Tag Archive for: blood work

30-Year Acute Myeloid Leukemia Survivor Shares His Journey

30-Year Acute Myeloid Leukemia Survivor Shares His Journey from Patient Empowerment Network on Vimeo.

What might acute myeloid leukemia (AML) patients experience for symptoms, treatment, and coping with AML? AML patient and Empowerment Lead Art Flatau shares the experience of his AML journey from diagnosis, through treatment and AML survival, and advancements in AML treatments.

Art also shares his empowerment advice for patients and care partners to ensure optimal care and how he has found a sense of purpose in patient advocacy efforts.

See More from [ACT]IVATED AML

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Empowered AML Patient: Ask the AML Expert

Empowered AML Patient: Ask the AML Expert 

How an AML Survivor’s Resilience Saved Her Life

How an AML Survivor’s Resilience Saved Her Life 

Advice for Acute Myeloid Leukemia Patients Seeking a Clinical Trial

Advice for Acute Myeloid Leukemia Patients Seeking a Clinical Trial 


Transcript:

My name is Art, and I live in Austin, Texas. In 1992, I was 31 and married with two young children. I was in graduate school and working full-time. For a couple weeks, I had been feeling tired and had been running a low-grade fever. I also had a lot of bruises, probably because I was playing rugby at the time. I thought the fatigue was because I was overworked and getting  too little sleep.

On Saturday, I had a rugby game but was too tired to play more than a few minutes. The next day, I was too tired to do much. My wife and I decided that I would go to the doctor on Monday. 

Monday morning, I woke, and there was blood on my pillow as my gums were bleeding. My wife wanted to take me to the ER, but I convinced her to just call our doctor. I went to the doctor later that morning. She noted my symptoms, did a quick exam, and sent me for blood work. After lunch, she called and said I needed to go to the hospital and see a hematologist. I knew I was in trouble.

We talked to the doctor and he said, “We have to see what kind of leukemia you have.” What a shock.  I knew that I was sick with something I had not had before. The fact that it was cancer was a shock. I didn’t know that there were different types of leukemia but soon found out that I had acute myeloid leukemia (AML).

That evening, I received platelets and red blood transfusions. The next morning, I had a bone marrow biopsy, more platelets, and surgery to put in a central line. That afternoon, less than 24 hours after hearing the word leukemia in reference to me, I started chemotherapy. This was all overwhelming. We had no way to understand what our options were or to get a second opinion.

Three-and-a-half weeks later, I got out of the hospital with no hair, 25 pounds lighter, a lot weaker but alive. I had more chemotherapy in the next few weeks and more hospitalizations. A few months later, I was finished with chemo. I regained some strength, regrew my hair, and tried to get my life back to normal.

In early 1993, about 9 months after being diagnosed, we got another shock, I had relapsed. I needed to have a bone marrow transplant. Although we had a little time, a few days to figure out where to go for a transplant, we were again struggling to understand the process. We were also struggling to figure out how to move to Dallas for three more months for the transplant. The transplant was a long grind, a month or so in the hospital, a couple of months of going to the outpatient clinic two to three times a week, but we made it through. 

Now, 30 years later, I’m still around. My children graduated from high school, college, and graduate school and have successful careers. My wife and I are empty-nesters.  I am still working but hoping to retire in a few years. Although I consider myself very lucky to have survived and have had relatively few side effects, I do have some side effects to deal with, including low testosterone.

Some things that I’ve learned during my AML journey include: 

  • AML is a rare disease: The good news is that over the last several years a lot of new treatments have been discovered for AML. These new treatments are leading to more people surviving AML. However, these new treatments are evolving rapidly. It is important to find a cancer center and doctors who treat a lot of patients with leukemia. 
  • Consider volunteering: Advocacy work is an excellent way to help yourself and to support other patients and continued research efforts.
  • If something doesn’t feel right with your health, advocate for yourself and ask for further testing.

These actions (for me) are key to staying on my path to empowerment.

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Understanding MGUS, Smoldering and Multiple Myeloma

Understanding MGUS, Smoldering and Multiple Myeloma  from Patient Empowerment Network on Vimeo.

What is the difference between smoldering myeloma and monoclonal gammopathy of undetermined significance (MGUS)? Dr. Mark Schroeder defines these diagnoses and discusses how asymptomatic myeloma is monitored.

Dr. Mark Schroeder is a hematologist at Siteman Cancer Center of Washington University School of Medicine in St. Louis. Dr. Schroeder serves as Associate Professor in the Department of Medicine. Learn more about Dr. Schroeder.

