Sunday, July 5, 2015

Early Relapse in Follicular Lymphoma

There's a Follicular Lymphoma-related story that's been in the news over the last few days. It's a little more negative than I like to write about, but I've seen it discussed on about 8 different cancer news sites (like this one), so I think it's probably worth writing about.

The stories come from an article in the Journal of Clinical Oncology called "Early Relapse of Follicular Lymphoma After Rituximab Plus Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone Defines Patients at High Risk for Death: An Analysis From the National LymphoCare Study."

That's a pretty scary title. So let's look at the details.

First, this was a retrospective study. That is, the researchers looked at data from patients that had already been collected a while ago. In this case, the data comes from the National LymphoCare Study, a very large (almost 3000 patients) study of FL patients that has already resulted in a whole bunch of great articles and presentations. For this particular study, the goal was to see if there was a relationship between early Progression of Disease and Death. In other words, if patients get treated, but the disease comes back within two years, does that mean they are more likely to have a short Overall Survival?

Unfortunately, the answer seems to be that, yes, they do.

OK, before we get upset, let's look at the details:

The study looked at 588 patients that received R-CHOP as their first treatment. Of those patients, about 19% of them had early POD (that is, the disease came back within two years). Of the rest, 71% went longer than two years before the disease came back, and the rest either didn't follow up with the study or died of something other than lymphoma within two years.

Those 19% that had the disease return within 2 years ended up with a lower Overall Survival over 5 years -- 50%. Of those who went over 2 years, the Overall Survival was 90%.

The researchers conclude that this means patients in this group are at much higher risk of death that other FL patients, enough that they should be considered a special subgroup.

This isn't great news for some of us. But let's step back for a minute.

First of all, it's important to remind ourselves that we are dealing with numbers here, not people. None of us is merely a statistic, and statistics cannot predict what our futures will be. they can only tell us what happened in the past.

That said, if you do want to focus on statistics, then please keep this one in mind -- the population described here (Progression of Disease in less than 2 years) applied to only 19% of those in the study, and that group had a 50% OS of less then 5 years. 50% of 19% means that this issue doesn't even effect 90% of us with Follicular Lymphoma. So changes are good that, if you are under that 2 year mark, it's not going to effect you.

But for those of you unfortunate enough to be in that group? Well, I'll say again, statistics that look at the past are not a prediction of what will come in the future.

The researchers make it clear that they think this is enough to consider this as a special population. That's a good thing -- it means oncologists should pay special attention to someone in this situation. And paying special attention means they can offer some help (and maybe change those statistics in the future).

The kind of help they recommend might mean treating things more aggressively -- perhaps going for a Stem Cell Transplant right away. And of course, we know that STCs have a pretty good chance of success. (See for more on STCs.)

The researchers also suggest that patients in this special group could be directed toward clinical trials that are focused on more aggressive types of Follicular Lymphoma. We've seen the many new treatments in the pipeline, and we know that genetic testing is allowing us to move toward better targeting of treatments for patients.

So all of those news articles about this study have scary titles. But remember that nothing is certain - even the negative outcomes that cancer news writers like to predict in their headlines.

There's still a whole lot to be hopeful about, kids. Stay positive, even when you read the bad stuff.


Anonymous said...

Hi Bob,

I was waiting for you to mention this study, as I came across an interesting associated article that says most FL patients can now expect to live 20 years and therefore if this 20% to 30% of patients subject to early relapse are identified and treated as a distinct sub-set, conversely the remaining 70% to 80% are probably being over treated. Therefore, greater consideration needs to be given to the long term adverse side effects of treatment for the majority of patients not subject to early relapse, as this has the potential to have a greater adverse impact on long term survival and QOL than the disease itself.

Lymphomaniac said...

Great point. I saw a bunch of articles that summarized/commented on this JCO article, but I don't think I saw the one that made this point exactly (could you maybe post a link?). Pretty significant analysis: if our FL is growing slowly enough for the great majority of us to not need as much treatment as we seem to need, then we need to re-evaluate what we're doing and maybe place more value on watching-and-waiting AFTER first treatments, and perhaps cut down on Maintenance therapies for less-aggressive FLs. I can see why so many cancer sites had something to say about this. The implications are potentially huge.
Thanks for posting.