Saturday, May 24, 2014

ASCO: Patterns of Care for Follicular Lymphoma

OK, here we go -- the latest and greatest in Follicular Lymphoma treatment. First up -- just who gets what when it comes to FL treatment?

A group of researchers in Pennsylvania were curious about patterns of care -- who gets what kind of treatment for Follicular Lymphoma. They were particularly interested in differences between academic and community settings; that is, whether there were differences in preferences for treatment between research hospitals and plain ol' oncologists.

The researchers looked at 152 patients, with ages between 30 and 86, over two years. Of those patients, they found that 59% were given straight Rituxan as their first treatment. 21% got R-Bendamustine; and 23% got R-CHOP or R-CVP. (Important to note: there's no mention of Watch and Wait here. I assume that means they only counted the first thing that got put into a patient's bloodstream, and not the first treatment decision that was made. W & W is, of course, a treatment decision.)

They found that there wasn't a huge difference between frequency of treatments for the academic and the community sides: Both prescribed R-Bendamustine about 20% of the time, while the academic side went with Rituxan 56% of the time and R-CHOP/R-CVP 24%; community totals were 53% for Rituxan and 23% for R-CHOP and R-CVP.

They conclude that treatment patterns remain "static," given that Rituxan on its own is by far the preferred treatment. They also call it "a mild, gentle paradigm," since Rituxan has relatively few side effects. They suggest that, given how much more successful Bendamustine is than R-CHOP, we should going in that direction much more aggressively than we are. They also wonder how much more successful we might be in extending Overall Survival if we were to be more aggressive in first treatment (that is, pushing Bendamustine over everything else).

It's an interesting study, with a couple of problems, I think. The first is that their percentages (59 + 21 + 23) add up to 103%. We'll assume that's either a rounding error or a typo, but it doesn't inspire much confidence either way. This is also a very small study, both in the number of patients and the time frame. It would be interesting to compare this to something like the Lymphocare study, with many more patients and a longer time frame. (Results from Lymphocare do look at this kind of data, but it's older and doesn't include Bendamustine in its treatment options.)

I'm also not sure how I feel about the "aggressive" push. Of course, this is influenced by my own treatment history, which began with W & W, and moved on to straight Rituxan, based on my oncologist's philosophy of "do no harm" -- use as little treatment as necessary, and only when necessary. I've come to accept the wisdom of this approach, so starting out with a relatively Big Gun seems unnecessary to me.

So I'm torn. I appreciate their desire to push for Bendamustine; it's a worthwhile treatment, and in my own humble opinion, a better option than R-CHOP for an initial treatment, with R-CHOP being reserved for possible transformation. On the other hand, I'm not sure a one-size-fits-all, we-should-be-more-aggressive approach is the best way to do things, either. (To be fair, they are calling for more research into whether this really is the best approach, though they seem to favor it.)

If anything, the future seems to be moving toward less aggressive treatments, with better targeting based on genetic profiling. We may be able to tell which treatments are likely to work best, with the fewest side effects, based on a better understanding of the differences between individual patients.  That seems to me to be the best place to put our efforts. Of course, we're not quite there yet.

So what this study highlight, for me, is that we still don't have anything resembling a standard of care for Follicular Lymphoma. We don't have anything that tells us we'll be better off if we try A first, then B, and then if we need it, C and D.

What we do have is good doctors who know patients and know treatment options, and who are hopefully up on which ones will work best for each of us. So the best treatment option right now? The one that you and your doctor decide on after a long, careful discussion with lots of questions and lots of listening.

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