Monday, September 30, 2013

Talk to the Doc

The lesson for this one seems really obvious, but that doesn't mean we get it all the time.

Researchers interviewed 374 survivors of Non-Hodgkin's Lymphoma about their Health-Related Quality of Life (HRQOL) -- basically, how much their disease interfered with their "normal" lives (and I know "normal" is a funny choice of word, cause nothing is normal after that diagnosis).

Specially, they wanted to know about their physical, daily, emotional, social, and sexual lives. Did the lymphoma cause any problems to their bodies? Did it affects them at their jobs? Do they get depressed? Did it make it harder to get close to people, or stay that way?

Important questions, and probably not the kind of thing that a doctor will ask about, apart from the physical stuff. I think that's partly because they tend to be so focused on the disease, but also because it's hard for them to deal with. (There's no kinase inhibitor for emotional problems, after all.) It's up to patients to start those conversations.

Some numbers: 94% of the patients said they would start a conversation about physical problems. 82% would start one about daily problems. 76% for emotional issues, 43% for social issues, and 49% for sexual issues.The reasons they gave for not talking? Probably not surprising: Nothing can be done about it. It's not the doctor's job. They were talking to another clinician (another medical doctor or a mental health specialist, I presume).

In some ways, it's a little scary that people aren't willing to share problems with their oncologist, especially if the problems are obviously related to the lymphoma. On the other hand, there's no indication that the patients talked to someone other than a clinician. For some problems, I think it's legitimate to talk to, say, an online support group. That certainly helped me quite a bit. As much as I love Dr. R, there are questions he can't answer -- and those questions have a lot more to do with the social and emotional aspects of cancer than the physical ones. I want to know if that low-grade fever means my condition is getting worse? I'm talking to my oncologist. I want to know if it's normal to feel like people at work are treating me differently? I'm asking another patient.

Do I want people at work to avoid me? Absolutely. I kind of wish some of them would leave me hell alone. But that's not the point.

The point is, we all do better with a wide support network. Sometimes a doctor helps. Sometimes a spouse helps. Sometimes a semi-anonymous stranger on the internet can help. The bigger point is to get help when you need it. Especially when a key part of your support network isn't doing the job.

This all made me think about someone I know, a cancer survivor, who didn't tell anyone about her cancer, at least not right away. She had some valid reasons for it, as I found out later. But she only started sharing after she couldn't hold it insider any more. She started opening up to a few people, including me, and that helped. But I couldn't help but wonder if she would have been better off with different choices.

I think it's important that we be advocates for ourselves. For me, that means learning as much about Follicular Lymphoma as I can, so I can ask the right questions and understand my treatment choices.

But it's just as important to be emotional advocates for ourselves. That means surrounding ourselves with people who are going to help us, whether they are friends in our lives or virtual friends online. And if they can't help. we need to find people who can. And if we can't get rid of them, then we need to talk to them and make sure they give us what we need form them.

There's more than just a doctor involved in all of this. But as someone who is interested in us, and who has some expertise, that doctor seems like the perfect person to practice some communication skills on.

Talk to the Doc.

Friday, September 27, 2013

Dr. R Visit

I had my 4 or 5 month or so check up yesterday with Dr. R. Everything looks fine.

As usual, we do a three-part visit: I get blood work done (complete blood counts, plus LDH), he does a physical exam, and we talk about how I've been feeling. Without a scan, it's about as thorough a check of my lymphomic health as I can get.

The results: Blood work looks "perfect," as he said. My check on how I'm feeling (good -- nasty asthma this fall, but I'm still running three days a week) led to the physical exam. The last few visits, I've had some lumps on my upper right arm. Hard to say what they are -- they are kind of on the edge of the area of where the nodes are located, but they're spread out, and they don't grow terribly fast, if at all. They aren't bothering me (that is, they aren't making my arm swell, the way the nodes in my leg did, leading to the Rituxan). The only bother is that I wonder what they are. Maybe nodes, says Dr. R.; maybe collections of lymphoma cells under the skin; maybe lipomas, fat deposits under the skin. But at this point, nothing that causes alarm.I'm keeping an eye on them.

