Tuesday, October 28, 2014

Ixazomib (Another Inhibitor)

The Blood Cancer Journal recently published the results of a phase I clinical study on Ixazomib, a proteasome inhibitor. It showed some promise for use on Follicular Lymphoma.

The article compares Ixazomib to Bortezomib (also known as Velcade), which was the first proteasome inhibitor to get approval. (It was approved for Mantle Cell Lymphoma, though some clinical trials for Follicular Lymphoma have looked good.) Bortezomib/Velcade works by blocking proteasomes, which help keeps cells healthy by getting rid of older and messed-up proteins. Protease inhibitors block that process in cancer cells, so all of those messed up proteins pile up in the cell and cause it to die.

Ixazomib will work in a similar way, though it has a different structure than Bortezomib/Velcade, which the developers hope will result in greater effectiveness and fewer side effects.

The phase I trial was meant to test whether or not it would work on certain types of lymphomas, to measure side effects, and to determine what the ideal dose would be. Of the 26 patients who went through the trial, 11 had Follicular Lymphoma, and 4 of them had a response. This is good enough to move on to a phase II trial.

The usual warnings apply here:

Phase I is very early. There will be a lot of time between now and when (and if) this gets approval, and clinical trial volunteers will be needed. It will also face the hurdle of needing to show it is better than what we have now, with Velcade. A response from 4 out of 11 FL patients is good, though not overwhelmingly good. We've seen a few  monoclonal antibodies try to outperform Rituxan, and so far no one has hit on the magic formula that will do that. Will the same thing happen with some of these attempts to improve various inhibitors?

We shall see.

Sunday, October 26, 2014

Treatments for Follicular Lymphoma

You ask for it, you get it. That's how things work here at Lympho Bob. Satisfaction guaranteed or your money back.

A couple of weeks ago, an anonymous commenter asked:

Thank you for your blog! It has been really informative and helpful. I was diagnosed a month ago and reading your blogs has provided much insight into the medical and emotional aspects of this disease. I was wondering if you would consider doing an outline of the current treatment options available at this time. There is a lot of information out there and it can get confusing in terms of what the current options are. Thanks again! 

My response was to list a few, with the warning that I'd surely miss something, and to check the "Treatments" section at Lymphomation.org for more detail. I still think that's pretty good advice, but I also came across a piece in The Pharmaceutical Journal a couple of days ago that lays out current treatments for a few different types of lymphoma, including Follicular Lymphoma. It seems like the kind of list that the reader above was looking for.

But here are some warnings about the list:

First, it was published in a journal that is put out by the Royal Pharmaceutical Society. It refers to treatments that have been approved in the United Kingdom, not necessarily the United States. I think everything discussed here is also available in the US, but there may be some small differences in dosage, or in stage of treatment (frontline or refractory -- that is, some treatments are approved for patients as the first treatment they will have, while others are approved for patients who have already had certain types of treatments that stopped working).

Second, the author of the article gives his opinions about some of the treatments, and while he is objective about a lot of it, and gives links to specific articles in medical journals, he also throws some opinions in there, directly and indirectly. Goodness knows I don't have any objection to opinions, since I throw so many out there myself. But I think some commentary on some of what he says is necessary.

Third, it sounds to me like the person who wrote the comment above does not have an aggressive form of Follicular Lymphoma. A month in, and still considering treatment options? The oncologist must feel like there is some time to decide. I was in the same situation, and that colors the way I look at this article. Aggressive forms of Follicular Lymphoma require different decisions.

So here's some of what he has to say, with my commentary: 
  •  “Common Chemotherapy Schedule for non-Hodgkin Lymphoma”
The author provides a nice chart with the treatment schedules for four different types of traditional chemotherapy with Rituxan. I’m not going to pretend to know if those are the same dosage schedules for the US. Honestly, I have no idea. But it is important to note that all four (R-CHOP, R-CVP, FCR, and R-Bendamustine) are available in the US, and are still used.  In fact, the commenter left the comment on a post I wrote about these chemos. So I don’t need to get more into my feelings about them, other than to say, I think they’re on their way out, especially the first three, and that’s a good thing. They still have a place in Follicular Lymphoma, but I think if an oncologist suggested one of them as a first treatment, I’d have a conversation about why, and why other options aren’t being considered.


