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A diagnosis of CLL is stressful under the best of circumstances, but the COVID-19 pandemic adds an additional layer of complexity for the management of CLL, particularly as it pertains to social distancing. There are three scenarios that CLL patients may find themselves encountering that are worth highlighting: (1) newly diagnosed patients, (2) stable patients who are either on active surveillance (“watch and wait”) who have never been treated or are stable and in remission after treatment is finished, or those who are on long term oral medications and are very stable, and finally (3) those in need of new treatment.
In the first case, if a diagnosis has been recently established, there was probably some in-person encounter with the health system and/or a hematologist-oncologist. For patients who have additional questions who wish to have a second opinion by a specialist but don’t want to expose themselves to additional risk by traveling to a referral center, an e-consult is a very good option. At the Cleveland Clinic, we are offering 60 minute virtual visits for new patients during the COVID-19 pandemic. Many other referral centers are doing so as well. Although an in-person appointment is hard to beat, virtual consults typically give patients the opportunity to ask many questions and decide whether they would like to continue following up with a particular provider in the future.
In the second scenario of patients who are being monitored, a good option is to have labs drawn within a few days of a follow-up virtual visit. By checking the CBC and asking about symptoms, we cover a lot of what is important for follow-up. Although a full physical exam is not possible, if there are specific areas (enlarged lymph nodes and spleen, rashes, etc.) it can be helpful to use the video to evaluate areas of concern.
Finally, for CLL patients who need treatment, additional considerations that take COVID-19 into account needs to be considered. In particular, it may be worth discussing the risks/benefits of treatment given on-site due to the IV administration of medications (such as monoclonal antibodies) or monitoring for tumor lysis with frequent blood test as opposed to oral home medications such as the BTK inhibitors, which might be easier to use when clinic visits may carry some degree of risk.
Clearly, COVID-19 is adding an additional layer of complexity to all aspects of our day-to-day lives. For people with CLL, it is more important than ever to be sure to individualize your plan of care taking the current global situation into account as well as the specifics of your individual case. Be assured that with such an individual approach, combining remote care and when needed in person visits and lab work, CLL still can be well monitored even in these extraordinary times.
Dr. Hill is the Director of the Lymphoid Malignancies Program at the Cleveland Clinic Taussig Cancer Institute