Ask The Doctor Q4 2018
By Richard Furman, MD
Questions submitted by readers and answered by the CLL Society Medical Advisory Board
I recently went to see an allergist to see what I’m allergic to. I was quite asthmatic as a child and well into my adulthood. I was particularly allergic to dogs and cats. I’ve not had an asthmatic episode in a long time. The results from my recent skin antigen test came back negative for EVERYTHING! My son, who got tested at the same time, was positive for an assortment of antigens. Is it possible that my negative responses were in any way attributable to my CLL? Presumably my allergist would have suggested this if this is the case.
It is possible that the lack of response is related to the CLL or any treatment for the CLL. There are certain things that would predict for being unlikely to respond (anergic), including receiving fludarabine or alemtuzumab, or having many infections. Ultimately there is no way to be certain until one does the test. There should be positive controls that everyone reacts to which can help elucidate the usefulness of the test results.
I understand that the B-Cells are affected by CLL, and as a result the affected B-Cells can emit chemicals and proteins that will make CLL patients feel tired and fatigued. Can these proteins be detected in my urine? During my physicals I am told there is a trace of blood. However, the urologist said even though there is no evidence of blood in my urine, there must be some type of protein that is causing the dip stick to show trace amounts.
These chemicals are called cytokines and are used for immune cells to communicate with one another. They are not able to be detected in routine blood or urine work.
I have been tested for Mutational status 3 times from 3 labs and each time in comes back inconclusive. I am told I might be on the border between Unmutated and Mutated. What does my status likely mean? Is inconclusive more favorable, like being Mutated?
It is important to distinguish between inconclusive and borderline. Borderline is a situation where you are mutated at approximately 2%, which is the cut-off between mutated and unmutated. This is not usually read out as inconclusive. They would report the percentage mutated. Inconclusive typically means the primers did not work and they did not get a sequence to analyze. This typically has no implications and relates to the CLL clone not having a rearrangement that could be analyzed.
Shingrix is not approved for immune-compromised individuals, like CLL patients. But we spouses of CLL patients could get it. It is not a live vaccine, so is it correct that after getting the vaccine we caregivers need not avoid contact with our CLL patient spouses?
Also, I read that there is an ongoing study of the safety and efficacy of Shingrix for immune-compromised individuals for which results should be available next year. Do you have any further information about that study? Can the results be generalized to CLL patients?
Shingrix is a recombinant (not live) vaccine and should not present any problems to immunosuppressed patients. The questions that remain relate more to whether it has any efficacy in immunocompromised individuals. I believe there is no downside to taking the Shingrix, so it is worth doing.
Richard Furman, MD is Director of the CLL Research Center at Weill Cornell Medical College and a member of the Lymphoma/Myeloma Service in the Division of Hematology/Oncology. He is a member of the Medical Advisory Board for the CLL Society.
Originally published in The CLL Tribune Q4 2017.
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