(Guest Lecture): The New Normal in an Age of Uncertainty | MCRT Webcast: Experts Discuss COVID-19 and Myeloma

[Music] you you now I'd like to go to dr. Morey Gertz I've been working in myeloma now for 22 years and and dr. Gertz was the person who explained myeloma to me once I heard him speak I got it and people constantly ask me you know if you were diagnosed with myeloma where would you go and I never give them that answer but I tell them one thing I said the first person I would go see is dr. Gertz because not necessarily for treatment but he would be able to explain to me what I needed to know better than anybody and so with that I know that dr. Gertz I know you've been doing a lot of research on Kogan and myeloma I know that you've got a paper that has either to be published or has recently been published III but I did see the manuscript so could you take this time to give us a sense of what you know about myeloma and cancer at myeloma and patients and kovat today and what your recommendations are moving forward and what are the known unknowns that you focus on good nice to see you again dragon undermount good to be with you on this conference you just over the background Minnesota is not New York in terms of population density we're half urban or rural Olmsted County Minnesota well I'll start with the state of Minnesota the state of Minnesota's had two thousand two hundred patients diagnosed we're a state of five and a half million that's about one person instead it for every 2,500 population and the state is here a hundred and twenty-one deaths so a case mortality rate of approximately five percent Olson County Minnesota which is where the Mayo Clinic is and probably three quarters three thirds of the people who live in the county work male or some male subsidiary and so therefore it's quite enriched in health care workers has had a hundred and thirteen cases for a population of 100,000 170 for a population of 100,000 about one person in 600 the wheel running four fold in Falconeri compared with the rest of the state in County however of the one in 600 we've only had two deaths so the case mortality rate therefore is about a percent and a half in the two patients who died were 84 and 90 years old one of them was in the nursing home all of whom had pre-existing conditions so we're not running the epidemic levels that are reported in some of the hot zone nonetheless we've done what every other large medical center has done right now stem cell transplant is absolutely at a complete standstill for myeloma patients and patients who are not relapsing or stable or continuing their induction chemotherapy no one's going to transplant Celgene the makers of pomalidomide pomalyst Atlanta litter my Revlimid have relaxed their rules it used to be that they could only dispense 28 days at a time now they're allowing 56 tablets to be a dispense at a time so for patients were on all oral therapy we're moving their visits now out or once every eight weeks we've been a lot of what dr. Jagannatha said if patients were receiving or Tesman Velcade we move them to X as amid new tomorrow so they can move oral regimen so we're using a lot of your salesmen lenalidomide Revlimid dexamethasone so it's all pills and it's only one visit required every four weeks although we're trying to have them you have there blood drawn locally at the closer lab rather than as a population thence Mayo Clinic and then we will videoconference in phone conference so we are fully set up now we do consultations for sure transplant or for relapse or diagnosis using outside records and then videoconference he just like I'm doing now at a patient's home or by the following patients who are receiving Daraa to remember DARS elects if they were receiving a weekly we've moved it to every two weeks if they're getting it every two weeks it moves it every four weeks and based on how long patients have been on therapy how well their control is we've been pretty laughter than delaying resumption of therapy if they do it for weeks we're letting it go if they've been in a stable home for some period of time and so transplants is done we're favoring oral therapies and we're delighted so if someone was getting subcutaneous injections of or testament Velcade every other week we're moving that to every four weeks or everything is trying to minimize exposure with our healthcare center our waiting rooms you have been moved for social distancing chairs have been removed from the lobby so people can't sit close to one another uniform asking for all healthcare personnel in the outpatient visitors aren't allowed in the hospital in patients both admissions all are COBIT screened any patient coming for chemotherapy is kovin screened greg started out by asking about multiple myeloma or I should say the state of Minnesota no I said say Minnesota asked about myeloma here's the issue myeloma is a disease of the cells that make antibodies the proteins then treat infections and so we refer to these antibody proteins as immunoglobulins and almost all myeloma base don't have functioning immunoglobulin some patients prior to the epidemic due to recurrent infections might be receiving intravenous immunoglobulin injections that's replaced the loss of antibodies they have their body normally suppressive but the myeloma cell replaces the normal antibody producing cells of the body so there's this unique lack of antibodies that makes I think the myeloma patient far more predisposed in addition there are certain medicines dyes electrode our tumor man particularly will you clearly see an increased risk on upper respiratory infections that's unequivocal and then the other medicines can have an effect on the white blood cell count and lowering your body's resistance in that way when you're on continuous therapy and so there are multiple facets where myeloma patients are uniquely predisposed to develop complications and we're quite concerned about it actually from my own personal population one of the bothersome things is I have an firefighter who's now on maintenance treatment with DARS Alexan and Laurel who developed a fever as did his wife lasted about eight days but we swab them two weeks later he was still positive so he delayed him coming we swab him again three days later which was yesterday and he's still positive so even at 17 days he hasn't cleared the virus and so it's getting me a little nervous about this 14-day self quarantine it's not so easy for me to know where the 14 day came up was because at least in this one instance he's persistently positive the virus hasn't cleared so we're keeping him in quarantine we're not letting him out well we know he's continuing to be positive and when he called it positive patient isn't a lot of year our institution can access the chemotherapy unit every individual comes in to the Mayo Clinic building is we've got 80% of the doors locked so there's only two entrances now and they're questioned about coffee shortness of breath fever exposure to someone who has a positive and then they have your temperature taken and then they get a sticker that they put on their lapels with the day of the week it's a different color every day so when they're walking around you can look and see their patient has been screened so those are some of the precautions but even business we've Minnesota and we're beginning to discuss reactivation of the practice based on need for their patients that we would consider urgent which in the