I go back in early January. He doesn't think a scan is necessary, though maybe we'll do one next year just to see how everything looks inside. Of course, he said that last year, too. At one time, I would get nervous if I went too long without a scan. I feel less anxious about it these days.


One comment about the office: I can officially say I don't like it. Over a year ago, Dr. R and colleagues private practice was taken over by Yale New-Haven Hospital. It's actually a branch of the hospital now, so when I go, I have to check into the hospital and get a bracelet and everything else. Since this has happened, my visits have been less satisfying.

Don't get me wrong -- I love Dr. R. I love the nurses and office staff. The phlebotomist draws blood and I barely know the needle is in. But lots of other stuff is My appointment was for 10:15, but my reminder call said it was for 12:00, so I had to call and get that straightened out. They didn't do blood work (which I thought was strange, and asked Dr. R to do it), so I had to interrupt my visit to get blood taken. When the nurse reviewed my history, she had the wrong pharmacy down. None of a big deal, really, but it's all different from the way it was before. I don't know if it's the computer system messing things up, or if it's human error that comes about because they have so much extra stuff to do. I've given it a year, and I don't like it.

No plans to change oncologists. Just one more thing on the road to making me a grumpy old man.


But the upshot is: it was a good visit. I'm still a pretty healthy guy, for a cancer patient, and happy (and a little grumpy) about it.

Wednesday, September 25, 2013

Marriage and Cancer

First of all, let me express my now-annual disappointment at not being awarded a MacArthur Genius Grant. Even worse, they raised the amount given this year from $500,000 to $650,000. Frankly, I could have used both the money and the ego boost.

Even worse, there were no cancer-related geniuses named this year, no one who is showing us some new pathway to curing cancer. The closest we have is some guy who has found a way to make sure that people who need health care can get it, efficiently and effectively, while lowering costs.What the heck does that have to do with me?

So disappointing.

Meanwhile, a new study appearing in the Journal of Clinical Oncology shows that outcomes are better for cancer patients who are married. The researchers looked at data from over 700,000 people diagnosed between 2004 and 2008 with one of the ten most deadly cancers (including Non-Hodgkin's Lymphoma). The numbers are kind of startling: "unmarried cancer patients, including those who were widowed, were 17 percent more likely to have metastatic cancer (cancer that spread beyond its original site) and were 53 percent less likely to receive the appropriate therapy." They speculate it's because married patients are more likely to have someone come to the appointment with them and ask question and remember important information. Probably true.

I think you can't discount the idea that you have a support system next to you. (Ideally, anyway -- you hear horror stories of people whose spouses just shut down and stop helping, but I like to think they are rare.)

Of course, I have my own excellent support system in my wife. She keeps me sane, asks questions, remembers stuff I don't (during doctors' appointments, and at lots of other times), and generally takes care of me.

And I was smart enough to marry her.

Which, I guess, makes me a genius.

Monday, September 23, 2013

Raw Fear

Just read a nice piece from Slate called "My Leap of Faith in Medicine," by Danielle Ofri.

Ofri is a medical doctor, and a PhD in Biochemistry -- she's wicked smaht, in other words. But she never really got how fearful it can be for a patient to talk to a doctor, until her 18 month old had a minor medical procedure that required anesthetic (he had "tubes in his ears," which you parents might be familiar with). Seeing her baby lying on a table brought what she called "raw fear" to her heart, and her advanced degrees did nothing to help her.

The lesson she learned?

"When I sit with a patient now, deciding on a treatment, I still lay out the risks and benefits as systematically as I can. But then I take a moment to acknowledge the raw fear that cannot be assuaged by even the most convincing clinical data. This conversation can’t eliminate the necessary leap of faith. But at least there is some recognition of the stomach-plummeting sensation that occurs when the patient edges their toes out onto that clear glass bridge."

