Tuesday, October 22, 2019

Still No "Best" Trestment for Early Stage FL

According to research presented in the journal Blood Advances, there is still no "best" treatment for early stage Follicular Lymphoma.

I don't write a lot about early stage (stage 1 or 2) FL, for a couple of reasons. First, not many FL patients have it. Most of us are diagnosed with stage 3 or 4 disease. Less than 20% of us are diagnosed with early stage disease. Symptoms just don't show up very clearly at those stages.

The other reason is that there really isn't a lot of research on early stage disease. For many years, the thinking has been that early stage FL can actually be cured, in many cases, with traditional radiation. It makes sense -- staging is based on location. Stage 1 lymphoma is isolated to one area of the body. Radiation doesn't work on other stages because a single radiation beam can't get to it. But it can with stage 1.

But is that the best approach? That's what the Blood Advances article tried to answer.

The article is called "Outcomes of stage I/II follicular lymphoma in the PET era: an international study from the Australian Lymphoma Alliance."

The research looked at how effective a bunch of different treatments were on stage 1 and 2 Follicular Lymphoma -- Watching and waiting, radiation alone, systemic therapy (like chemotherapy), or  chemo + maintenance.

The big outcome is that they found that there was no difference in Overall Survival among all of the choices.

This is not a surprise. It's the golden ring that no one seems to be able to grab -- lots of treatments seem to do good things for FL patients, like increase time between treatments, or do the job with fewer side effects. But all of them seem to give the same survival benefit. They can do different things for us, but in the end, none of them keep us alive any longer than the next best one.

The patients that received Maintenance had better Progression-Free Survival. Again, not a surprise. That seems to be the case with many studies -- Maintenance keeps the disease from coming back longer than not getting Maintenance (though it does come with the side effects that come with long-term treatment). Better PFS, but with the same Overall Survival.  

The good news is that all of the different treatments resulted in "excellent outcomes."

And that's about where we are, still, with Follicular Lymphoma, with a few exceptions. We have lots of options, which lets us choose treatment based on our goals. The important thing is to know what those options are, know what your goals are, and have a doctor who is willing to talk about it all with you.

Thursday, October 17, 2019

Get a Flu Shot

The Journal of Clinical Oncology just published an article that looked at the effectiveness of the flu vaccine on patients with cancer. On the surface, the results don't look all that great. But the researchers' conclusion is very clear:

Cancer patients should get a flu shot.

The timing of the publication is great, because this is the time when cases of the flu start to ramp up. (I just saw an article yesterday that the first flu case in my sate was reported a couple of days ago.)

The study looked at 26,463 cancer patients in Ontario, Canada, between 2010-2011 and 2015-2016 (the flu season overs fall into early spring, so one season takes place over parts of two years). They used records of patients who who were tested for having the flu, and checked those against records of patients who had been diagnosed with cancer. About 16% of the group tested positive for the flu, and about 45% had received a flu shot.

For cancer patients, the flu vaccine was less effective than it was for the general population. It was effective for about 21% of cancer patients overall. For patients with a solid tumor, the effectiveness was about 25% effective.

But for patients with blood cancer, it was much less effective -- about 8%.

The reason for this lower effectiveness isn't clear, though researchers think it could be because so many blood cancer patients go through treatments that cause myelosuppression -- less activity in the bone marrow. And that's where blood cells are created.

It makes sense -- our treatments work to harm the blood cells that are cancerous, but those same cells are the ones that help our immune systems do their job. Fight the cancer -- lower our immunity -- make us more vulnerable to the flu.

Some treatments for solid cancers also target the bone marrow, but not all, so they may be a ittle less likely to have problems with myelosuppression.

So the question is, with only an 8% effectiveness, is it even worth it for blood cancer patients to get a flu vaccine?

The answer is a very loud YES.

“Overall, our results support current clinical practice guidelines recommending influenza vaccination for patients with cancer and survivors...This recommendation acknowledges the safety of vaccination and the potential severity of influenza infections among strongly immunocompromised patients with hematologic cancers.”
In other words,  even an 8% increase is worth it. For someone with a weakened immune system, the flu can be devastating. Anything you can do to protect yourself is important.

I've been following the conversation about this article on Twitter. I follow a lot of oncologists, and they all same the same thing -- get the flu vaccine.

And just as important -- encourage the people you send time with to also get the flu shot. You want to do everything you can to keep that nasty bug far away from you.

Have I gotten my flu shot yet?

No. But I will very soon. My wife and I usually go together. We go right to the drugstore down the street, which has a walk-in flu clinic. We pick a day when we can both take some time off. We get the shot, and then we go to lunch, and then eat something with bacon in it and complain about our shoulders hurting. It's a weird date, but I get to have bacon. And we get to protect ourselves. 

So please protect yourself, too. Get a flu shot.

Sunday, October 13, 2019

Rituxan Injections as Safe as IV

The British Journal of Haematology has published the results of a phase 3 study that shows that subcutaneous Rituxan (and injection) is just as safe as the intravenous method.