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Expert Advice for Newly Diagnosed Myeloma Patients

Transcript:

Katherine Banwell:

As a patient, engaging in your care starts with understanding your diagnosis, so I’d like to go through some definitions. What is multiple myeloma? 

Dr. Mark Schroeder:

Multiple myeloma is a blood cancer. It’s a cancer in particular of a blood cell called a plasma cell. Everybody has normal plasma cells in their body. It’s part of your immune system that responds to infections; they are also cells that respond to vaccinations.  

And when a plasma cell becomes a cancer, it often forms a cancer called multiple myeloma. And that cancer results oftentimes in damage to bones, low blood counts or anemia, potentially kidney problems, or possibly seeing high levels of calcium.  

Katherine Banwell:

What about smoldering myeloma? What is that? 

Dr. Mark Schroeder:

So, smoldering myeloma is a stage that happens prior to the development of myeloma that is causing organ damage. I talked about the damage to bones, kidneys, blood cells – that is called the CRAB criteria. The C stands for calcium, the R renal, A anemia, and B bones. We define myeloma by having damage to one of those four essential systems.  

Smoldering myeloma can happen when we actually see plasma cells that look like myeloma – that look like cancer cells, but they’re not causing the CRAB features of multiple myeloma. And there is a chance that sometimes that smoldering form of myeloma, it’s not causing any damage, but it can evolve and change into myeloma. 

Katherine Banwell:

What is MGUS? 

Dr. Mark Schroeder:

MGUS is a stage that happens prior to smoldering myeloma. We know that MGUS which stands for monoclonal gammopathy of undetermined significance – it’s a mouthful. That’s why we like to say MGUS.  

Katherine Banwell:

Yes. 

Dr. Mark Schroeder:

But it’s a protein that can be detected in your blood. Sometimes that protein does not mean you have a cancer. We can detect proteins like that in blood in patients who have, say, autoimmune diseases, and they’re at low levels. It’s just an immune response; it’s produced by those plasma cells that can be cancerous, but sometimes plasma cells grow because they’re stimulated – they’re overstimulated.  

And so, that monoclonal protein of MGUS can be detected in the blood, but we don’t see an increase in the number of cells in the bones that are classic for myeloma. But we know that about 1 percent of patients who have MGUS, every year, 1 percent might progress on to develop multiply myeloma. So, it’s a risk factor; it’s on the spectrum of disease from MGUS to smoldering myeloma to myeloma.  

Katherine Banwell:

Okay. And how is asymptomatic myeloma monitored?  

Dr. Mark Schroeder:

So, asymptomatic patients, I would consider those are the patients who have smoldering myeloma, so they don’t have the high calcium, the renal issues, anemia, or bone problems. And typically, those patients are followed up about every three to six months, depending on where they fit in kind of that spectrum of MGUS to smoldering myeloma to myeloma.  

Sometimes patients who have clinically identified myeloma and it presents very heterogeneous sometimes. They may not have a lot of organ involvement or organ damage, and maybe they’re frail, they’re elderly. And it may be appropriate also to observe patients who actually have some of the findings of myeloma, but the disease doesn’t seem to be as aggressive. 

What Does Remote Patient Monitoring Mean for MPN Patients?

What Does Remote Patient Monitoring Mean for MPN Patients? from Patient Empowerment Network on Vimeo.

Myeloproliferative neoplasm (MPN) patients are a patient group who already used remote patient monitoring before the COVID-19 pandemic. Watch to learn about remote patient monitoring, recent advancements for MPN patient care, and expectations for future developments from remote patient monitoring.

See More From the MPN TelemEDucation Resource Center

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What Do Telegenetic Consultations Mean for MPN Patients?

What Do Biosensors Mean for Myeloproliferative Care?

Should MPN Patients and Their Families Continue Telemedicine?


Transcript:

Remote patient monitoring was already in use before the COVID-19 pandemic hit, and technology improvements were fast-tracked by federal grants from the U.S. government. Telemedicine appointments and monitoring of the heart, lungs, brain, and muscles through remote technologies can be easily carried out for improved remote care.

Though remote patient monitoring of MPN patients was already in practice through periodic monitoring of blood work, advancements have been made in recent months. These improvements allow patients to visit their MPN specialist less frequently as their provider advises. While protecting patients from virus and infection risks, fewer visits save time and travel costs while also allowing optimal patient care in collaboration with their provider.  