It's a nice reminder for physicians that sometimes we patients get irrational with our fear. A kid getting tubes in his ears is tough enough. As cancer patients, it's even worse. I want honesty, but I want some compassion, too. Some recognition that I'm scared about things. As Ofri says, that won't make it go away, but it's nice to know the doctor understands how I feel.

This has nothing to with the fact that I have an appointment with Dr. R on Thursday. Just a coincidence that the article appeared this morning.....

(Really, I have no reason to be scared. Things seem to be going well. I'll let you know on Thursday.)

Friday, September 20, 2013

Grading Follicular Lymphoma

Another thick artcile from a medical journal: "Immunophenotypic Features and t(14;18) (q32;q21) Translocation of Chinese Follicular Lymphomas Helps to Distinguish Subgroups," by a Chinese research team, to be published very soon in the journal Diagnostic Pathology.

The researchers looked at the genetic make up of different grades of Follicular Lymphoma to determine whether or not grading is helpful. In some ways, what they have to say isn't really all that new. But the way they got there is, and may have some important implications.

First, some background: Follicular Lymphomas are graded as 1, 2, or 3. Grading is a measure of, basically, how aggressive the disease is. (This is different from staging, which tells where in the body the lymphoma is occurring.) This has traditionally been a microscope issue, counting the number of large (and more aggressive) cells there are in a sample. Grade 1 and 2 are typically considered indolent, or slow-growing, less aggressive lymphomas -- not as many large cells. Grade 3 gets a little trickier. A Follicular Lymphoma graded 3A is generally thought to be indolent as well, and is usually treated as such. Grade 3B, however, while appearing to be Follicular Lymphoma, is often more aggressive, and is treated as an aggressive lymphoma, such as DLBCL (which stands for Diffuse Large B Cell Lymphoma -- it's those Large Cells that get all aggressive).

The grading scheme was developed by the World Health Organization, and is still a little controversial -- particularly the stage 3 splitting into A and B. They're still working on that one....

The article linked above tries to address this issue. Rather than looking only at the numbers of large calls, they did some funky genetic analysis, to see if there were differences on a much more "morphologic" level, to use their word (that is, looking at the form, not necessarily the behavior of the cells).

The group looked at 115 specimens from Chinese FL patients, and did some genetic testing to look for some very specific markers: CD10, a surface protein common to FL cells; BCL6, a protein commonly found in DLBCL cells; BCL2, which is thought to cause resistance to lymphoma treatments; MUM1, another protein present in DLBCL; and the t(14; 18) and q(32;q31) gene translocations (they switch places, perhaps causing Follicular Lymphoma).

In short, they looked at a lot of stuff in the cells.

What they found was a lot of stuff that distingushes the different stages.

You can see the stats for yourself, but basically, Grade 1 is more "Follicular-y" than Grade 2, which is more so than 3A. Grade 3B is the least Follicular-y of them all. That is, it contains the most DLBCL cells of all the stages, and the most markers associated with DLBCL.

As I said, I don't know if this is really news. We knew that grades 1, 2, and 3A act more like indolent lymphomas, and 3B acts more like an aggressive lymphoma. What's new is that there is morphological confirmation -- that is, it's not just a matter of behavior, but of actual cell make-up. They conclude with this: "Thus we hypothesize that FL may in fact be a heterogeneous indolent lymphoma encompassing entities with distinct molecular pathogenesis and genetic characteristics."

In other words, we might actually be talking about 4 different lymphomas here. They found that FL with the CD10 protein, for example, was more likely to have MUM1 and t(14;18) translocation. This suggests that it started in a different way, genetically, than other types. There are important implications there for how we might treat it, especially since we seem to be moving toward genetic-based treatment options.

The upshot of all of this: for now, it doesn't change a thing. But it might help focus the debate about the WHO grading classification, and that could influence the way treatment decisions are made down the line. More likely, it will help researchers focus on diagnosing and treating by distinguishing between different sub-groups of Follicular Lymphomas. This might help us figure out which treatments will work best for which patients.

