How COVID-19 is Impacting Care for Blood Cancer Patients

As our society grapples with the COVID-19 pandemic and scientists search for potential solutions, we must take care to protect ourselves as well as others in our communities, by limiting the spread of the virus. This is especially important for health care workers, who interact with people who are at high-risk for severe disease, including those with cancer.

With respect to COVID-19, special considerations must be taken into account for people with certain types of cancer. These include lung cancer, due to the respiratory nature of COVID-19, as well as blood cancers, which can affect the immune system’s ability to root out infectious diseases like the new SARS-CoV-2 coronavirus.

To gain a better understanding of how this current situation is impacting clinical cancer care, especially for blood cancer patients, and how our health care system and physicians are adapting to meet the moment, we spoke with Melody Smith, MD, of Memorial Sloan Kettering Cancer Center (MSKCC).

Dr. Smith, who currently works in the MSKCC lab of CRI Clinical Accelerator Advisory Committee member Marcel van den Brink, MD, PhD, is a board-certified hematologist and medical oncologist with expertise in using cellular immunotherapies and bone marrow transplants to treat patients with blood cancer. In the lab, her research is focused on investigating how CAR T cell immunotherapy administered after bone marrow transplant may be able to improve outcomes for patients with leukemia and lymphoma. Prior to joining MSKCC, Dr. Smith earned her MD and did a residency in internal medicine at the University of Texas Southwestern.

Dr. Melody Smith (MSKCC) pipetting in the lab of Dr. van den Brink

Arthur N. Brodsky, PhD:

Dr. Smith, thank you for joining us today! Given the importance of the immune system in fighting infectious diseases, and that our immune cells develop from our blood, are people with cancers of the blood more susceptible to infection by the new SARS-CoV-2 coronavirus?

Melody Smith, MD:

When it comes to blood cancers—leukemia, lymphoma, multiple myeloma—there's an underlying abnormality within the bone marrow, which produces all the cells of our immune system. So, when those cells are impacted, you can have impaired immune function. Additionally, many of the treatments that we give to patients with blood cancer suppress immune activity further because they eradicate disease from the bone marrow and other parts of the body. Unfortunately, these treatments also place patients at an increased risk for infection.

I specifically treat patients who receive bone marrow transplants. This is a particularly vulnerable group because patients have a window of time after their transplant when their immune function is not what it should be. Notably during the first year following the transplant, they have increased susceptibility to viruses, bacteria, or fungal infections. In regard to COVID-19, patients who have had a transplant or who have received a therapy that decreases T cells, will have impaired ability to fight a viral infection.

Arthur N. Brodsky, PhD:

How has the current situation altered how you provide care for blood cancer patients?  Have you had any situations where treatment needed to be postponed or put off altogether?

Melody Smith, MD:

For patients who need a bone marrow transplant, we are carefully considering the potential risk of delaying their treatment and balancing that with the potential risk of COVID-19 infection in an immunocompromised patient. These risks are discussed with our colleagues so that we can make collaborative decisions on the care of our patients. We are also having open conversations with our patients in regard to these risks during this challenging time.

Additionally, the decision to delay is under the assumption that it will likely be for several months, but we don't know when we'll be able to say we can move forward with this. An unfortunate reality is there are some patients for whom this delay may end up being deadly. Some would have gotten a transplant prior to the pandemic, but by the time things are safe enough to proceed, it may be too late based upon the aggressiveness of their disease. That very difficult possibility also factors into our consideration.

Impact of COVID-19 Pandemic on Global Oncology Clinical Trials

Arthur N. Brodsky, PhD:

The current crisis also limits interactions between patients and their care team. So how have you worked to maintain your relationships with your patients in lieu of in-person contact? Have you incorporated more telemedicine?

Melody Smith, MD:

For clinic visit, we are scheduling telemedicine visits for patients who do not need to be seen in person. We're doing our best to keep patients at home to minimize their exposures.

Arthur N. Brodsky, PhD:

This moment has been trying for everyone but must be especially stressful for those of you involved in such serious decision-making. Have you found anything to be particularly helpful when it comes to making the most of these digital appointments?