As remote patient monitoring technologies continue to increase and improve over time, they will continue to help refine patient care. MPN patients can expect personalized care that becomes even more tailored to their needs, which will result in improved quality of life and less time in care appointments and traveling time for care appointments.

Please remember to ask your healthcare team what may be right for you.

My MPN Journey, Getting the Best Care After ET and MF Diagnoses

My MPN Journey, Getting the Best Care After ET and MF Diagnoses from Patient Empowerment Network on Vimeo.

Myelofibrosis and essential thrombocythemia (ET) patient Julia had experience as a health educator and hospital administrator before receiving her MPN diagnosis. Watch as she shares how she later connected the dots from her symptoms and blood work, lessons learned about myelofibrosis patient journeys, and her advice for living well with MPNs.

Related Resources:

Expert Advice for Learning About Your MPNs Online

MPN Caregivers: How to Provide Support During Appointments


Transcript:

Julia:

My name is Julia, I was diagnosed with essential thrombocythemia in 2007, and then with myelofibrosis a year later, after routine blood work. The diagnosis came out of nowhere. I was healthy and active prior to my diagnosis and raising five children with my husband. I’ll never forget the day I received a voicemail from my primary care doctor’s office, I really couldn’t believe what I was hearing. I didn’t have time for this illness in my life. I had a bone marrow biopsy that showed I was positive for JAK2 and had a 5q deletion genetic mutation. I started on daily aspirin, and it was a hard pill to swallow for many reasons.

As a certified health educator and former hospital administrator, I understood the importance of treating a rare disease, but I had a difficult time with the idea of taking medicine daily, and I felt like I didn’t have any symptoms. I reviewed my old lab print-outs that showed elevated platelets 15 years before, that slowly increased over time. I recall having severe migraines that would put me out of commission for the day, and tenacious fatigue in the years before, I didn’t connect the dots with the symptoms, and neither did my oncologist. By 2007, my platelets and white blood cells were very high.

I decided to find an expert with extensive experience with ET and MF to get top-notch monitoring and treatment. I connected with a specialist for many years and hope to keep living with my disease for many years ahead. I’ve had several hospitalizations and ER visits over the years, but keep on going. MF has absolutely changed the path of my life and how I live it, but I still do most of what I want to do while I’ve been lucky in maintaining stable myelofibrosis with no true signs of disease progression or serious myelofibrosis complications, it’s important to understand the path for other myelofibrosis patients might be quite different.

My advice for others MPN patients is:

  • Pay attention to how you feel and pace yourself.
  • Keep track of your blood counts, so you can alert your care team.
  • Find an MPN specialist for your care.
  • Don’t forget to be present and spend time with your family.

These actions are key to staying on your path to empowerment

Remote Monitoring

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TelemEDucation_Remote Monitoring

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Dr. John Pagel’s Top Tips for Preparing for Your CLL Telemedicine Visit

Dr. John Pagel’s Top Tips for Preparing for Your CLL Telemedicine Visit from Patient Empowerment Network on Vimeo.

For chronic lymphocytic leukemia (CLL) patients, telemedicine has emerged as an option that requires new ways of working with their health team. Watch as CLL expert Dr. John Pagel shares his advice to patients and caregivers for getting the most out of telemedicine visits.

See More From the CLL TelemEDucation Empowerment Resource Center

Related Resources:

 

Will Telemedicine Be a Long-Term Survivorship Tool for CLL Patients?

Is Remote Monitoring for CLL Patients on CAR T Therapy the Future?

What CLL Symptoms Can Be Monitored via Telemedicine?


Transcript:

Stephanie Chuang: 

You had mentioned, patients need to be prepared when they come to their telemedicine visits, doctors have limited time, of course. So what are your top three tips or so for patients and their caregivers who are preparing for their telemedicine visit?

Dr. John Pagel: 

So here’s a good important thing to say around that. Number one, you know, what happens is you’ll get told you have a telemedicine visit at 10:00 AM on Tuesday. And so you’re looking forward to 10:00 AM on Tuesday. And 10:00 AM comes around, and you’re waiting by the phone, and it doesn’t ring immediately, or the Zoom doesn’t come up immediately, please understand you have to be a little bit flexible with your physician. Just because it says that time…it’s the same thing kind of like in the clinic, it all kind of flows and works together. And so please be flexible and be patient. Not accepting excessive delays, that’s not really cool, we get that, but it’s often very hard to be right on the dot at 10:00 AM. So number one, be flexible. Number two, have your questions written out or focused about what you want to learn and understand that visit. It may not be a lot different than the last visit, that’s okay. But if you don’t have those, often, what will happen is that when the visit’s over the phone is hang up or the Zoom call is put away, you’ll remember, “Oh, I forgot to ask X, Y, or Z.” don’t let that happen.

