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CLL Horizons Meeting 2016 – An Interview with Dr. Ben Kennedy on Immunoglobulins in CLL
CLL is a cancer of the immune system. It affects the B cells and for many, the level of the antibodies in the blood drop. This in turn may compromise our ability to fight off infections. That is one reason why we urge all those with CLL to update their vaccinations (killed vaccines only!) when first diagnosed, as immunity generally gets worse as the disease progresses and with certain treatment.
Dr. Ben Kennedy took a break from speaking at the inaugural CLL Advocacy Network Congress in Belgrade, Serbia to explain the basic facts around this issue. You can read the transcript below, or listen to the audio interview here.
Brian Koffman, MD: Hi, I am Dr. Brian Koffman and I’m here in Belgrade, Serbia at the first meeting of the CLLAN, the CLL Advocacy Network. Want to introduce yourself, please?
Ben Kennedy, MD: My name is Dr. Ben Kennedy. I’m a Consultant Hematologist at Leicester in the UK.
Dr. Koffman: Dr. Kennedy, you’ve done some interesting research and have an interest in the role of immune globulins. Can you explain what an immune globulin is and why that’s relevant in CLL?
Dr. Kennedy: Sure. So, my patients with CLL have a problem with their immune systems. We all rely on immunoglobulins, we call them antibodies sometimes. These are the same as antibodies that we use for therapy, but these are antibodies against infection. So, we call these immunoglobulins. CLL is a disease of B-cells. These are cells that are destined to make an antibodies. Their role in life, what they’re going to do, is to make an antibody to help you fight infection. And when we have a disease such as CLL, we have a problem with our mechanism. Gradually over a period, usually of years, the immunoglobulin levels will fall and as they fall, there is an increased risk of infection. This is a big problem for my patients with CLL. They often struggle with infection. We need to look at the immunoglobulin levels to see what we can do to help them, because there is a possibility that some patients benefit from immunoglobulin replacement therapy. This can be given as a monthly intravenous infusion or even a subcutaneous injection on a weekly or two weekly basis. This will often restore that lost immunity that people have as a gradual process, as a natural part of their disease progression over years. Sometimes with a step-wise reduction after therapy, but if we can replace the immunoglobulin in patients who really need it, this will help people significantly. It significantly reduces the risk of infection, and it can help prevent some of the structural problems that happens in our lungs when we have recurrent infections. So, problems in our lungs like bronchiectasis where the airways are damaged, and that in turn leads to a further increased risk of infection. So here is a major problem and something we should be looking for actively in our patients with CLL, and there is a solution for those patients who have severe problems with infections that we can prevent this and reduce their risk significantly.
Dr. Koffman: Now I know that the replacement therapies, the immunoglobulins are rather expensive, and somewhat inconvenient. Are there criteria that you look for that say this patient should get it, this patient shouldn’t? How to you decide? And it’s also a limited resource because it’s a pool of blood product.
Dr. Kennedy: Right, like anything in the world of healthcare, there’s health economics around this and we have clear criteria. So, for example, in the UK, to be able to qualify for immunoglobulin therapy you have satisfy certain criteria. Now those criteria will include a low level of the immunoglobulin, infections that are carrying despite antibiotic prophylaxis, and a lack of response to the pneumococcal vaccine. So, this is an important point – Why would we look at pneumococcal vaccine? This is because when patients have a low immunoglobulin level, one of the important infections that people will get will be a bacterial infection and commonly, community acquired pneumonia could be the pneumococcal vaccine. And we can vaccinate against this, however, this is a difficulty in patients with CLL. They don’t always respond to the vaccine. So, we must measure the response by doing a specific immunoglobulin assay about four-weeks after the injection (after the vaccination), and if there is no significant response, then this is one of the criteria for accessing immunoglobulin replacement.
Dr. Koffman: I’m very keen on this and I think it’s really an important point for patients to hear because pneumonia is often the alpha and omega in CLL. Often people get pneumonia before they’re diagnosed, or at the time of diagnosis, and often, sadly, it’s the final event for them – a pneumococcal infection or some other form of pneumonia.
Dr. Kennedy: That’s right. Infection is a major problem in our patients with CLL. I see it time and time again, and as you say, sometimes it is sadly a final event. People die of infection. People die of bacterial infections in CLL. And we need to increase and approve the awareness of this. Our patients need to be aware of this and can ask, “What is my immune system like, please? What are my immunoglobulin levels?” This is a simple question. It’s a simple test.
Dr. Koffman: Dr. Kennedy, thanks so much for the research you’re doing. Thank you.
Dr. Kennedy: Pleasure, Brian. Thank you.
Ben Kennedy, MB ChB, FRCP, FRCPath (Haematology) is an Honorary Senior Lecturer in Cancer Studies at Leicester University. He is also a Consultant Haematologist in the Department of Haematology at the University Hospitals of Leicester.
Brian Koffman, MD 12/12/16