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Chief of Hematologic Malignancies
Swedish Cancer Institute
John Pagel, MD, PhD, has disclosed that he has received consulting fees from AstraZeneca, BeiGene, Gilead Sciences, and Loxo.
Telemedicine in the COVID-19 Pandemic
COVID‑19 has certainly had an impact on patient care across the globe and, for my practice, it has had a large impact on my care of CLL patients as that has been my primary clinical and research focus. Of course, we want to protect all of our patients from this serious viral infection that can lead to life‑threatening complications. Fortunately, severe complications are rare and it is important to recognize that while the prevalence of ongoing complications and problems for patients who have CLL is quite small, it is real and significant.
We have, of course, worked extremely hard to ensure that patients are adequately informed and counseled on how to avoid infections and this needs to be recognized not only for CLL patients but for the population at large. So obviously social distancing, proper handwashing techniques done frequently, and the use of masks are all critically important. We have taken all these precautions extremely seriously in our CLL patients, in addition to limiting their clinical involvement, as needed.
As a result, we have employed a great deal of telemedicine in CLL patients, many of whom have relatively routine follow ups and routine care. Telemedicine has allowed us to stay in touch with patients and routinely monitor them while limiting the clinical concerns around potential exposures in the clinic or hospital settings. Over the last few months, for those patients who are not on an active treatment, such as those on active surveillance or routine follow ups, we schedule video‑related visits or even phone calls, to ensure that no intervention is required.
Preparing for the Telemedicine Visit and Managing Expectations
While we recognize that many patients enjoy the telemedicine approaches, it is important to manage their expectations and prepare them for the fact that despite having a telemedicine visit scheduled at an exact time, unexpected delays can often arise during the course of a busy clinic day or the clinician may need to spend time at the start of the visit reviewing prior laboratory work, notes, or imaging studies. Some flexibility around the engagement on the virtual endeavor along with establishing some guidelines and expectations, on both sides, helps to facilitate a smooth and productive interaction.
It is highly recommended that patients use a video platform such as Zoom or Doximity, such that the physician and patient can see each other. While not a perfect substitute for a face-to-face meeting, video conferencing certainly provides more meaningful mutual interaction than a phone call.
It is also helpful to have patients come to the virtual visit prepared with a list of the issues they would like to discuss. This will not only facilitate time management for the physician but also help the patient with their expectations. It is important to stress the need to focus virtual visits on the issues germane to that visit and allow the physician to address their concerns related to their CLL management and to more effectively meet their needs.
Limiting Exposure for Patients Requiring Laboratory Work
It is true that many people who have CLL are doing very well, either on or off therapy, and in the current climate of COVID-19, it is reasonable to obtain routine laboratory work and thus avoid unnecessary exposure in the clinic. Nonetheless, in my clinic, we ask patients with requirements for lab review to perhaps have their laboratory work drawn locally or in a smaller venue, where they are likely to have less exposure. We also have some patients come in for lab work and then schedule a subsequent telemedicine visit. We also recognize that many people with CLL can forgo the labs for a while and if not, we try to limit their exposure by scheduling them during a period of reduced traffic and flow of patients in and out of the laboratory.
Other Strategies to Limit Exposure in the Clinic
Delaying the start of therapy is an option for some patients, as well as choice of therapy. Single-agent targeted therapies, such as BTK or PI3K inhibitors with less concern about myelosuppression that would require other interventions are preferred over chemoimmunotherapy and combination approaches. Of course we try to prevent complications for patients with CLL that could end up requiring them to come into clinic, thus we avoid those therapies that are more likely to lead to an infection. Lastly, we try to limit the use of infusional agents. We do not use much chemoimmunotherapy anymore, but while monoclonal antibody treatments are still important, we limit the use of those agents to try and keep people out of the infusion room as much as possible.
How have you adjusted your practices during the COVID-19 pandemic in managing your patients with CLL? Have you employed telemedicine? What are the advantages and challenges you’ve faced? Please share your thoughts in the comment box below!