A thick article with a minor immediate payoff, but promising for the future.

Tuesday, September 17, 2013

Cancer's Super Responders

Really cool article from Yahoo! News a couple of days ago on Cancer "Super Responders." These are patients who respond to treatment when no one else does. Researchers can now learn from these Super Responders to help further refine what we know about particular cancers, and how we can treat them.

 Up until a few years ago, the closest we could look at a tumor was through a microscope. Two cells for, say, Follicular Lymphoma, looked pretty much the same under the microscope, something like this:

And then a few years ago, we mapped the human genome. Now we can look even deeper, and see that, upon closer examination, not all Follicular Lymphomas (or other cancers) are necessarily the same.

This very helpfully answered the question, "Why do some patients respond to a treatment but other patients don't?" Well, it's because those patients actually have variations of the same cancer that aren't exactly the same. There are small genetic differences that make a treatment work for one person but not for another.

Which is where the so-called "Super Responders" come in. Oncologists used to speculate that there was something about that patient that made them respond. Now they know what that something special might be.

So now, a bunch of major research hospitals are going back and looking at old biopsies of Super Responders and doing some genetic testing to see just what made them so different. Eventually, we can catalog the differences in genetic makeup, and begin to tailor treatments to sub-classes on particular cancers.

Right now, it costs about $5000 to do a full mapping of a patient's genome, finding all of the differences between a "normal" set of 20,000 genes and the ones that have mutated.  In a few years, the process will cost less than $1000 -- not much more than a 10 mL vile of Rituxan from Walmart (with coupon).

(Yeah, I'm a little freaked out that you can buy Rituxan at Walmart -- with a coupon. Just doesn't seem right that something so amazing is so easily available....)

Anyway, in a few short years, it will be really inexpensive to get ourselves mapped, and this will 1) help researchers figure out which mutations matter for which cancers, and 2) help oncologists figure out which treatments are most likely to work.

It's pretty exciting. I'm not sure we're in for a CURE anytime soon -- still a lot of work to be done once mutations are identified -- but it's very promising stuff.

Sunday, September 15, 2013

Lymphoma Awareness Day

Happy Lymphoma Awareness Day!

Smack dab in the middle of Lymphoma Awareness Month, today is the day to make the world aware of what Lymphoma is and why it's important. 

Of course, everyone here knows why it's important -- cause we have it, or love someone who does. We're plenty aware, thanks very much.

But others are not. So, even if you don't do so today, maybe take some time over the next couple of weeks to educate someone who needs it. Post the Lymphoma Research Foundation's "Know Your Nodes" quiz to your Facebook news feed, for example.

Or (if we're being more inclusive) find an online presence and "light it red" in honor of Blood Cancer Awareness Month. (That's what I'm doing with this post, in case you were wondering.)

This is our month, people. Let's make the most of it.

Friday, September 13, 2013

Follicular Lymphoma: Idelalisib / CAL 101

Gilead, the company that makes Idelalisib, has submitted an application to the FDA. They seek approval for Idelalisib for use in Indolent Lymphomas (which would include Follicular Lymphoma) in patients that have developed a resistance to Rituxan and alkylating agent chemotherapies (these would include both Cyclophosphamide, the "C" in CHOP and CVP, and Bendamustine). That covers a lot of common treatments. So, basically, if you had chemo and it stopped working, chances are pretty good that you'd be eligible for Idelalisib.
alkylating-agent-containing chemotherapyal

Idelalisib (which has also been called CAL-101 and GS-1101 at various times during its life) is a type of kinase inhibitor that blocks pathways necessary for B cells to survive. The FDA application is based mostly on results from a phase 2 trial that was reported on in June (I wrote about it here). The results were good: 125 patients, Follicular Lymphoma and other indolent lymphomas, with 53.6% achieving an overall response and 89% achieving some measure of lymph node shrinkage.