  • “R-bendamustine is increasingly being used as the combination schedule of choice.”
And if an oncologist is in favor of chemotherapy, R-Bendamustine would probably be the best choice of those four mentioned. The author acknowledges this, discussing how R-B has results as least as good as R-CHOP, but with less toxicity and fewer side effects. He also points out that Fludarabine (in the FCR combo) is no longer recommended in the latest European treatment guidelines, since it “has been found to increase rates of haematological toxicity” (which I think means it might give you a secondary cancer).


  • Follicular lymphoma often presents asymptomatically and does not always require immediate treatment. Treatment is usually reserved until the patient becomes symptomatic, which occurs a median of 2.5 years after diagnosis, but can be more than 10 years.
 I think this is more or less true, though I would quibble over "treatment is usually reserved until the patient becomes symptomatic." That's describing watching-and-waiting, and I don't think it's accurate to say that W & W is the "usual" strategy. I think it's just the opposite, with maybe a quarter of patients holding off on treatment. Whether or not to begin treatment immediately, let alone which treatment to try, is still a big controversy in Follicular Lymphoma, at least in the US. I think that matters. Watching and waiting is a big decision, one that involves emotional and not just physical factors. It's a false impression to imply that most patients watch and wait until they show symptoms. 


  • "Treatment with rituximab at diagnosis is currently being evaluated in clinical trials and, although it has yet to demonstrate an overall survival benefit, it does appear to improve progression-free survival rates."
And this is about all he has to say about Rituxan. I think it plays a much larger role in first-line or initial treatments for patients in the US, whether or not they have symptoms. It's an option, and a very valid option, for someone who is considering a first treatment. It's also such an important part of Follicular Lymphoma treatment (it's part of all of those chemotherapy options without ever being discussed) that maybe it's easy to take for granted and overlook. It should be overlooked.

  • "Patients who present with limited disease can be treated with radiotherapy alone, which may cure the lymphoma."
Here, he's talking about stage 1 or stage 2 disease, something very limited and isolated, that can be treated with radiation, the way some solid cancer are treated. The problem is, only about 15% of Follicular Lymphoma patients are diagnosed at this early stage, since they are often without symptoms. 

And this is where I might talk about RIT -- RadioImmunoTherapy. Liquid cancers like FL, with that stage 1 exception, can't be treated with traditional radiation, since blood cells have a tendency to not keep still (since they are moving through the blood). RIT tracks down those cancer cells and brings a dose of radiation directly to them. It's a treatment that works for a lot of people, and for a lot of reasons is not used as much as it should be. This article is just further evidence that RIT is ignored.

  • "It is unclear whether ASCT should be used in preference to rituximab maintenance therapy in follicular lymphoma. Younger, fitter patients may be considered for an allogeneic stem cell transplant using reduced intensity conditioning, as this is the only potentially curative option for this form of non-Hodgkin lymphoma."

And finally, he discusses Stem Cell Transplants. And again, this could use more space than it receives here. He refers to Allo Stem Cell Transplants, but there are also Auto SCTs, and both types are used for different purposes.

The article also includes some "future treatment options," including Ibrutinib and Idelalisib. There are even more than that, of course.

I don't think this is a bad article. It's not really meant as a definitive guide for patients, so it would unfair to criticize it for not being one. But I also think it's important to read carefully.
I'll give the same advice as before: for more information, Lymphomation.org is a good place to go. Lots of other websites give some basic infiormation about the different types, but, like this article here, you end up getting only part of a story. 

The best place to go for information is your oncologist. He or she is the one who knows you and your situation best.


Friday, October 24, 2014

Dr. Sharman on Lenalidomide for Indolent Lymphoma

Dr. Jeff Sharman has another excellent blog post that is of interest to Follicular Lymphoma patients. This one looks at the combination of Lenalidomide and Rituxan for Indolent Lymphoma, including Follicular Lymphoma.

The inspiration for the post was a study from The Lancet Oncology that described the results of a phase II clinical trial for that combination. I haven't had a chance to read it yet, but we can let Dr. Sharman do that work for us. I highly recommend his post.

Dr. Sharman does an excellent job of explaining Immunotherapy, and how this particular combination serves to jump start the body's natural immune reaction to fight cancer.

As he describes it, B cells (one of three types of immune system cells) are able to put the other two types (T cells and NK cells) to sleep, in something called "psuedo-exhaustion." While they sleep, the B cells do their work. (Follicular Lymphoma is, of course, a type of B cell cancer.) 

