several measures clinics take to keep infusion centers safe for people with lymphoma, including:
“Through that combination of efforts, we're hoping that infusion centers will stay safe. But it's a risk,” Dr. Blumenthal said. “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.
“We are hopeful that immunotherapy doesn't increase a patient's risk very much,” Dr. Blumenthal said. “Immunotherapies 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, in general, those are safe to continue.”
“I've certainly continued 100 percent of my patients so far with immunotherapy,” Dr. Blumenthal continued. “Again, I’m 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.
Radiation therapy is an option for some kinds of lymphoma. Given that radiation therapy requires visiting a hospital or treatment center, Dr. Blumenthal said that radiation centers are trying to do everything they can to mitigate patient risk. Centers are decreasing the amount of traffic into their facilities, postponing the treatments that can be postponed, physically spreading out chairs in waiting rooms, sanitizing treatment and changing areas, and screening staff and patients as they come in.
“Fortunately, radiation does not cause very much, if any, immunosuppression. So the risks from COVID-19 are less concerning than they are for patients who have to have chemotherapy right now,” Dr. Blumenthal said.
During the COVID-19 pandemic, many doctors are considering delaying stem cell transplants 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 [for whom] can we safely defer the transplant.”
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.
Chimeric antigen receptor (CAR) T-cell therapy is a newer type of immunotherapy treatment. Dr. Blumenthal described CAR T-cell therapy as “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.”
Given that CAR T-cell therapy is newer, its risks are less well known. “This means that we really don’t know the impact of COVID-19 on people going through these treatments,” Dr. Blumenthal said. “We presume that those patients are going to be 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.”
Dr. Blumenthal suggests reaching out by phone or email to ask your doctor questions about your treatment and COVID-19.
“Now more than ever, I would encourage people to reach out to your doctor if you have questions,” said Dr. Blumenthal. Providers are available mostly through telemedicine appointments. He said his organization, Kaiser Permanente, is seeing nearly 100 percent of visits via telemedicine right now.
Dr. Blumenthal explained that oncologists everywhere are thinking through key questions about whether the benefits of continuing a treatment outweigh the risks. These include the risk of:
Dr. Blumenthal reassured members of MyLymphomaTeam that oncologists are mindful of all of these factors. He said, “Nobody is getting treated right now without their oncologist reviewing that decision.”
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.
Dr. Blumenthal also emphasized 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,” he said. “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.”