myeloma setting to me would be relapsing disease those patients are given access for face to face console unless urgent patients are done by phone or video conferencing and so far for the patients that we're screening we're doing I think a credible job in preventing transmission of the infection I'll stop there Greg for additional questions you might have or what about how you know we see so much in the news about opening dates about when things will get back to normal do you pay attention to that and and and just give me your feel your sense of that so today for yesterday for example the beaches opened up in Jacksonville Florida and there were a lot of people out there what from from your medical point of view what does that make you think I don't think we have the infrastructure to make the decision I think the big question on everybody's mind is how many people are carriers of the virus who have no symptoms at all so if you want to just look at popular media George Stephanopoulos became positive for Corona as he parted from his wife and so he put himself himself quarantine however George Stephanopoulos had no symptoms at all nothing he's got some lower abdominal pain hardly no but he had none of the typical symptoms of off fever runny nose sneezing and he was infected he's the problem then how many people on the beaches he's all great are carriers of the virus I wouldn't let my myeloma patients visit Jacksonville Beach out of concern and so then the question is well then if we're going to start talking about opening up don't we need to know how many people actually are carrying the virus who are not simply recovering but we're not symptomatic in the first place and right now the state of Minnesota is looking to test four thousand people a day thirty thousand people a week and we're a relatively small state and we don't have that capacity and until we have the capacity to know how many people at the beach at Macy's at Walmart are walking around feeling great with the virus I think it's pretty difficult to make a evidence-based decision about when we're supposed to reopen the economy right and I think one of the things you know we there were so many people out of work and what I find you know I feel fortunate to be working but I find myself working harder than I ever have I feel even though I'm at home and I don't commute back and forth and all of that what's a typical day like for you in terms of how you interact with patients how you see people in the clinic and and how you keep your mental health right I think part of the problem is that there's no activity other than going to work and sitting at home there's nothing in between for me last weekend Saturday my activity consisted of going to get the mail that was it I was in the house and I got the mail last Sunday Minnesota's snowed seven and a half in Seoul I plugged myself to the foot of the driveway that's as far as they went the foot of the driveway otherwise I'm inside streaming video on Netflix and going crazy there really isn't this is a welcome diversion I'm thrilled to be on a video conference seeing friends because it gives me something to do other than watch old movies and there is a mental health issue here I'm not really living in fear of getting the virus I'm just I mean life as far as I'm concerned is on hold and I think nationally we're facing this chronic tension and that tension is between individual liberties and societal responsibilities I'm watching protesters in Michigan saying you have no right to keep me quarantined I need to be out and about and I think major sense of responsibility to the rest of the population people who you know if your myeloma patient and a vaccine was available I'm not convinced that you're gonna respond to the vaccine and so we need to be certain that everybody else gets vaccinated so that the vulnerable populations either can't receive a vaccine or it's uncertain whether they'll respond to a vaccine from if you will the community isn't just I'm feeling well and on board it's because I'm worried about all of the other people in my city county state that I may be responsible for infecting and I think there's some level of irresponsibility where the individuals disregard the governor's orders in their respective states pay of all the data no one that's right to reopen and say yeah I'm not I'm gonna go to the funeral the church my kids basketball game the party at the house invite 20 or 30 people I think it's very responsible and I also you know you you had your you love to read history you love to read and I've been rereading John Berry's book about the great influenza of 1918 and the one thing you know as I compare that that was yes it was bad but it was a different time we know who so much more today about how to deal with hygiene and things like that than they did back then there's a lot more openness and communication today than there was back then but one of the things that that that I hear a lot and and one of the points that comes up in that book is that there was a lull in in nineteen in nineteen by the spring of 1919 everybody thought this was over and people got back to their lives and then in the fall of 1990 knit came back with a vengeance do you fear that and if so why and if not why not don't we have a lot of data because Mayo Clinic was open in 1918 the Mayo brothers were alive and doing surgery and caring for patients so those records exists during it and in fact the Mayo brothers were commissioned officers in World War one and so we did have capacity for managing the influenza endemic couple comments in mind at that time it was known that bacteria existed viruses were not known to exist the particle of transmission was too completely unknown but of course the real problem because it was during the demobilization of World War one we still had very large barracks that housed thousands of soldiers and infantrymen and that was really who is they couldn't they didn't practice social distancing get consequences and as a consequence the lack of social distancing their clustering was result in addition people lived a lot closer together in the cities in those days because there was much to my public transportation or cars so most people had to walk work needed to live relatively close and so their act people into apartment buildings and poor areas they be called tenements and so it facilitated spread and so this issue about what to do about it wasn't very clear and of course there were no vaccines no antibiotics that read secondary pneumonia no antibodies to treat cytokine release syndrome when you got respiratory distress syndrome from corona virus or influenza virus it was very different but the big piece here is that the case mortality rate for influenza today was about one in a thousand and nationally in the United States it's about one in 50 and so even though influenza at that time was actually greater then coronavirus was is now the fact the number of patients dying who were infected was much much greater and this appears based on what the published cellphone data is the transmissibility of this virus appears to be greater than influenza and that explains why you got fifty people on a cruise ship who get infected you and then you've got a dis naval military vessel where the captain was fired trying to get resources and you've got over a hundred and sixty incepted on that ship so and that just goes to how easy this virus somehow latches on and in fact people you [Music]