Lenalidomide basically reverses the psuedo-exhaustion, and wakes up those other two immune cells. Combine Lenalidomide with Rituxan, which seeks out B cells, and you have a (literally) killer combination that works very well.

How well? When you combine the two, you get an overall response rate of over 90%, which is comparable to Rituxan + chemotherapy. However, the Complete Response rate for the combo is about 87%. Compare that to Rituxan + chemo, which has a CR of about 35%.

Wipes it out for that many FL patients, and without the side effects of chemo? Very nice.

Dr. Sharman concludes with some information about clinical trials for Lenalidomidefor Follicular Lymphoma. When you read the bog post, be sure to check out those links as well.

Another great post from Dr. Sharman.

Monday, October 20, 2014

I Need a New Oncologist

I got a letter from my oncologist, Dr. R, over the weekend. He's leaving the practice and moving away.

I'm really saddened by this. I've been with him since I was diagnosed.

I've come to like certain things about him. He's on the young side, and I always felt (since my bone marrow biopsy) that his youth had made him a little less jaded, a little more sympathetic. I like his nerdiness. I like that he keeps up with what's going on in the field, and seems open to new things (even if they aren't his first choice). I like that he takes the first 10 minutes of our appointments to just chat, ask about my kids, make fun of the Red Sox, and whatever else is on our minds. I'm going to miss all of that.

And now I have to find someone new.

When I got the letter, I said to my wife, "I really don't have the time or the energy to train a new oncologist."

I was only half joking.

It's going to be hard to replace all those good things that I like about him.

It's only been a couple of days, but I'm already considering options.

I could stay with same office of the practice. The letter mentioned the name of the new oncologist, and I looked her up. From what I can tell, she isn't a hematologist/blood cancer specialist, like Dr. R is. She seems very good, though I want someone who is up on all of the good things that are happening in the world of Follicular Lymphoma.

I could stay with the practice, but go to a different office. I did a quick search, and there are a couple of blood cancer specialists at the other offices. They've been around for a long time. They won't have that youth that I like so much in Dr. R. And while there's something to be said for experience, we're in a rapidly changing world, and some of that experience maybe won't matter as much soon.

I could go to Dr. C, the lymphoma specialist I saw a few days after I was diagnosed. I'm officially his patient, since I'm in his system. He teaches in a medical school, which has advantages when it comes to being cutting-edge. But being a patient in a research setting isn't always fun. Lots of medical students poking around me. I certainly support education, which is a consideration. But I also remember Dr. C as being more straightforward than I might like (as Dr. R had warned me he would be).

Or I could try to find a new oncology practice altogether. I've done some searching online. Do you know how hard it is to find an oncologist online? It's really kind of hard. There are a bunch of websites that allow patients to rate physicians, but the ones I have found are not very active (one or two reviews per doctor), or pretty outdated. I found what seemed like a great hematologist nearby, did some deeper searching, and found an article all about his retirement party in 2012. Not very trustworthy sites.

Dr. R's last day with the practice is December 15, and my next appointment is scheduled for December 18. So I could try to move my appointment to see him before he goes. But right now, just thinking about that final conversation with him makes me sad.

We face so much uncertainty as cancer patients -- especially, I think, as patients of indolent lymphoma -- that it was really nice to have a Dr. R there. I figured he was young, and he'd be around for a long time, just like I plan to be. And now I have to face that one more uncertain thing.

And it stinks.

I'm going to keep chipping away at this, and figuring out what to do. I don't have much choice. But I'm a cancer patient, and that's what we do. We can't ignore some of our problems, so we face them and deal with them, using whatever knowledge we can find to help us make good decisions.

This problem is no different.

But it still stinks.

Saturday, October 18, 2014

Runner Bob

This morning, I ran in my first 5k road race in well over a year -- 16 months.
It didn't go as well as I had hoped, but I guess it was nice to be out there again.

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If you've been a long-time reader (or were curious enough to go back and read old posts), then you know that running has been important to me for a long time. As a cancer patient, running has been a way for me to stay healthy, to stay motivated, and to think about cancer in different terms. Let's just say I do not have a "traditional runner's body," so being able to overcome running challenges has been a way of thinking about overcoming other challenges, too.

