August 19, 2020
Featuring Dr. Susan DeWolf and John McCaffrey
Dr. Susan DeWolf
Dr. Susan DeWolf graduated summa cum laude from Harvard College with a degree in neurobiology in 2010. She then attended Columbia College of Physicians and surgeons for medical school where she was elected to Alpha Omega Alpha. She continued at Columbia City Medical Center for her residency training in Internal Medicine in the clinical scientist pathway and she is currently senior fellow at Memorial Sloan-Kettering Cancer Center where she is focusing on the intersection of Leukemia and Transplant and is continuing her Immunology training. She has been incredibly involved with the study of covid-19 in recipients of cellular therapies at Memorial Sloan-Kettering cancer center. And of course, she is one of the heroes. She was in New York when it was hardest hit with covid in the beginning.
I will say that my biggest message from today is going to be that this is a new world and we are truly learning every single day how to do our job in this new environment. We are sort of at a learning stage and everything that we are doing is sort of baby steps as we are trying to understand what the safest way is to receive cancer care in in the world that we live in. However, we do not have a lot of data yet. And so my goal for today is to share a little bit of with everyone about what my experience has been in New York how we’ve sort of transformed medical care here overnight and then to give a little bit of background on what we’re trying to learn at this time. I will also update a little bit about what is has been published.
In March when we were sort of learning about the virus and everything was changing day by day, we were getting new guidelines. We were trying to really learn how to take care of patients with a condition that we have never encountered before and it’s really been just incredible watching the whole medical system come together in the city to really do miraculous things. I am so proud of all that sort of healthcare work.
Things are incredibly well under control here for the moment. Cancer care is not something that we can just put on the side as everyone in this audience knows and just say well, we are going to wait a few months and then try and get back to it. We had to learn to continue to care for our patients in the safest way possible while also learning to deal with this new virus and take care of patients both who tested positive for the virus and those who just needed to continue to receive treatment during this period which every day we were learning how to do some of them.
Any sort of changes that we have done here has been a dramatic shift to telemedicine platforms and it certainly has been a learning curve for us as providers and as well as patients, but I think it’s really been a cornerstone of what we’ve been able to do to keep everyone safe so that we could continue to really interact with patients and not have patients coming back and forth from the hospital.
Many changes have been made, testing all for the virus, protective gear, etc.
Even doing some cellular therapies. A major change has been recommendation of cryopreservation of all donor products so that we have a little bit more control over when exactly patients are going for their cellular therapies and ensure that both donor and recipient have had adequate covid-19 testing. So, one of the things that is now first and foremost here, is that before any patient has any invasive procedure, receives chemotherapy, comes into the hospital we perform a covid-19 testing within typically 72 hours before the for their admission. Everyone is getting very sort of routinely screened and that is just now becoming how we are taking care of patients. New York has very extensive travel guidelines, quarantining restrictions, and we just we do as our state tells us to do.
We are now five patients admitted currently at Sloan-Kettering right now, which is really an incredible thing. We do have numerous trials for patients who develop covid-19 that were running here, and we are trying to learn like everyone about these new treatments.
We are following the literature to learn as much as we can as results are being are being published. We too are trying to contribute to the knowledge and so we are very actively working on a study of all of the patients that we took care of here at Sloan-Kettering who received either partly or had received at all, autologous or allogeneic transplants. So, we have an exceptionally large cohort here over. 70 patients who tested positive for covid-19 during the spring. What we are doing is we are looking through many of their outcomes, whether they must be admitted, whether they were able to stay outpatient, and in fact nearly half of them were able to stay outpatient. We are monitoring clearance of the actual PCR for covid-19 and investigating antibody responses.
We’re doing some very basic Immunology studies on this patient population that you know is obviously in the setting of receiving a cellular therapy and being immunocompromised and then having to sort of build a whole new immune system for many patients after receiving treatment. We are learning as much as we can about the immune system in these patients. It is critical and that is something that we are really dedicating a lot of effort to right now. We look forward to sort of moving all that knowledge forward as we learn just like everyone else because truly, we are learning every day. I did want to talk a little bit about what has been published so far about patients particularly with hematologic malignancies with covid-19.
My number one message is to work very closely with your own physician. As you know, guidelines are changing, and every patient really has a unique situation.
Just this month. It was published August 14th. The largest studies today of patients who have either had an autologous transplant or an allogeneic stem cell transplant was published, and this was a study of patients from three different hospitals. Some of the interesting takeaways that we are learning from this is that most common presentations were fever cough and shortness of breath. This is the same types of presentations that they expect. There was not a clearly distinct pattern of covid-19 symptoms in the transplant population at least in this small series compared to the general population. But again, it has only been a few patients that have been studied not all the patients had severe disease. About 59% have categorized as it were mild or moderate disease. 74% in this study required hospitalization and there was a very wide range of length of duration of hospital stays. The medium was around eight days, but that is some shorter some longer. There was report of worse outcomes for patients who were within their first-year post transplant. But again, this is an exceedingly small series interestingly immunosuppressive medications on their own were not specifically associated with worse outcomes.
And so, you know, we are grateful that this group has begun to publish some work and we look forward to sharing our experience. And mostly we have a lot more we need to learn every day about taking care of patients who have who are going to have this virus and who been who received a cellular therapy. MSK has already had a couple of publications about the cancer population in general.
