Protecting the Most Vulnerable

By Steve Blanchard - March 18, 2020

Patients faced with an impending blood or bone marrow transplant at Moffitt Cancer Center are among the most vulnerable to infection. The very nature of the treatment puts a patient’s immune system at risk, and compromised immune systems are especially vulnerable during the COVID-19 pandemic.

So what can doctors do to further protect patients?

Dr. Michael Nieder

It depends on each individual case, according to Dr. Michael Nieder, medical director and fellowship director of Moffitt’s Blood and Marrow Transplant and Cellular Immunotherapy Program.

Limiting the number of visitors to the Blood and Marrow Transplant (BMT) unit is one way to protect patients, Nieder said. New guidelines limit BMT patients to just one visitor in both the outpatient area and the inpatient units.

All visitors are required to report to the nursing station and thoroughly wash their hands. Any visitor with a cold or other infection will not be allowed into the unit. Children under 12 are not permitted in the inpatient units.

If the local COVID-19 infection rate escalates, Moffitt may decide to suspend all visits to the inpatient units, Nieder said.

Most importantly, Moffitt doctors are reviewing the specific plans for each patient to consider whether the procedure could be delayed as a safety measure.

This is critical, Nieder said, because bone marrow transplant patients who contract COVID-19 during the early post-transplant period are seriously at risk and are not likely to survive.  

“Our decision to move forward with a transplant depends on the urgency of the procedure. We also consider additional risk factors such as chronic lung or heart disease and the risk of relapse for the patient without the transplant,” he said.

Most patients in Moffitt’s BMT program have leukemia, lymphoma, multiple myeloma or aplastic anemia. Treatments for those patients typically fall into one of two kinds of transplants: autologous and allogeneic.

An autologous transplant is a procedure that extracts a patient’s own stem cells, which are frozen and then re-infused after the patient undergoes a very high dose of chemotherapy.

“Autologous transplants allow us to administer that high dose of chemotherapy when conventional doses are ineffective,” Nieder said. “This procedure is most commonly used for patients with multiple myeloma and lymphoma.

“These transplants can be delayed if there is good disease control with chemotherapy and the patient is in remission or has a small amount of slow-growing disease,” he added. “Many patients with myeloma can be delayed and some patients with lymphoma can be delayed.”

An allogeneic transplant, which involves stem cells from a donor, is a more complex procedure and could be viewed as a higher risk.

Allogeneic transplants are used for patients with leukemia, aplastic anemia, lymphoma or sickle cell disease. The procedure requires a patient to remain on immunosuppression medicine for months or years following the transplant.

In extreme cases, allogeneic procedures can be delayed, but not for more than a month or two, Nieder said. There is a small subset of patients with leukemia that can be delayed as well.

Another treatment for blood cancer patients is CAR T therapy, or chimeric antigen receptor T cell therapy. It is an immunological treatment that uses the body’s own immune system to destroy cancerous cells. Generally speaking, a patient may be eligible for CAR T therapy if other forms of treatment have been unsuccessful or were not an option.

CAR T is seen as a more urgent procedure because patients have either relapsed or have not responded to conventional therapies. Determining whether these procedures can be delayed is done on a case-by-case basis.

Moffitt is following the guidance provided by national and international groups.

“The guidance changes rapidly, so we will make our decisions rapidly as well,” Nieder said.

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