I stopped running in January, after I slipped on ice and tore my rotator cuff. Surgery in late February, then my arm in a sling for 7 weeks, and then physical therapy for a long time (and still going) before my therapist said it was OK to run. That was mid-summer. I started running again, slowly. And never really picked up the pace.

Once the fall rolled around, the kids' activities picked up, as did my own work, so my running schedule was erratic. And then my fall allergies picked up, which made breathing a challenge. And then there's the matter of the 10 pounds I put on since the surgery, due to lack of exercise.

My point is, I wasn't exactly in tip-top shape for this race.

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I'm going to spare you the details of the race, which in the past I have provided. This was a small race -- only 43 runners -- and most of them were young, maybe 18-25. There were maybe 5 older guys, like me, including an 80-something man who has been running for almost 70 years. I always tell myself, no matter how bad the race is, you're not going to come in last. At the starting line, I looked around and thought, "By golly, this one time, I just might come in last."

It was not a good race for me. I started out fast, which I usually do. And then I usually settle down into a nice rhythm. But not this time. I just couldn't catch my breath. I could see my shadow as I ran, and I could tell, that shadow was moving slow.

How slow? Well, I have for years had a "5k mix" on my iPod. It's made up of songs that inspire me as I run, and it's timed pretty well so that I can finish a 5k and have a couple of songs left over for the cool down and happy feelings afterward. But this time, I ran out of songs. That's how slow I was going.

And I had to stop and walk. I've only done that a couple of other times in races. It's a point of pride for me -- I can't ever stop. Not as a cancer patient. But I stopped and walked once. I had to. I knew this course, and I knew what was coming, so I stopped and walked to conserve a little energy. And then a few minutes later, I stopped again. And again. I stopped and walked a total of 5 times during the race. My lungs were not happy, and they were taking it out on my legs.

As I got close to the finish line, I looked back and didn't see anyone. I thought maybe I was in last place, but I also saw the police who were blocking traffic for us were still in place, so I knew there was someone out there still on the course. I took little comfort in that.

In the end, I finished in 37 minutes and 56 seconds. By far my worst race ever. I killed myself to finish in under 38 minutes, but that didn't make me feel any better.

As I drank water and waited to see who else ran even worse than I did, I overheard one of the other old guys talking to the race director about the course. It has changed from years past because of construction, and at one point it took us away from the finish line when we should have been going toward it, which threw me, psychologically.

"Yeah," said the race director, another one of those young people. "We need to tweek the course for next time. We measured it too late to change it, but it's actually a little more than 3.1 miles" (which is what 5 kilometers works out to).

"How much longer?" the old guy asked, and I thought.

"Oh, it's about 3.4 miles."

Now, to me, an extra third of a mile is not "a little over 3.1 miles." And it explains why I had no energy left toward the end of the race.

So I did some figuring, and if my time for 3.4 miles was translated to 3.1 miles, it would be about 34 minutes and 57 seconds.

I can live with that time. Still not great, but not embarrassing, either.

So I stood there, feeling slightly better about myself, when the other runners came in. 5 minutes behind me was a young man, tall and lanky, who looked like a runner, but wasn't.

10 minutes later, my 80-something year old friend came in. He got a huge ovation.

And then we waited for the last runner. Another 5 minutes. 10 minutes. 20 minutes. Someone asked who was still out there. "Emily," someone else said.

And then Emily showed up. She was another off those young ones.

But she was in a wheelchair. She got even bigger cheers. And seeing her struggle up that last uphill was inspiring. She wasn't in one of those special racing wheelchairs, either. This was just her everyday wheelchair, which she pushed almost 4 miles, over bumpy sidewalks and big hills.

So yeah, I "beat" those last two, but they certainly put things in perspective.

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It was nice to get back into my Red Shirt, a gift from my mom soon after I was diagnosed, with "RELENTLESS" stitched on the sleeve.

I'm going to keep running. I don't know when I'll race again, but I certainly will at some point in the future. And I have a new goal -- a pretty basic one -- getting myself back into running shape.

Stay tuned for more.


Tuesday, October 14, 2014

Ibrutinib Combo for Follicular Lymphoma

Some say the future of lymphoma treatments won't be in finding a single "magic bullet" treatment that will wipe out the disease. Instead, recognizing that cancer involves a complex series of operations, those folks say that treatments will involve a combination of approaches. Those combinations will target several of the pathways that are necessary for cancer cells to survive.

It looks like one such combo is going to be tested.