And the way you don’t let that happen is to be focused there with what you want to learn. And then lastly, if it’s possible, don’t be excessive. Meaning that, focus on the things that are important, meaningful, relevant to what’s happening to your health, your disease in your interaction with your physician. There are things that we all can list that could be very, very long in the list, but many of them aren’t going to be something that the physician can get to in a very meaningful, important way. Ask though, if you can’t get to those things that are important, that you try and follow up with them very quickly, perhaps in another visit relatively soon. But keep your expectations, if you could, to a very realistic approach, directed and focused on taking care of you and managing your CLL. 

Will Telemedicine Be a Long-Term Survivorship Tool for CLL Patients?

Will Telemedicine Be a Long-Term Survivorship Tool for CLL Patients? from Patient Empowerment Network on Vimeo.

With telemedicine as a part of the chronic lymphocytic leukemia (CLL) toolkit, what will its role be in the future? Watch as CLL expert Dr. John Pagel shares his viewpoint of how telemedicine will play into long-term survivorship care for patients.

See More From the CLL TelemEDucation Empowerment Resource Center

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What CLL Population Will Benefit Most From Telemedicine?

Is Remote Monitoring for CLL Patients on CAR T Therapy the Future?

What CLL Symptoms Can Be Monitored via Telemedicine?

 

Transcript:

Stephanie Chuang: 

We really haven’t scratched the surface, it seems, when it comes to using telemedicine as a long-term survivorship tool. So for the sub-group of CLL patients who never need treatment, does telemedicine still bring any major advantages?

Dr. John Pagel:

There are people, and it’s not uncommon, who actually never even get treated. I’ve had people in my clinic who have had CLL diagnosed and never treated for over 20 years or more. It does happen. And those people often can be managed with their primary care physician, even though it’s good to have a CLL focused clinician, an oncologist or even expert in their back pocket, but they may only need to have that televisit with that expert or oncologist once a year. So those are the ideal kind of patients who it’s not great to drag them in if there’s nothing going on with them, but they still need to be evaluated and have a discussion about what’s happening, at a minimum once a year in many cases. 

What CLL Symptoms Can Be Monitored via Telemedicine?

What CLL Symptoms Can Be Monitored via Telemedicine? from Patient Empowerment Network on Vimeo.

For chronic lymphocytic leukemia (CLL) patients, some symptoms can be monitored via telemedicine, while other symptoms are best to check in-person. Watch as CLL expert Dr. John Pagel discusses getting optimal care by CLL symptom type.

See More From the CLL TelemEDucation Empowerment Resource Center

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What CLL Population Will Benefit Most From Telemedicine?

Is Remote Monitoring for CLL Patients on CAR T Therapy the Future?

Will Telemedicine Be Part of Routine Management for CLL?

 

Transcript:

Stephanie Chuang: 

There are CLL patients on specific treatment protocols and those who need follow-up for potential adverse effects of treatment compliance and, of course, progress. And so the question is, how effective of a tool is telemedicine for this group?

Dr. John Pagel: 

I’ve been very impressed that we can meet the needs of patients, we can meet the needs for clinical trials. Clinical trials have really adopted and been flexible with the idea of being able to do telemedicine in a large degree because of COVID in CLL. And I would say clearly that a conversation and close discussion with the physician’s critically important, it comes back to what we mentioned specifically, it’s about education. Patients need to understand that if they’re not feeling well, meaning, they’re having drenching night sweats or they’re losing weight or they’re having pain, those aren’t things to sit back and just wait for your telemedicine visit, they need to contact the physician and to be able to be seen urgently or quickly if needed. 

Telemedicine is going to be a bridge to make that happen, but in general, those are people that are in a bit of a different class of what we’re discussing here today. So monitoring disease, taking care of people with regard to assessments of their blood counts can be done all again through telemedicine, but more acute problems, those patients do, of course, need to be seen. 

TelemEDicine ToolBox Visit Checklist

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Will Telemedicine Give More CLL Patients Access to Clinical Trials?

Will Telemedicine Give More CLL Patients Access to Clinical Trials? from Patient Empowerment Network on Vimeo.