Curious, though, that they are applying based on phase 2 results; there's no indication from the press release that they are asking for accelerated approved. It's not unheard of to get approval after a phase 2, though phase 3 (which involve a larger base of patients) are more typical. I haven't seen anything on what their strategy is for "going up early," but I'm guessing it's something like "Why not? The worst they can do is say they want to see phase 3 results."

Perhaps, in its favor, is the fact that this will be the first treatment in its class to be approved. There are a whole bunch more behind it in the pipeline that work on a similar mechanism. Collectively, they really change the way we might think about treating Follicular Lymphoma.

I'm certainly hoping for a successful application. Another arrow in the quiver.

Wednesday, September 11, 2013

Cancer Crisis?

Yahoo! reported yesterday on a statement from the Institute of Medicine that found "daunting" barriers to  health care for cancer patients. These include an aging population, and thus a likely increase in the number of boomers who get cancer; an essentially under-informed medical field (many doctors don't have the time to keep up with cutting-edge treatments); and a lack of knowledge on the part of patients. Cost of treatment in itself doesn't seem to be a factor -- but understanding the cost/benefit ration of treatment is one. (Will a newer, more expensive treatment give the patient a better chance at survival than an older, less expensive one?)

The full report (all 322 pages) is available here, along with a 22 minute video describing the problem.

What struck me most about it all is the problems that doctors seem to be having in keeping up with developments in the field and explaining it all to patients. Part of that is a communication problem. I think doctors in general aren't good at giving bad news, and that's more of a cultural problem than a personal problem. People don't like to hear it, so doctors don't like to say it. I've yet to have a doctor tell me to just stop eating so damn much and lose some weight. I'm encouraged to exercise, but no one has told me specifically what I need to do. And I don't want to hear it. It works out nicely. So I can certainly see a doctor sugarcoating a treatment that's meant to be palliative rather than curative. We don't want to hear it. I'd much rather have that sliver of hope.

More disturbing, though, is doctors' lack of communication about treatment options. I get that they're busy, and maybe can't keep up with medical literature as much as they would like. On the other hand, it seems to me that the job of an oncologist, more so than most specialists, is to keep people alive. I'd want to know as much as I could to help me reach that goal.

Of course, I'm a Cancer Nerd.

(But, gosh, shouldn't an oncologist be one, too?)

One of the recommendations from the Institute of Medicine is that patients need to be given information on treatments that is easy to understand, and compares the pros and cons of treatments.

More importantly: "Patients can't be passive...It's an important partnership that we need."

To me, that's key. I assume if you are reading Lympho Bob that this isn't a surprise. As patients,we don't need to know everything about our disease (I certainly learn new things all the time, even basic things that I thought I understood). But we do need to know enough to have a conversation, to understand what our doctor says and be able to ask questions. And more importantly, to be able to slow her down and say, "Wait, why are we going with A? Why not B?"

It's easy to just accept what our doctors say to us. But, certainly, as the Institute of Medicine report shows, sometimes they know a little bit less than they let on. For patients, knowledge is power.

Overall, I'd say that's a nice message for Lymphoma Awareness Month. Don't just be aware -- know enough to feel empowered.

I love to get comments from readers who tell me that they find the blog informative. I'm happy to be able to help. I've always said that I write this, first and foremost, for myself, because it forces me to keep reading and learning. But it's great to hear that I'm helping others, too. I hope the blog can play a small part in helping other Follicular Lymphoma patients learn more about their disease.

And there are plenty of other places, too, many of which I link here (though I still say is your best one-stop shop for all things lymphoma-related).

And the best reason of all to keep learning about Follicular Lymphoma? It brings hope.

Saturday, September 7, 2013

Ribbons (and Not the Cancer Kind)

Well, the results are in.

A couple of days ago, I wrote about my (and my daughter's) entries in The Fair. This is our second year. And I have to say, it's becoming important for me. As a cancer patient, I feel like I need things to look forward to -- a road race, a guitar recital (years ago), an agricultural fair. Things that challenge me. That drive me, even for a little while. I think it's important. It's too easy to get down sometimes, to get too down to try hard things. Or worse -- to convince yourself that, hey, you have cancer, so you earned the right to sit on your butt and not try anymore.