A phase I/II clinical trial is being developed that will test the combination of Ibrutinib and Nivolumab.

We know a little something about Ibrutinib. It is a BTK Inhibitor -- that is, it stops Bruton’s tyrosine kinase, an enzyme that is necessary for cancerous B-cells to grow. It has been approved for a couple of other types of lymphoma, and is in clinical trials to see how well it might work on Follicular Lymphoma. (Early results show that it might work pretty darn well.)

For those of us in the Follicular Lymphoma family, we know less about Nivolumab. Nivolumab is one of several treatments that target PD-1, a protein found on immune cells known as T cells, which attack invaders. Cancer cells sometimes produce a substance that can bind to PD-1, shutting down the T cell, and allowing the invader (a cancer cell) to survive. Nivolumab stops that substance (which is called PD-L1) from binding to PD-1, allowing the T cells to do their job and attack the cancer cells. It's good stuff -- it's been tested on solid tumors like lung cancer, kidney cancer, and melanoma. More importantly, it received a Breakthrough Designation from the FDA for some Hodgkin's Lymphoma patients, so we have some sense that it can work on blood cancers as well.

Ibrutinib and Nivolumab will attack lymphoma cells in two different ways that seem like they will work well together. We can only hope. The trial will involve patients with several types of lymphoma, including FL. The ones that have some success will move on.

Of course, the usual warnings apply -- phase I is very early, and it's not going to work if people don't actually sign up to participate in the trial.

Definitely another one to watch. I'm guessing we'll be seeing more of these combinations in the near future.

Friday, October 10, 2014

Chemotherapy for Follicular Lymphoma

The medical journal Leukemia and Lymphoma just published a study called "Comparison of the Effectiveness of Frontline Chemoimmunotherapy Regimens for Follicular Lymphoma Used in the United States."


It looks at how well Follicular Lymphoma patients responded, over the long-term, to three traditional chemotherapy treatments, all with Rituxan: R-CHOP, R-CVP, and R-Fludarabine.

It made me think immediately of another study from Italy from last year (April 2013 Journal of Clinical Oncology) that looked at the same three treatments, and with similar results.

In the more recent study, which looked at patients in the United States, overall response rates were high for all three (R-CVP 87%, R-CHOP 93%, R-Fludarabine 94%). Five-year survival was higher in R-CHOP and R-Fludarabione (86%) that R-CVP (76%). Same with Progression-Free Survival after 5 years (R-CVP 49%, R-CHOP 58%, R-Fludarabine 64%). Similar to the Italian study, which looked at 3 year statistics.

When I wrote about that study a year and a half ago, my question was this: why bother with a study like this? Traditional chemo is halfway out the door. Do we really need to know that R-CVP won't do as good a job as R-CHOP, when we have so many other targeted options to choose from right now?

Looking back, it's kind of an unfair question, for a couple of reasons.

First, this study involves a 7 year follow-up. So the patients in the study were starting their treatment even before I was diagnosed. To be fair, those three options were on the table for me way back when. So it wouldn't be fair to tell those researchers that their life's work is useless at this point.

Second, their work really isn't useless. There's still a place for traditional chemotherapy in treating Follicular Lymphoma. I haven't seen anything that says R-CHOP, for example, isn't a valid option for transformed FL, though we are seeing more options being explored these days. And I know there are still some oncologists who go to chemo for a first treatment, whether or not there are other options available. If it's still happening, it's good to know what the best options are.

All that said, a study like this is still a reminder to me, more than anything, of how far we've come, and of how many options we have now -- better options than I had when I was first diagnosed. I remember, almost seven years ago, laying out for myself what I thought I would need to do when treatments failed: I'd start with Watching and Waiting, and then go to straight Rituxan. After that, R-CVP. Then R-CHOP. Then an Auto Transplant, and then, if my body could deal with it, an Allo.

Other than Rituxan, I can't say any of those things are even on my list any more.

And that's all changed in just six years.

I've been talking about Hope lately, and this is a great illustration of why we should be hopeful -- look how far we've come. How many of you have had a conversation with an oncologist about Fludarabine lately? How many of you even know what it is?

Now, I'm not saying I would never consider R-CHOP, or that an Allo Stem Cell Transplant is out of date. Those options are valid, and they are available.

But we have so much more to talk about now.

And so much more to be hopeful about.

How can you not be excited about the future?