Though some with chronic lymphocytic leukemia (CLL) may have limited access to clinical trials at expert centers, telemedicine may change access for some patients. Watch as Dr. John Pagel shares how telemedicine might improve CLL clinical trial options. 

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Telemedicine & Second Opinion Options

How Will Telemedicine Impact Time-Limited Therapy in CLL?

Will Telemedicine Activate More Remote Tools to Manage CLL?


Transcript:

Stephanie Chuang: 

There is a lot of attention being paid to clinical trials and progress, and so how might telemedicine impact clinical trials when it comes to CLL therapy?

Dr. John Pagel: 

Well, I want to first tell the audience that clinical trials are critically important for many patients who have CLL. Clinical trials are really an opportunity to get something that’s better than the standard of care most often, or at least just as good and has the promise again, to be better. We have advanced major new paradigm changing therapies over the last many years through clinical trials, and now we’re looking at really exciting things like bispecific antibodies, newer generations of these targeted therapies that are better tolerated and perhaps even more active in resistant patients. And even as we talked about CAR T-cell therapies, those are all only available through clinical trials, and then that’ll continue to evolve and go on as well.
 
I would encourage patients to think about clinical trials, and because of telemedicine, now we’re going to be able to reach to other patients who are further away from an expert, perhaps where clinical trials are only available, and they can be then involved in one of those opportunities. Telemedicine, I hope, and I believe, will be a major advance for getting the cutting-edge, best therapies for patients who might be very far away from a very important expert center. 

Will Telemedicine Activate More Remote Tools to Manage CLL?

Will Telemedicine Activate More Remote Tools to Manage CLL? from Patient Empowerment Network on Vimeo.

As telemedicine has grown in the management of chronic lymphocytic leukemia (CLL) care, will its use bring other remote tools into patient care? Watch as CLL expert Dr. John Pagel explains.

See More From the CLL TelemEDucation Empowerment Resource Center

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Telemedicine & Second Opinion Options

How Will Telemedicine Impact Time-Limited Therapy in CLL?

Will Telemedicine Be Part of Routine Management for CLL?


Transcript:

Stephanie Chuang: 

Dr. Pagel, there are tools out there like video otoscopes, electronic stethoscopes, thermoscopes, retinal imaging systems, will CLL patients be able to have access to those tools for themselves one day, and on that note, what are the tools you believe will impact the future of CLL care?

Dr. John Pagel: 

Yeah, in fact, that’s really where we’re going. We do stuff like that already through the hospital. As you may know, as an example, if someone comes in with a cardiac condition, they need to be monitored remotely, they can’t stay in the hospital indefinitely we need to kind of know what’s happening, perhaps as an example with their heart rhythm. So they actually have tools where they can wear a little monitor even on their wrist that communicates with the doctor. So the doctor can see even in real time what’s happening with that individual patient. 

These types of tools are the future, and we’re not going away from them, we’re embracing them. We’re not there yet for routine standard care, especially in CLL but they will be simple things like heart rate, blood pressure measurements that are very simple and easy to do that not only are able to be read by the patient, but actually again, from a remote standpoint, be electronically downloaded and delivered to the physician, real time. That’s going to be important. And actually, I believe that we’ll even add advances for that in the blood work or other approaches in the near future. So just stay tuned we’re just scratching the surface there. 

Stephanie: 

Okay, so you’ve heard it here first from Dr. Pagel, stay tuned on this.  

Telemedicine Challenges and Opportunities for CLL Patients

Telemedicine Challenges and Opportunities for CLL Patients from Patient Empowerment Network on Vimeo.

For chronic lymphocytic leukemia patients, some challenges have emerged with care via telemedicine. In this telemEDucation program, CLL expert Dr. John Pagel explains opportunities for patients and providers to optimize these visits.

See More From the CLL TelemEDucation Empowerment Resource Center

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What CLL Population Will Benefit Most From Telemedicine?

How Will Telemedicine Impact Time-Limited Therapy in CLL?

Will Telemedicine Be Part of Routine Management for CLL?

 

Transcript:

 Stephanie: 
Let’s highlight both the challenges and opportunities that come with telemedicine. So first, it does seem to be reshaping the traditional CLL doctor-patient relationship to some extent, and you’ve touched on this. So with your experience as a CLL expert, what are the limitations of telemedicine?

