CLL Patient Management During COVID-19 and Telehealth

Danielle M. Brander, MD: Helping to care for patients during COVID-19 [coronavirus disease 2019] has caused us to go back and look at our practices, evolve, and change them very quickly. We had to think about how that might have an impact on how we see patients, in person or telemedicine, how we conduct clinical trials, in guidance with national guidelines and institutional guidelines. When we have multiple therapeutic options, the pandemic has also affected which we choose for patients considering their risk in the short and long term. Notably, in the short term we consider how extra visits, infusions, or certain risk factors and exposures affect the patient who is high risk for COVID-19.

This has changed a lot since March here at Duke Cancer Institute and across the country. Like many institutions, there have been a lot of steps trying to protect patients as much as possible but also allow them access for the situations where we do need to see patients. We’ve seen patients who have come in for treatment where we identify that their exam or in-person testing is needed, but then we also identify patients who could have local labs and do telemedicine visits to prevent the travel as well as potential exposure within the institutions. Over the summer when things changed across the country and cases were going down, we tried to get some of the patients back in that had been telemedicine. As cases go up again, we’re shifting the patients to telemedicine where possible and safe for the patient.

This takes into account how long the patient has had their disease, what kind of therapy they’re on, etc. In terms of what type of therapy in CLL [chronic lymphocytic leukemia], because many of the novel therapies are oral, that has helped in many cases. However, if you’re talking about 2 treatment choices for that given patient in the short and long term, what is known about them is fairly equivalent. It has caused us to shift more toward trying to offer therapies that wouldn’t require as many visits, treatment room time, or added risk factors.

Alan P. Skarbnik, MD: Since the pandemic started, it shifted how many patients were on telemedicine and how many come into the office. Between April and July, 35% to 40% of my patients were on telemedicine. Since August, the number dropped to about 10% to 15%. As we’re seeing a spike in the cases again, we’re transitioning more back to telemedicine. The majority of patients need to follow up with telemedicine, with a physical exam here and there. We can intermingle a bit. There are a number of our patients who need to be seen because of physical exam abnormalities or alterations that need to be discussed and addressed in person.

Catherine C. Coombs, MD: At the beginning of the pandemic, we were doing almost all telemedicine. There were a lot of unknowns at the time. Many of us hoped that the pandemic would have subsided. As time went on, the amount of telemedicine has declined. In my practice I started with almost all patients doing telemedicine, to limit exposure. About 6 to 8 months in, there were a lot of patients who wanted to come in person. There are things you can assess in person that you can’t over the telephone, such as a physical exam. Also, the doctor-patient relationship is different in person in the same room as opposed to over a video or phone. We have been deferring to patient preference, but we have made ourselves available. Some patients still feel safer doing videoconferencing, and some prefer to come in person. About a third of my patients are still doing telemedicine, and the other two-thirds come in person at this point in the pandemic.

We’re going to continue seeing some proportion of patients via telemedicine as long as COVID-19 is active. Some patients are extremely cautious, and I applaud them for that. There isn’t a completely right or wrong answer. UNC [University of North Carolina School of Medicine] has adopted safety protocols so it’s safer to come in person, but it’s never without risk.

Transcript Edited for Clarity