In a keynote lecture hosted as part of an Amgen Multiple Myeloma webinar series Dr Brian Durie, Chairman of the Board of the International Myeloma Foundation International Myeloma Working Group and specialist at the Cedars-Sinai Medical Center, talked to delegates about the lessons learned so far in managing multiple myeloma patients during the COVID-19 pandemic.

1. Mortality rate for COVID-19 is higher in patients with MM vs matched controls^1-3

Presenting research from the International Myeloma Working Groups in Spain, the UK and the USA, Dr Durie noted that data so far indicated the mortality rate from COVID-19 is higher in patients with multiple myeloma (MM) compared to matched controls.^1–3 Dr Durie used these data to emphasise the importance of preventing infection with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) as the first-line strategy for managing MM patients during this pandemic. “Avoiding exposure is key in multiple myeloma patients, you do not want to get a myeloma patient infected [with COVID-19].”

When asked about the immune response to COVID-19, Dr Durie explained, “a key thing to understand about the [COVID-19] virus is that it reproduces rapidly early on and it shuts down production of the main factors that would normally slow [viral] replication – such as type 2 interferon. The second thing it does is overstimulate cellular immunity, causing a drastic overreaction in the lungs. So, we need to shut down replication of the virus.”

When it comes to patients with MM, Dr Durie noted that “in terms of treatment, dexamethasone (a common myeloma treatment) is also proving effective for COVID-19 infections that affect the lungs and reduce oxygen uptake.”

2. Social distancing is important, but finding ways to maintain social connections are even more important for patients with MM

Thinking about the most urgent questions for cancer care in MM patients, Dr Durie highlighted the importance of maintaining a social connection whilst physically distancing. He gave the example of grandparents wanting to see their grandchildren, stating “whilst it may not be what your patients want to hear it’s necessary to advise caution against physical contact. However, maintaining the connection with family members is very important – encourage ways of connecting that are not physical, for example doing activities together over video chats.”

3. MM will be a patient group that will have to wait for extensive data before we start using a COVID-19 vaccine

Another hot topic Dr Durie broached was considerations of a COVID-19 vaccine for MM patients. He noted, “discussions about a COVID-19 vaccine may be too pre-emptive for patients with MM. These patients tend to be older, immunocompromised and, depending on their treatment, could be less responsive to a vaccine. Whilst COVID-19 vaccinations are under development it will be a while before we have the safety and efficacy data we need to prescribe them with confidence in this patient population. Before we have a vaccine that we know will work and be safe in patients with MM we are more likely to have developed anti-viral therapies targeting COVID-19. If we look at experience with acquired immunodeficiency syndrome (AIDS), we still don’t have a vaccine against the human immunodeficiency virus  (HIV), but we do have anti-retroviral therapies that are sustainable in the long-term. Perhaps we will see a similar model in COVID-19.”

4. The pandemic has challenged us to be innovative in the delivery of patient care

Some treatment strategies Dr Durie recommended for treating patients with MM during the COVID-19 pandemic aim to reduce potential risk of infection. They included:

• Use of telemedicine or equivalent
• Limit lab testing – try and ensure samples are sent to or processed at the same lab as previously to allow for comparable results
• Temporarily reduce/eliminate intravenous (IV) bisphosphonates
• Modify therapy to reduce risk of neutropenia and subsequent infections
• Consider oral drugs instead those requiring IV administration
• Use caution with autologous stem cell transplant (ASCT) and/or IV therapies
• Be aware that clinical trials may have been modified in order to continue through the pandemic.

Considering the long-term implications of the COVID-19 pandemic on the management of MM, Dr Durie offered the following advice, “I would discourage making permanent changes to treatment plans based on this pandemic. We have and will need to make changes, of course, but I would recommend keeping the original treatment plan in mind. For example, if you originally thought autologous stem cell transplant was the ideal treatment, you may have deferred this during COVID-19 but try to get back to that original plan once it is safe to do so. Another example would be swapping an IV therapy for an oral therapy – if the IV therapy was initially chosen over the oral option for a reason, try to revert back to the original IV therapy when safe.”

References:

1. Cook G, et al. Br J Haematol. 2020; doi: 10.1111/bjh.16874 [Epub ahead of print]
2. Martínez-López J, et al. Blood Cancer J 2020;10(10):103. doi: 10.1038/s41408-020-00372-5.
3. Wang B, et al. J Hematol Oncol. 2020;13(1):94. doi: 10.1186/s13045-020-00934-x.