Melody Smith, MD:

Patients have been incredibly understanding of the transition to telemedicine. Their flexibility to embrace telemedicine so that we can decrease the potential of exposure to COVID-19 has been very helpful.

Additionally, since visitors are not in the hospital with the patients, I do my best to communicate with family members and caregivers so that they feel more involved in the plan of care.

Arthur N. Brodsky, PhD:

It’s heartening to hear that even amid this hectic moment, you and your team are taking such great care to comfort patients and their families and make them feel at ease throughout this ordeal.

Melody Smith, MD:

The pandemic has created challenges for patients, particularly for our patients with cancer. We want them to know that we see the added stress and isolation that they may be experiencing at this time. We will navigate these difficulties with them.

Arthur N. Brodsky, PhD:

I bet that means a lot to them. I’d now like to discuss CAR T cell immunotherapy. This type of cell therapy has been transformative for patients with lymphoma and leukemia, including children. In some patients treated with CAR T cells, an immunological phenomenon known as cytokine release syndrome (also called cytokine storm) has been observed. More recently, this phenomenon was identified as a potential culprit in deaths due to COVID-19.

Does cytokine release syndrome differ in these two situations? And how are we using what we've learned about it in the context of cancer immunotherapy to help address people afflicted with COVID-19?

Melody Smith, MD:

The underlying biology is still similar in both situations. The key difference to note is that following administration of CAR T cells the cytokines are secreted due to tumor-specific killing. On the other hand, cytokine release syndrome in the setting of COVID-19 occurs as a result of T cells attacking virus-infected cells.

From a clinical perspective, the symptoms and treatment approaches are similar. Anti-IL-6 treatments that have been used for cytokine release syndrome due to CAR T cells are also being investigated for this indication in COVID-19 patients. It's important to assess these treatments in a rigorous fashion and develop algorithms for when they should be administered.

Dr. Melody Smith (MSKCC) with microscope in the lab of Dr. van den Brink

Arthur N. Brodsky, PhD:

Let’s turn to another potential treatment that's being evaluated against COVID-19. It’s called convalescent plasma treatment, and it involves taking antibodies from the blood of COVID-19 patients who have recovered and transferring them to those who are still afflicted.

What are your hopes for this approach, and is it something you and your team are considering?

Melody Smith, MD:

Yes, we are considering this therapy. At my center, we are investigating the use of convalescent plasma. It is also important to note that there is clinical data from respiratory viruses, such H1N1, that support the use of this approach. However, many of the prior studies have included a small number of patients.

Arthur N. Brodsky, PhD:

That's promising to hear. Overall, how has the pandemic shifted the focus of your clinical research, especially clinical trials?

Melody Smith, MD:

For me, as a lab-based physician scientist, I have been impacted in several ways. With the labs being closed until things resolve, I’ve turned my attention to work involving data analysis. In terms of clinical trials, we are now assessing the impact of COVID-19 on our patients through several clinical studies. The pandemic has caused us to shift our focus so that we may understand how we can improve outcomes of cancer patients who become infected with COVID-19.

Unfortunately, the pandemic has also caused disruption to clinical trials for non-COVID-19 indications. The decisions that have been made in this regard have been guided by safety considerations for patients as well as the need to ensure that there is hospital capacity to care for our patients who may contract COVID-19.  

Arthur N. Brodsky, PhD:

What about patients who are already enrolled on a clinical trial?

Melody Smith, MD:

Patients who were already enrolled on a clinical trial remained on study.

Arthur N. Brodsky, PhD:

Dr. Smith, thank you so much for taking the time to speak with us today and, more importantly, for the invaluable work that you and your colleagues continue to do each and every day. Stay safe!

Learn about immunotherapy for blood cancers

For more information about how cancer patients might be affected by the current COVID-19 pandemic, see our interview with Joshua K. Sabari, MD, a lung cancer expert at the New York University Langone Health who currently leads a CRI-funded immunotherapy clinical trial.