Friday, April 18, 2014

Rituxan Maintenance in Follicular Lymphoma

It's a few weeks old, but there's some nice research from the journal Cancer on Rituxan Maintenance for Follicular Lymphoma.

The research comes from the massive (and massively important) LymphoCare Study. It compares patients who received R-Maintenance after a Rituxan + chemotherapy with patients who were only observed. The patients had received their R-Maintenance between 2004 and 2007, and there were 1186 patients in this study. (That's a lot.) The researchers were interested in measuring Progression Free Survival (PFS), Time To Next Treatment (TTNT), and Overall Survival (OS).

The results showed that Rituxan Maintenance did a better job than not doing anything in measuring PFS and TTNT, but not in improving OS. More on that in a second.

The study also has some interesting little nuggets about who was more likely to receive R-Maintenance: patients who were grade 1 or 2 (that is, less aggressive forms of FL); stage 3 or 4 (more advanced disease, affecting several regions of nodes); receive community-based care (that is, the patient goes to an oncologist in a medical building down the street, rather than in a university hospital); and lives in a region of the U.S. other than the West. The stage and grade are easy to explain: the disease is advanced enough to see, but slow moving enough to watch. The community-based might also be explainable -- a clinical oncologist has maybe seen good results, and thinks the R-Maintenance is worth it, while a research-based oncologist is more interested in statistical measures that don't fully justify it? (I'm thinking of Dr. Bruce Cheson here, and his concerns about R-Maintenance).

As for why it's used less commonly in the West, I have no idea. Maybe just a regional medical school bias or something?

One more interesting thing that the researchers point out, even as they say that this might study justify making R-Maintenance a more common practice, is the lack of agreement on whether Progression Free Survival and Time To Next Treatment are really valid measures of how good a treatment is. So while it's great that these measures keep us out of the chemo chair, the real measure (some argue) should be Overall Survival. And that's been the toughest nut to crack in treating Follicular Lymphoma.

But it's also the squishiest, since it measures survival by any means -- the patient can die because of lymphoma and its complications, or because of getting hit by a bus. It all counts. The researchers are hoping that longer follow-up (this one was for more than 5 years) will make the picture a little less cloudy.

Finally, they address some of the other concerns that people like Dr. Cheson have about long-term use of R-Maintenance -- toxicity (harmful side effects) and Rituxan Resistance (for some patients, for some reason, Rituxan just stops working after a while). Their research seems to calm some of the fears about these two issues. It will be interesting to see what the response is from the oncology community.

A lot of what comes out of this study seems to support the positive conclusions of other recent studies on Rituxan Maintenance, which would maybe tip things in favor of R-Maintenance becoming more common and more accepted. But even the researchers here acknowledge that the picture is still a little cloudy: because this study looked at how people were given R-Maintenance "in the real world, rather than a study that they controlled, there isn't any consistency in the treatment that could be truly comparable to the other studies. In other words, they didn't say to 1000 people, "Hey, we want you to do R-Maintenance for 2 years, stating two months after your R+ chemo, with one treatment every month over that time." Instead, they ;looked back at what people got when they said they did R-Maintenance, and some people got different doses, or started at different times, or went for 6 months or a year or two years. So while the study results look great in many ways, there's still more to be learned if we want to compare it to some of the other studies out there.

So what does it all mean? Well, your oncologist will know that best. If you're coming off initial treatment or haven't started yet, then a conversation about Rituxan Maintenance is worth having.  In my own case, Dr. R argued against it, and I accepted his argument. He said most research dealt with R-Maintenance after chemo, and I had straight Rituxan, so there wasn't much evidence for how well it would likely work for me. Plus, he's kind of a minimalist, believing in doing only as much treatment as necessary. It's been over 4 years since my treatment, so he was right about that working, I guess.

The bottom line, as always, when thinking about treatment decisions: inform yourself and talk to your doctor, and work together to decide what's best for you.

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