Many of us have had Rituxan (or MabThera as it is known in some parts of the world) through intravenous administration. That was my experience -- six hours in a chair, the Rituxan very slowly dripping into a vein. The slow rate was necessary, since it is common for patients to have an allergic reaction, especially to the first round. The slow drip helps to control the reaction. I did have a reaction to the first round, and my five later rounds were a little quicker -- but not all that quick (4-5 hours).

Subcutaneous Rituxan, given a shot under the skin, has been available in the U.S. for a couple of years now, and even longer in other parts of the world. It is much, much quicker -- only 5 to 7 minutes in most cases -- and is available to patients who did not have allergic reactions, or whose reactions were under control. The subcutaneous version of Rituxan is called Rituxan Hycela in the U.S., and it was approved by the FDA based on clinical trials.

The BJH article reports on another clinical trial, this one from Spain. Its main goal was to test the safety of subcutaneous Rituxan by comparing it to IV Rituxan. The trial looked at the two types of Rituxan as part of a combination with chemotherapy. It found that most patients (there were a totla, of 111 with Follicular Lymphoma) did have some kind of reaction, including numbness, fatigue, and rash. About 38.6% of patients had a grade 3 or greater reaction (considered the most serious), but about half of them came from the chemo, rather than the Rituxan. In comparing the two types of Rituxan, there was no difference in safety. In other words, subcutaneous is as safe as IV Rituxan.

The study also tried to measure some other things, including effectiveness (seems to be as effective, but they're still gathering some data). More importantly, they tried to also measure Quality of Life.

They did this by asking patients to fill out a survey, and about 60% of them did. They found that Quality f Life was as good or better with subcutaneous Rituxan. This makes a lot of sense -- my QoL would have been greatly improved if I didn't have to send 4-6 hours on six consecutive Fridays sitting in a chair with an IV in my arm. In general, the cost is less, too, since the patient doesn't need to be supervised for that long. Patients also said that they didn't have any problems with moving around, taking care of themselves, or just doing their usual activities, and didn't have problems with long-term pain or anxiety and depression.

In some ways, the study confirms what we already knew -- subcutaneous Rituxan is as good as the old IV version, and in some ways even better.

But more importantly, the study focused on why it's even better, and that's where the Quality of Life data comes in. Safety and effectiveness are very important, obviously -- we want all of our treatments to be effective, and to not cause additional health problems. But so few studies now include Quality of Life data that would show that a new treatment is worth the cost because it allows us to not just stay alive, but to live a life that's meaningful and fulfilling.

This is a good time to remind you that the good folks at Lymphomation.org are still collecting signatures for a petition that asks the FDA to require that ALL clinical trials collect Quality of Life data. If you haven't had a chance to read the petition and sign it, take a few minutes to do it now.

There are lots of ways to measure success for a treatment. Let's make sure that researchers measure the ones that matter. 

Wednesday, October 9, 2019

TED Talk on CAR-T

There's a CAR-T resource that I came across in the last week or so. Many thanks to William, a frequent commenter, who helps run the CAR-T and Follicular Non-Hodgkin's Lymphoma blog, and whose wife was an early CAR-T patient.

It's a TED Talk by one of the researchers who pioneered the research that led to the development of CAR-T, Dr. Carl June. It's called "A 'Living Drug' That Could Change the Way We Treat Cancer." It was filmed last November.

(And let me say straight away that I really appreciate his saying "could change the way." There's so much hype around many treatments, including CAR-T,  that I like that he's humble enough to say it could change things, but that doesn't mean it definitely will.)

Dr. June really tells a story about immunotherapy -- the idea that the body's immune system can be used to fight cancer. And, of course, that's what CAR-T does. The immune system is meant to fight invaders -- outsiders like bacteria and viruses that get into our bodies. But cancer isn't an invader -- cancer cells are part of us that don't know how to die, like normal cells.

So a treatment like CAR-T works by taking a patient's T cells (an immune cell that seeks out invaders) and changing it so it recognizes cancer cells as invaders.

Dr. June gives some history of how CAR-T was developed. It took a long time, like many great developments, with lots of tinkering and changing and making things better. Like the story of Dr. James Allison, it's an inspiring tale of persistence.

It's a great video, and one that should inspire all of us. There are some amazing people doing some amazing things to help us.

Friday, October 4, 2019

Beakthrough (The Movie)

There's a new movie out called "Breakthrough." It's a documentary about Dr. James Allison, a cancer research whose work on immunotherapy won him a Nobel Prize in Medicine.

Last week, he did an interview with Mary Elizabeth Williams, a writer who was diagnosed with terminal melanoma until she received the treatment that was developed through the work that won Dr, Allison his Nobel Prize, a combination of Ipilimumab (an antibody, like Rituxan, but this one works on something called Cytotoxic T-lymphocyte–Associated Antigen 4, or CTLA-4] and Nivolumab (another antibody that works against Programmed Death 1, or PD-1, receptors).

