CLL Experts Favor Social Distancing, but Vary on Treatment Continuation Amid Pandemic

A new survey of chronic lymphocytic leukemia (CLL) specialists finds most recommend generally following World Health Organization (WHO) guidelines when it comes to social distancing and testing during the coronavirus disease 2019 (COVID-19) pandemic, but the survey also found some disagreement with regard to whether to continue with therapy.

The survey is the latest attempt to figure out how best to manage patients with CLL amid the pandemic, given that patients with the cancer tend to be older in age, have comorbidities, and be immunosuppressed.

In a letter to the editor of the American Journal of Hematology, corresponding author Mazyar Shadman, MD, MPH, of the Fred Hutchinson Cancer Research Center, in Seattle, and colleagues reported on a survey sent to 62 CLL specialists in the United States, Canada, Europe, and Australia. Of those, 59 responded to at least 1 question, and 44 completed the entire survey.

When asked about social distancing recommendations for patients with CLL, 32% said they would advise patients to follow the same guidelines as the WHO and Centers for Disease Control and Prevention (CDC) recommend for the general public. Twenty-one percent said they would advise patients to follow those guidelines but also limit regular outings by asking friends to pick up groceries or medications for them. Another 35% went even further, saying patients with CLL should avoid work, even if they are essential workers. The remaining 12% said they would recommend all of the above, plus wearing N95 masks and gloves outside of the house.

In terms of testing, most experts said it was not necessary to test all patients with CLL for COVID-19. Specifically, 62% of experts said they would limit testing to patients who call to and report symptoms, and another 9.5% said tests should be limited to patients who come in for an office visit and report symptoms.

Still, while clinicians generally had a low bar for what types of symptoms warranted testing. “Most favored testing patients with any levels of reported symptoms, even with limited testing availability,” Shadman and colleagues wrote. “With unlimited access, 23% recommended universal testing.”

Though their approaches to social distancing and testing were in line with recommendations for the general public, the experts expressed caution when it came to continuation of outpatient therapy. Only 14% said CLL therapy should be continued unconditionally. Most (60.5%) favored treatment discontinuation, and 25.5% said they favored continuation only based on the specific clinical situation.

However, when it came to bruton tyrosine kinase inhibitors (BTKis), such as ibrutinib (Imbruvica) and acalabrutinib (Calquence), the proportion of experts favoring unconditional treatment continuation was much higher, at 44%.

Shadman and colleagues said the more favorable responses concerning BTKi continuation may be due to concern about disease flares if treatment were stopped.

“Also, there is a theoretical benefit of BTKi’s in blunting the hyperinflammatory stage of COVID-19 disease by targeting macrophages and/or inhibiting pro-inflammatory cytokines,” they said.

Most experts (72%) recommended against the use of intravenous immune globulin (IVIG), though the authors noted that the survey was conducted in late March and early April, “before passive antibodies in the gammaglobulin pool would be expected.”

Shadman and colleagues said additional study is warranted to better understand the optimal approach to management of patients with CLL during the pandemic.

Reference

Koffman B, Mato A, Byrd JC, et al. Management of CLL patients early in the COVID-19 pandemic: An international survey of CLL experts. Am J Hematol. 2020;95(8):E199-E203. doi:10.1002/ajh.25851