Dr. John Pagel: 
Well, one of the, of course, things about telemedicine is it’s not just figuring out how to do it from the provider’s standpoint, but it’s also figuring out how to do it from the patient’s standpoint. So we can’t expect, to be honest, that this goes just like it would if you were in the clinic, sitting on the exam table with your physician there at the computer right next to you in that exam room, it shouldn’t be expected that it’s going to go like that. And unfortunately, to this point, we’re trying to figure out that. It doesn’t do that. And so that takes some alteration in our approach, on the provider’s side and on the patient’s side as well – and in particular, what the expectations are for these patients and for the providers.

So it needs to be very focused, and it needs to be concise. So what is my message there? For the patient’s side, know that the doctor’s busy, they’re doing their work all day long with lots of sick people potentially, and so they need to be very focused on what the issues are and the direction of the conversation. So come prepared to a telemedicine visit, if you’re a patient. Come prepared to know what you want to talk about and what the focus is with the priorities that you might have that are issues for you around your CLL disease. And the provider will do that hopefully as well. It’s a learning thing. But I will tell you, the first time will take a little bit of learning. By the second, third time that you’re actually interacting with your doctor, that same one-on-one relationship, it really

Will Telemedicine Mitigate Financial Toxicity for CLL Patients?

Will Telemedicine Mitigate Financial Toxicity for CLL Patients? from Patient Empowerment Network on Vimeo.

The cost of chronic lymphocytic leukemia (CLL) care can be inappropriately high for some patients. Watch as CLL expert Dr. John Pagel details how telemedicine can affect the high cost of care.

See More From the CLL TelemEDucation Empowerment Resource Center

Related Resources:

 

What CLL Population Will Benefit Most From Telemedicine?

How Will Telemedicine Impact Time-Limited Therapy in CLL?

Will Telemedicine Be Part of Routine Management for CLL?

 

Transcript:

Stephanie: 
Dr. Pagel, we know the stresses of paying for cancer treatment. So how can maybe telemedicine help to mitigate financial toxicity for these countless CLL patients and their families?

Dr. John Pagel: 
Well, this is an important part of medicine in general, and it’s certainly relevant, of course to the CLL patients. The cost of care is inappropriately high, not just the pharmaceutical agents, but, of course, the visits. So there are evolving ways of figuring out how reimbursement will happen for physicians and how payments happen on the side of patients. We’re still not completely clear on that, but likely what will happen, over time, is that we will be doing less and less unnecessary tests. And with less unnecessary tests, the cost of care will go down for the individual specific community and patients. It’ll be very important for us to figure out what we really need to be doing and what we don’t, and telemedicine’s going to help us figure that out. 

Is Remote Monitoring for CLL Patients on CAR T Therapy the Future?

Is Remote Monitoring for CLL Patients on CAR T Therapy the Future? from Patient Empowerment Network on Vimeo.

Will telemedicine play a greater role in CAR T remote monitoring and help some CLL patients avoid long hospital stays? Learn how harnessing technology could optimize care for CAR T patients.

See More From the CLL TelemEDucation Empowerment Resource Center

Related Resources:

 

What CLL Population Will Benefit Most From Telemedicine?

How Will Telemedicine Impact Time-Limited Therapy in CLL?

Will Telemedicine Be Part of Routine Management for CLL?

 

Transcript:

Stephanie: 

There’s excitement around telemedicine and CAR T, so specifically remotely monitoring CAR T to help avoid patients having to deal with long hospital stays. Is this the future?

Dr. John Pagel: 

It’s clearly the future. So what you’re alluding to, of course, is a way that we are now doing to trick a patient’s own immune system cells into targeting and fighting the cancer, and of course, we’re talking about CLL here. It’s a revolutionary treatment in CLL, we still have quite a ways to go, we are doing a lot of important trials and advancing the field, but we don’t have an approved approach in CLL yet, but we will. No doubt. And the goal of that therapy is not just to eradicate the disease and keep it from coming back, but it’s also to do it in a very safe and actually appropriate way, and that’s as an outpatient.

Those patients clearly have risk for an adverse event or a side effect, that can be problematic. So they have to be in close contact with a physician and sometimes they’re required to be very close to the treating center for prolonged periods of time. Most of the time that’s very uneventful. So it’s a major disruption to a patient’s life. You could imagine that you’re traveling hundreds of miles to go to a center, and not just go to a center that provides the CAR T-cell therapy, but is actually monitoring you for a month or more, so you’re away from home for a long time, living in a hotel, that’s a problem.

Telemedicine is a way to get around that. We will evolve to being able to treat patients, get them home, and then telemedicine will work where the visits can be done in a very expeditious manner, and again, in a very appropriate way so that that will also reduce the interactions away from home, and as we said cost of care as well.