I can't not try.

So here are the results:

My cherry tomatoes won a blue ribbon.

I was unsuccessful in defending my plum tomato title from last year; I came in second this year. Oh, well.

My other attempts were pretty good, too: 2nd place for my cucumbers and my eggplant; third place for my green tomatoes.

I would say this cements my status as an award-winning gardener.

Maybe most important to me is that my chocolate cupcakes with ganache icing won third place. This is very cool for several reasons: first, unlike with the veggies, baking was something I had more or less complete control over. Bad weather doesn't get in the way of melting chocolate. Second, I was tempted to enter the "For Men Only" category for this, but I decided instead to test myself against the women who make up most of the bakers in this contest. So third place was satisfying.

No awards for my bar cookies, my bread and butter pickles, or another tomato category, but overall, I'm pleased with the way things turned out.


The night, however, belonged to my daughter.

Last year, while I won a first- and a second-place ribbon, she came home with a second place for a sketch and thirds for a clay sculpture and for her decorated cupcakes.

This year, she had fire in her eyes.

She worked on these things all summer -- planning, practicing, and executing.

Her results?

Like last year, a third place for her decorated cupcakes. And another third for her frosted brownies.

Which was fine. Neither were really her big categories.

Her chocolate cupcakes? Blue ribbon.

Her decorated cake? Blue ribbon.

Her clay sculpture? Blue ribbon, baby.

(Looking at those pictures, can you detect a theme about what matters to my girl?)

I'm pleased because she won, but I'm more pleased because of the way she won.

She was a little sad last year. There's no denying it. But her response wasn't to quit. It was to light a fire under herself.

Now, there's a big difference between cancer and decorated cupcakes, obviously. But the important lesson is one that I've always wanted my kids to learn. Everyone has setbacks. Your response should not be top go back to bed, because lying in bed isn't going to help. The only way your problems get solved is if you get up and start solving them.

The only way to beat cancer is to get up and figure out what you can do about it.

The only way to win a ribbon is to get up and start baking.

As I said last year, it's hard to be judged. It's harder still for a 12 year old girl. The proper response isn't to quit. It's not even to figure out what makes the judges happy and work hard all year to make sure they get it.

It's to figure out what makes YOU happy, and to work to make that happen.

For my daughter, what makes her happy is....baked goods.

And I couldn't be more proud of her.

Thursday, September 5, 2013

Vegetables, Baked Goods, and Dancing

What a day.

What a week.

Nothing bad. Nothing cancer-related. Just life.

The kids' first week back to school. Things getting crazy at work. And to top it all off, this weekend is The Fair. Every year, a neighboring town holds a fall agricultural fair, with prizes for best home-grown veggies, baked goods, crafts, etc.  Last year, I won a blue ribbon for my plum tomatoes (my kids are trained to refer to me as "an award-winning gardener"). This year, despite a horrible growing season, I entered some more tomatoes, some cucumbers, an eggplant, and my bread-and-butter pickles. And since I didn't get home from work until after 8 last night, I was too tired to bake, so I was up at 4:30 this morning to make mocha cupcakes with chocolate ganache frosting so I could turn them in before judging this morning.

More importantly, my kids have entered several contests themselves. I don't much care if I win anything, but I really, really want them to do well.

Is there some connection between all of this and cancer? I always have some kind of connection, after all.

Well, one connection is the one I say a lot -- As crazy and hectic and exhausting as life can be, I'm happy to be busy. I'm healthy, I have a good job that I like, and I'm able to do things for my kids.

But, as I discussed last year when I wrote about this fair, the experience makes me focus on my kids. There's something about entering a cupcake decorating contest, or a photography contest, or something else that forces you to put yourself out there, to be judged and compared. It's not always pleasant. It's great when you get a ribbon, certainly, but not so great when you don't. Or when you don't get the one you expected. Or when your dad gets a first place for his tomatoes, and your sculpture gets a third.