Recently, the Journal of Clinical Oncology and Nature Medicine shared that a study of 423 patients with covid-19 from March to April had about a hundred and two of them with hematologic malignancies, mostly lymphoma. The major sort of take away from that paper was that being on treatment with chemotherapy was not in itself a clear predictor for needing hospitalization or for having severe disease and the similar message came out from another large paper the dco paper with over 300 patients. And so unfortunately, we are learning that patients with hematologic malignancies overall seem to be at higher risk from this infection, but the treatment it, from what our limited knowledge is right now.
What we really need are more studies and more information so that we can use data to guide our decisions. Because unfortunately right now we are doing the best that we can with the information that we have but it is very much a learning curve. And we and imagine that all the guidelines will be evolving rapidly as we understand even more about how to remain safe and continue cancer.
I just want to jump to some of the sort of major things that I wanted to sort of highlight for everyone who is listening here. It is so important to keep in close touch with your doctor. Doctors’ offices are very much open and are all working hard. I now I can only really speak to my own experience here in New York, but everyone wants to be able to continue to take care of patients safely. And I think it is especially important that you be in close touch with your physician any new symptoms any new exposure because even though we think we know how this virus presents we do not. We are learning every single day and especially in patients who received transplants and car T therapy,
I think we all must take this virus very seriously. Certainly everyone who is here in the workplace is wearing a mask adhering to you know, very strict rules about social distancing refraining from non-essential travel, hand washing all of the sort of basic things which sometimes we take for granted but really I think are going to be critical for keeping control. I think another important message is that we can look at different studies to understand overall trends and we can try to make a good understanding, but this virus is different in every patient. So therefore, everything really must be a conversation with the patient and their physician, and we have a lot to learn about.
Talk to your doctor about the risk versus benefit of all vaccinations before you consider one when it is made available.
John is a 63-year-old lymphoma cancer survivor in New York who has survived Covid and he is here to share his experiences with you. So, John, can you tell our listeners a little bit about your experience? And what helped you through?
Yes. It was early March late February. I started showing signs of sore throat chills and bad headaches. I thought it was something to do with a cold or maybe I was getting early signs of flu, and then as time went on in March, the fever started coming back. It started off as a low-grade hundred. Then it kept rising from101 to 102 and it got as high as 104.5. It was probably about three weeks that I ran the fevers at home, but I was constantly in touch with my doctor to inform them what was going on. It is so important that you inform them and tell them everything you are experiencing and what you are going through.
So as that being said one day I went to the bathroom and I passed out. My wife called Sloan Kettering and said what happened. She told them I had to go in. I was having issues breathing. My oxygen level was at 88 which is low, and they got me upstairs. They put me on an oxygen mask and ICU was constantly in contact with me because they were going to take me if there were any available beds. Thank God there was not any available bed that evening.
I just kept thinking in my mind, I got to breathe. I had to force myself to breathe. and the nurses had found that sleeping on your stomach released pressure on my lungs. So, I am not much of a back sleeper and I am not much of a stomach sleeper. I am side to side. So that was hard just to do but I listened to them and it helped.
And me trying to force myself to breathe. Well, ICU could not take me that evening. They said they will find out in the morning how I am doing, and I started getting a little better. As the morning time came, they said they would keep track of me for the day and see what happened. So, I was hooked up on antibiotics. I was hooked up on Hydroxychloroquine.
I also had plasma. Sloan Kettering gave me every possible chance to beat this virus. So as time went on, my fever started coming down. They were constantly taking scans of my lungs to see how the virus was proceeding and if it went out of my lungs.
What happened was the oxygen I required went down, you know half the amount of oxygen I needed to breathe. So that meant I was going in the right direction. I was on it for about one more week. They pretty much told me that the “glass” was pretty much gone. That is how they referred to the virus on my scans. They said, “we can hear a little wheezing in your chest but not much.” So, I was beside myself because it was so terrible when I came into the hospital with double pneumonia and spitting blood up. It is a scary thing, you know, when it is when it is coming from your lungs. It is scary.
So, I am a nosy type of person, I would talk to the nurses and I would talk to the doctors. I would ask what do I have to do for me to you know, start feeling good? They told me I had to get up. They had me move around even though it was only a little area there was somebody there watching me.
I was walking, I was doing, I was you know, working my lungs. I was constantly using the spirometer and let me tell you that is a savior. I would probably do about an hour a day with it and that solved my lung issue. I got better. On the 24th day I end up leaving.
I came home and they kept telling me to take it easy for the first week. The second week you can start back to work and your chores. Well the fourth week I ended up experiencing small grade fevers again. So, I am like, I cannot believe I am going through this again. So those fevers were maintained with Tylenol in the beginning, but after a while the Tylenol does not really do anything. So, it kept going up. My wife said we are going back to the hospital. They ended up giving me more plasma. After about two days being there the fever started coming down. The first hospital stay was 24 days, this time was only a week. They said I was starting to make antibodies this time.
Leaving the hospital, they told me to again take it easy for the first week. Do your exercises. The nurses were fantastic. So, the nurses did everything possible to make sure that I was constantly sleeping on my stomach and they will always constantly be monitoring me. My oxygen levels went up and they were constantly going up.
Today I have no symptoms whatsoever. During my experience with COVID, I had about 11 of them all together.
I know people hate to take that spirometer to blow, but you know, it really did help my lungs and you know, I just let people know you need to. Cancer patients and those with weak immune systems can fight this. Sleep on your stomach and drink tons of fluid. I also wear my mask.
My doctor wanted me to quarantine a month when I came home the second time. So, this way I kept from going to any stores or any place where it is a fair amount of people. All I got to say is stay in contact with your doctor, even if there is the slightest little thing going on with you.
They want to know what is going on because as every week was going by there was a different protocol in the hospital because Sloan was learning as they went along with this virus. This virus is no joke.