What are some challenges that COVID-19 poses in the management of multiple myeloma?
Dr. Fonseca: Myeloma doctors need to look at every case individually as they decide on the importance of continuation or starting therapy in the face of this COVID pandemic, and more so if the person is already infected or suspected of being infected.
We know there’s a group of myeloma patients that can be safely observed, and perhaps the best example for this would be those with early stages and smoldering multiple myeloma. The decision is rarely completely binomial, meaning there’s not necessarily a precise point when you need to start therapy, so if someone is getting to the point where you actually think the patient may progress and may do so, perhaps this is the time where it would be okay to watch and observe closely but not necessarily initiate therapy.
We all know that there are situations where myeloma cannot wait. So, if you have a person who presents with acute renal failure, hypercalcemia, or bone disease, the risk for that person for delaying treatment is much greater than any risk that could exist because of the possibility of COVID infection. In fact, the risk for loss of function of the kidney and ultimately loss of life would be much greater for delaying treatment inappropriately. So I would say for a patient that clearly needs treatment, they really should start.
An area that has been somewhat problematic is deciding who needs to move forward with a stem cell transplant, and things have moved rapidly over the last several weeks. When we started seeing what occurred in other health systems, particularly in Italy, and subsequently, what we saw on the East Coast, it made practical sense to think about the delay of stem cell transplant in patients with multiple myeloma. There were two reasons for this. One is because of the risk of infection itself, but number two is that transplant can lead to the need of additional support while the patient is going through the process, including ICU support. Not really knowing whether we would have that available for patients during that period, I just don’t think it was a wise decision to move forward.
As we have learned more and more, it seems that the effects to “flatten the curve” have been successful, at different levels in different locations, so there are many health systems now that have the capacity to think about moving forward with stem cell transplant. In fact, in our center, now, we have restarted stem cell transplant for patients with multiple myeloma, and it’s important to remember that while this remains a topic of intense research, stem cell transplants for suitable candidates remains a very important tool for the management of myeloma patients.
What about patients who are on maintenance therapy?
Dr. Fonseca: Likewise, the use of maintenance is something that should be continued. I have not stopped maintenance on patients who are maintenance post-stem cell transplant, and of course, I just advise patients that they should be careful, trying to avoid infection, but really, like anyone else.
The same principles apply in the setting of the relapse and refractory disease. You can sometimes have patients who will have a slow increase in the serum concentration of monochromal proteins, for which continued observation is fine. In the majority of cases, we decide to start treatment when we see clear evidence that the myeloma needs to be under therapy, and then those patients should be getting that because again, the risk for uncontrolled myeloma is much greater than that of the potential risk for a COVID infection.
Have there been changes in the way your team approaches individual patients?
Dr. Fonseca: One of the things that has been incredibly satisfying in the midst of all the terrible happenings that have occurred associated with the pandemic has been the fact that, if you look around, you see that people have come together. In particular, I am very impressed with the cancer community, and there’s many reasons why I think this has happened. The cancer community is one that is traditionally associated with performance of clinical trials. We have networks, we have the ability to do things like biobanking, and we’re constantly attuned to the science. So I think in a very sort of organic way, the cancer community has made itself available to work in partnership with epidemiologists and infectious disease doctors and in fact, in many cases, we have seen oncologists participate in the development of clinical trials. I hope that out of these many clinical trials, we continue to see new venues for hope and for future treatment for the disease.