Patient Worthy is honored to present Dr. Eunice Wang, who has herewith responded to questions from our readers about the effect of the COVID-19 virus on their cancer treatment.
Dr. Wang is a practicing Hematologist, Oncologist and physician scientist whose clinical practice focuses on the treatment of patients with acute and chronic leukemia, myeloid disorders, and benign hematological conditions. Dr. Wang practices at Roswell Park Cancer Institute, Inc. in Buffalo, NY.
Q: Dr. Wang, if a state’s health department issues guidelines, can a hospital issue its own guidelines?
Dr. Wang: Guidelines for patient care are determined by the individual hospitals under the parameters set by the state and the recommendations of the CDC.
For instance, in New York State, Governor Cuomo recently indicated that certain counties in upstate New York could resume elective surgeries. This directive has been taken into consideration as local hospitals in our region make individual decisions on which patients and procedures to resume. Considerations for which treatment, tests and surgeries can safely be performed are based on availability of COVID testing and availability of sufficient personal protective equipment.
Q: In your opinion, will it be possible for cancer patients who have had their treatment put on hold due to the virus have their therapy resumed within a reasonable time period?
Dr. Wang: Yes. Given the unknown duration of the viral pandemic, in my opinion, it is absolutely essential to resume cancer therapy for all patients who were previously deriving benefit prior to COVID-19. For patients to receive cancer care, however, it has been necessary to devise new chemotherapy regimens and change the way that care is being delivered in order to optimally protect patients.
For those individuals who are still coming in for chemotherapy and radiation, our cancer center has taken multiple measures to ensure patient and staff safety. All patients and employees are screened for symptoms and fever upon entry and are provided with surgical masks during their time on campus. Visitors have been restricted to one individual per outpatient and no inpatient visitors (except for pediatric patients and end of life care).
Our oncologists have also been altering chemotherapy regimens to reduce on site patient visits and shorten treatment duration. This includes minimizing the number of drugs and favoring oral chemotherapy if possible. In other individuals for whom cancer treatment is not likely to provide significant benefit, delaying and/or not prescribing treatment at the current time is also an option. For patients who live at a distance and for whom travel to our site is not an option, we are recommending treatment closer to home and virtual (or telemedicine) visits rather than in person.
As with all of these decisions, discussion between the patient and his/her treating oncologist is essential to ensure that optimal cancer care continues despite this global crisis.
Q: Do you recommend that newly diagnosed patients or patients with relapsed or refractory AML come into the office for further testing and treatment?
Dr. Wang: Yes, I strongly believe that all patients with newly diagnosed and relapsed or refractory AML have their cancer cells tested for genetic mutations prior to therapy initiation.
AML is not one disease but rather a number of different types of blood cancer whose growth is driven by specific biological events as reflected by many different gene mutations and DNA alterations. At diagnosis, patients with AML can also have many different leukemia cells, each containing a different set of mutations. Over treatment, these AML cells can also mutate and increase/decrease in number as a result of chemotherapy.
AML cells which survive therapy and regrow may be significantly biologically different from those detected at diagnosis. Recent studies have supported delaying chemotherapy to obtain the results of genetic and mutation testing, which does not lead to worse outcomes and may actually improve responses by allowing the oncologist to select the most effective and least toxic treatment for each individual patient based on the specific type of AML that he or she has.
Q: Can you share any examples of cases where mutation testing has changed the course of treatment and/or disease progression for your patients?
Dr. Wang: Yes, I had a patient whose AML was not characterized by FLT3 mutation at diagnosis.
Although her cancer went into remission with standard intensive chemotherapy, she developed relapsed AML a few months later. Her disease did not respond to additional high dose chemotherapy or a clinical trial drug; however, repeat testing of the relapsed AML detected a new FLT3 mutation which was not present at AML diagnosis.
Treatment with gilteritinib (a potent oral FLT3 inhibitor) led to disease control, and she was able to proceed onto bone marrow transplant within a short interval. She is still alive today with no AML recurrence.
Q: Many cancer therapies use a combination of drugs. If patients are precluded from receiving infusions at hospitals due to COVID-19 precautions but have access to oral drugs at home, could this be considered temporary maintenance?
Dr. Wang: Yes, combination therapies are certainly being used as standard of care as well as in many clinical trials for AML therapy.
For example, in many cases, standard chemotherapy is combined with a targeted or oral chemotherapy drug for increased efficacy. Because many of these oral drugs exert significant anti-leukemic effects even as single agents, they are often being recommended to prevent relapse as maintenance therapy after completion of infusional chemotherapy or bone marrow transplant.
However, long-term, many of these oral drugs are not potent enough on their own to cure AML. Therefore, ideally, these agents should be incorporated into a multiple drug regimen to optimize outcomes.
Q: When a COVID-19 vaccine becomes available, will extensive research be required to determine its effect when it is combined with a patient’s cancer treatment?
Dr. Wang: This is a great question. The COVID-19 vaccine will first be tested in healthy individuals, not cancer patients. How vaccines work in general is by activating the patient’s own immune system to recognize and destroy infection by a specific entity, in this case, the COVID-19 coronavirus. Like the flu vaccine, a COVID-19 vaccine would be designed not to prevent viral infection but instead to limit the severity of viral infection after exposure and prevent patients from becoming severely ill or dying from the disease.
Since the effectiveness of any vaccine depends on a functional immune system, it is not known whether cancer patients will be able to mount a strong enough immune response after vaccination to protect themselves from the severity of COVID-19 infection. This is particularly true in cancer patients actively receiving chemotherapy or immunosuppressive therapy after transplant and with hematological cancers such as AML which directly affect the immune system.
However, if there is a possible protective effect from a vaccine, I would advocate that all cancer patients receive the COVID-19 vaccine as they remain at higher risk of contracting and developing complications following infection for the same reasons.
Hopefully the COVID-19 vaccine would be more like a flu shot than an actual oral drug and would be given either once or only 2-3 times for maximal effect. If so, as long as side effects are not severe, hopefully there would not need to be any interruption or dose reduction of chemotherapy in most patients.
About Dr. Eunice Wang
Eunice Wang, M.D.
Chief, Clinical Leukemia Service
Professor, Department of Medicine
Roswell Park Comprehensive Cancer Center
Buffalo, New York
Dr. Eunice Wang earned her medical degree from the Keck (University of Southern California) School of Medicine. She completed her internship and residency in internal medicine at Yale-New Haven Hospital, followed by clinical and research fellowships in hematology-oncology at Memorial Sloan Kettering Cancer Center in New York. She is Chief of the Leukemia Service and Professor of Oncology in the Department of Medicine at Roswell Park Comprehensive Cancer Center, Buffalo, New York. She is also an Associate Professor in the Department of Medicine, School of Medicine of Biomedical Sciences at the State University of New York at Buffalo (SUNY-UB).
Dr. Wang is a member of several professional organizations including the American Society of Hematology and the American Society of Clinical Oncology. She serves on the National Comprehensive Cancer Network (NCCN) Clinical Practice treatment guidelines panels for acute myeloid and acute lymphocytic leukemia. She is a prior recipient of a NIH Cancer Clinical Investigator Team Leadership Award (CCITLA) and a Mentored Research Scholar award from the American Cancer Society. Dr. Wang has authored/co-authored more than 90 peer-reviewed articles in the field of hematological malignancies. She maintains an active clinical practice with a portfolio of early phase clinical trials in acute leukemias and myeloid malignancies. She also leads a translational laboratory focused on preclinical studies of novel agents targeting the marrow microenvironment and immune responses.