What I hope that experience teaches my kids is that you can't say "Forget it!" and not bother anymore. What I hope is that my kids will -- as my daughter did -- vow to make it better next year. $200 or so worth of Sculpey clay, and hours of sculpting, and she's back in it this year. That's exactly what I wanted to happen.

This morning, I read a story about this year's Dancing with the Stars. Valerie Harper, TV's Rhoda, is a contestant this season. Just weeks ago, there were stories in the news about her having terminal brain cancer. She's doing much better, and she decided to take a chance, at 74 years old, on dancing on TV. She credits the song "I Hope You Dance" by Lee Ann Womack for giving her the courage to go for it.

Whenever I hear that song on the radio, and I'm in the car with my daughter, I turn it up and I tell her to listen carefully. When she has the choice to sit it out or dance, I want her to dance.

Or to make and decorate a cake that looks just like a giant Hershey bar, and let it (and herself) be judged.

And to smile, whatever happens.

(And not just because, when it's over, she gets to eat that cake.....)

Monday, September 2, 2013

Transformation Research

Nerd Alert.

I haven't written in a few days because I've been working my way through an article called "Characterization of a Case of Follicular Lymphoma Transformed into B-Lymphoblastic Leukemia," posted August 28 to the medical journal Molecular Cytogenetics. It's a genetics journal, and I'm no genetics expert, so I've been wading through it all weekend trying to wrap my head around it. I'm still  not sure I fully understand it, but I think I can at least tease out the important stuff.

I'm going to go ahead and assume that no one who is reading needs a full explanation of what Transformed Follicular Lymphoma is. Anyone interested in FL is probably really interested in its transformation.

So you probably know that Follicular Lymphoma most often transforms into Diffuse Large B-Cell Lymphoma, though it occasionally transforms in to other types as well. One of these less common types is B- Accute Lymphoblastic Leukemia (B-ALL), a very aggressive type of leukemia originating in the B-cells (immature B-cells multiply in the bone marrow and crowd out normal cells). It's a less common type of transformation, but apparently it does happen.

The geneticists who conducted this study were interested in this type of transformation on a molecular level. Basically, they found that the chromosome switch normally associated with Follicular Lymphoma (t(14;18)(q32;q21), also known as BCL2, or B-Cell Lymphoma #2, for all you genetics nerds) is followed by two other mutations, MYC (which messes with chromosome 8, related to the very aggressive Burkett's Lymphoma) and IGH (which messes with chromosome 14). Basically, while Follicular Lymphoma comes from a a screwed-up chromosome pair, B-Accute Lymphoblastic Leukemia comes from those chromosomes being messed up even more. Plus, there are a bunch of related genetic mutations involved in there, too. There's a heck of a lot going on. It's like a frickin' Marx Brothers movie in there.

I'm not sure that's really even the most important thing the researchers learned, especially given the relatively small number of Follicular Lymphoma patients who transform to B-ALL. They also make much of the method that they used to find these mutations. In short, they used a bunch of tools to look at the chromosomes from several angles: karyotype analysis (getting a picture of all of the chromosomes in a cell), fluorescence in situ hybridization (a cool technique that uses fluoresent probes that light up when certain chromosomes are present, helping to track their locations), microarray analysis and gene arrangement analysis. Each of these techniques tells a little bit different bstory about the chromosomes being studied. It seems like it's unusual that all of these are used at once, and the researchers seem to be making a case for what would otherwise seem like overkill in doing this kind of analysis.

The takeaway here would seem to be that, in a narrow sense, we may have a better way of identifying B-ALL on a chromosomal level. In a broader sense, we may have a better method for identifying lots of chromosomal mutations. In a still broader sense, we are another step closer to figuring out why transformation occurs, and maybe detecting it early.

What it doesn't mean is that we need to worry about transforming to B-ALL. It's still pretty rare. In fact, I'm not sure we need to worry about transforming at all.

Keep an eye out for it? Absolutely. Worry? No. We have lives to live.