Without getting into too much detail, the combo works, like all immunotherpay, but making the immune system seek out cancer cells, when it would normally ignore them.

The "Breakthrough" movie is only playing in a few theaters right now. On the website for the film, you can see a trailer, and see the locations for where it's playing in the next few weeks.

From what I can tell, in telling the story of Dr. Allison, it does a few important things. First, it humanizes Dr. Allison, and shows how personally important it is to him that he was able to help so many people. Second, it shows how much work goes into developing cancer treatments. It takes years for something successful to get to patients, with a lot of failures along the way. And finally, from what I've read, the film also recognizes the people who have helped Dr. Allison along the way. There's no way that one genius can do it all alone. There are so many people, from other scientists, down to lab assistants, who play a role, that they should get some recognition, too.

Mostly, though, it looks interesting to me because it gives me hope. There are lots of Dr. Allisons out there. Some are building on the great work he has done. Some are trying new and wonderful things on their own.

And while it may take some time for their discoveries to get to us, it should give us hope that there are teams of people out there who are working hard to make it happen. 

Tuesday, October 1, 2019

Follicular Lymphoma Podcast

The podcast series Blooducation has a new podcast on Follicular Lymphoma.

Blooducation is a British organization that produces educational podcasts on lots of topics related to haematology (blood-related diseases of all kinds).

 Their latest is called "An Update on the Management of Follicular Lymphoma," and features an interview with Dr. Toby Eyre from Oxford University Hospitals. The podcast (like all Blooducation podcasts) is meant for health professionals, so it can get a little technical in spots.

Still, like most of these "updates" posts, I find them interesting because they give a good "state of the art" about Folicullar Lymphoma -- the latest treatments, some of the controversies, and just generally the opinions of a well-known expert.

This one is especially interesting to me because it's coming from the UK. While clinical trials take place all over the world, and the results of those trials can affect which treatments are approved in a particular country, there are still differences in the way patients are treated, depending on the country. I know I write a lot (mostly) about what is happening in the lymphoma community in the U.S. But we have lots to teach one another.

For example, just based on what I hear in the podcast, it seems like there is more of a consensus on treatment in the UK on the treatment path. In other words, most patients will get a certain treatment based on their stage and grade, and then get another if that doesn't work. It seems like that's not the case in the U.S., where a patient might have receive any of three or four, depending on the doctor (and maybe what private insurance will pay for).

All that choice is good, in some ways. But it also causes some potential problems, too. It's easy to wonder if you're getting right treatment when there are three other possibilities.

So, overall, I think it's an interesting podcast, with some good information, especially if you're a real Cancer Nerd like me.


Friday, September 27, 2019

Abexinostat is Fast Tracked for FL

The FDA has given Abexinostat a Fast Track designation for fourth-line treatment of Follicular Lymphoma.

Let's break that all down.

Abexinostat is an HDAC Inhibitor. Like all inhibitors, it works on cancer cells by stopping (or inhibiting) some process that's necessary for the cancer cell to grow and survive.

In this case, it inhibits HDAC, or Histone Deacatylase enzymes. These enzmyes are important for cell growth because they help arrange which parts of the cell control its growth. One of HDAC's jobs is to control the genes that allow cells to keep growing. By inhibiting HDAC, Abexinostat can help control cells that are otherwise out of control (and become cancer cells). There are other HDAC inhibitors being tested, but Abexinostat is different because it is given more frequently than others, and so can work on cancer cells continuously.

The trial that led to the designation is a phase 2 trial of 87 patients with a few different types of Lymphoma. The Overall response rate for the group was 28%, but for the smaller group of Follicular Lymphoma patients, the Response rate was 56%. Side effects were common, with 80% of patients in the trial having thrombocytopenia (low platelet counts), along with other nerve and blood count issues that often come with Lymphoma treatments.

The designation will be for fourth-line patients, which means, if it is approved, patients will need to have received three other treatments already.

The Fast Track designation by the FDA means the treatment will be handled a little differently than a regular FDA approval, like more frequent meetings with the FDA. It doesn't mean that the treatment will be approved faster, though the extra help from the FDA may move that along. Fast rack status is given to treatments that meet an unmet need, and that work on diseases that can become fatal without proper treatment.

I have to say, I'm not really excited about this one -- not yet, anyway. Fast Track status sounds like it should be really exciting, but it also signals that it's still pretty early in the process. The results we see are from a phase 2 study, which is always pretty small. But this is also a small group within a small study -- only 18 FL patients. And 56% percent is good, but it's also for Overall Responses, not Complete responses. And those side effects are not much of improvement over other treatments.

But it got FDA Fast track, so there must be some promise in it, right?

It's early. I try to keep my enthusiasm down for early studies. And if this goes to a larger phase 3 study, and there are even better results, then I'll start to break out a Happy Dance.

For now, we'll go with cautious optimism, and keeping an eye on this to see how it goes.