April 29, 2020

Commentary on COVID-19–Specific Myeloma Guidelines: The Cleveland Clinic Approach

Beth Faiman PhD, MSN, APRN-BC, AOCN^®, FAAN, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio

Catamero and colleagues’ article on considerations of COVID-19 guidelines for patients with multiple myeloma demonstrates the development of aggressive guidelines to protect patients and practitioners from contracting the life-threatening coronavirus (COVID-19). Addressing issues specific to treating patients in New York City, such as population density and community transit to appointments, was critical to their recommendations. Interventions to minimize patient risk of developing COVID-19, including transitioning patients to all-oral chemotherapy regimens, mailing blood draw kits to obtain blood draws in the community rather than have patients travel to the city, and employing telehealth visits, are now commonly recognized strategies across many health systems in US states. These strategies are also used in my practice at the Cleveland Clinic.

Cleveland Clinic

The State of Ohio, and the Cleveland Clinic in particular, sought to learn from the New York experience and flatten the curve over a month ago (Centers for Disease Control and Prevention, 2020; Ohio Department of Health, 2020). The Cleveland Clinic cancelled all nonessential surgeries and procedures. Nonclinical staff were asked to work from home. All clinical staff and patients have their temperatures taken upon building entry.

A strategic plan is in place for COVID-19 testing of caregivers and patients if the virus is suspected. We are fortunate to have excellent communication from Ohio’s Governor Mike DeWine and the Cleveland Clinic leadership. As a result of these aggressive measures, as of April 29, 2020, Ohio saw 17,303 total cases, with 937 COVID-19 related deaths. This is a far cry from New York City, but our State and healthcare system will hopefully now be able to keep up with the demand placed on health-care workers.

Multiple Myeloma and Blood Cancer Patients

As highlighted in Catamero and colleagues’ article, immunocompromised cancer patients have a high risk of death from infection. Yet, multiple myeloma (MM) and blood cancer patients do not seem to be developing and dying from the COVID-19 infection. In fact, there have been very few COVID-19 related deaths in cancer and transplant patients worldwide compared to those with chronic lung disease (Jazieh, Alenazi, Alhejazi, Al Safi, & Al Olayan, 2020; World Health Organization, 2020).

A few hypotheses include that proteasome inhibitors have antiviral properties, or perhaps myeloma patients are used to effective hand-washing and infection protection due to the chronicity of the cancer. Interestingly, selinexor, which is an FDA-approved medication to treat relapsed and refractory MM, is now being studied in low doses to treat COVID-19 infection. Selinexor is an oral, selective inhibitor of nuclear export (SINE) compound which blocks the cellular exportin protein, XPO1. Effective against cancer, XPO1 also facilitates the transport of viral proteins from the nucleus of the host cell to the cytoplasm and amplifies the activities of proinflammatory transcription factors. Based on this proposed mechanism of action, selinexor may be effective as the COVID-19 and other viral infections hijack XPO1 (Widman et al., 2018).

Concluding Thoughts

For the week of April 6, deaths due to COVID-19 were just slightly lower than heart disease, which barely remains the number 1 killer in the United States, with 12,392 deaths (The Washington Post, 2020). By the time you read this, COVID-19 will likely become the number 1 cause of death in the United States.

Our lives will be forever changed by the coronavirus. As this pandemic rolls on, well-trained advanced practitioners will remain critical partners in the health-care team. Our group will continue to perform our daily functions, even if it means being repositioned to other areas of the hospital. Flattening the curve in many areas such as Ohio will lead to a longer duration of this new normal. With effective patient and community education, I am optimistic that we, as a medical community, will emerge from this crisis with renewed strength and appreciation for health.

References

Centers for Disease Control and Prevention. (2020). Coronavirus (COVID-19). Retrieved from https://www.cdc.gov/coronavirus/2019-nCoV/index.html

Jazieh, A. R., Alenazi, T. H., Alhejazi, A., Al Safi, F., & Al Olayan, A. (2020). Outcome of oncology patients infected with coronavirus.  JCO Global Oncology, 6, 471–475. https://doi.org/10.1200/GO.20.00064

Ohio Department of Health. (2020). Coronavirus (COVID-19). Retrieved from https://coronavirus.ohio.gov/wps/portal/gov/covid-19/home

The Washington Post. (2020). Covid-19 is rapidly becoming America’s leading cause of death . Retrieved from https://www.washingtonpost.com/outlook/2020/04/16/coronavirus-leading-cause-death/?arc404=true

Widman, D., Gornisiewicz, S., Shacham, S., & Tamir, S. (2018)  In vitro toxicity and efficacy of verdinexor, an exportin 1 inhibitor, on opportunistic viruses affecting immunocompromised individuals. PLoS ONE, 13 (10), e0200043. https://doi.org/10.1371/journal.pone.0200043

World Health Organization. (2020). Rolling updates on coronavirus disease (COVID-19). Retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen

Read more from the APSHO Advance: Special COVID-19 Series