Saturday, September 26, 2015

Folicular Lymphoma is Complex....

Recently, the annual Debates and Didactics in Hematology and Oncology conference was held in Sea Island, Georgia. it is sponsored by Emory University.

A couple of weeks ago, The ASCO Post reported on the conference, particularly the session from Dr. James Armitage of the University of Nebraska (he also serves as Editor-in-Chief for The ASCO Post).

One of the main points that Dr. Armitage made was that Follicular Lymphoma is a lot more complex than we used to think. The cells surrounding the lymphoma cells, according to Dr. Armitage, play a role in the Lymphoma's survival. This probably doesn't come as a surprise to any of us. If you've followed where FL treatments have been, and where they are heading, it's easy to see that, gradefor most of us, a single treatment from a single agent just isn't going to do the trick, at least not permanently. Researchers are learning more and more about what makes FL so complex, and trying combinations that will deal with the different parts of the disease that make it so complex.

So Dr. Armitage tries to review some of the different treatment options available. This isn't an article that's offering anything new. But that's OK by me. I like to stop every now and then and see a nice summary of where we are now. It helps understand where we might be going.

Dr. Armitage looks at some controversies that have been in the news in the last few years, like the whole Watch and Wait issue (which I vowed not to write about again unless there was something new to report).

He has nothing new to report.

(W & W is OK if the patient is asymptomatic or elderly, but observation has to be very careful -- no just forgetting about it. As if that was possible for most of us......)

He also looks at research on R-CHOP vs. R-CVP, but says R-CHOP vs. B-R is more important. Both are better options than R-CVP, though a German study found Bendamustine worked better than CHOP. However, a United States study found Bendamustine to be not as effective as the German study fund it to be. Still, though, both have their place, and both work well.

He also mentions R-Squared -- Rituxan + Revlimid (or Lenalidomide), which had great results in trials, though as more patients use it, it seems to be not quite as effective as we thought. But as we learn more, he thinks it could be as useful as R-CHOP and B-R.

So how to choose among these options? Dr. Armitage thinks a bunch of things need to be considered -- age, health, symptoms, comfort with certain side effects, etc.

But he seems very clear about one thing -- the goal of the treatment should be a Complete Response. He doesn't think it is valuable to treat just to make the patient feel better or push things off for a while. Complete Responses have a "huge survival advantage," according to the article. He also thinks relapses are very difficult on patients (I think he means emotionally difficult), so he aims for CR and uses Rituxan Maintenance, which may prolong Progression Free Survival (though not Overall Survival), giving patients more time between treatments.

That's an interesting perspective. And one that some other oncologists would probably disagree with. (I remember the Lymphoma specialist I saw soon after I was diagnosed told me, Put 12 Lymphoma specialists in a room, and they'll have 13 opinions.)

Which brings us back to the idea of how complex Follicular Lymphoma is.

The good news, as always, is that we have some options, and there are even more on the way.

Nice to remind ourselves about that.


Anonymous said...

Thank you. Just had my one year diagnosversary. Onco and labs tomorrow. W &W. No B symptoms.
Grade1, Stage 4
I appreciate every piece of info you share

Lymphomaniac said...

Good luck tomorrow! Let us know how it goes.

Anonymous said...

Hi, good appt. Except for low lymphocytes, my other bloodwork is good. LDH creeped up but still within normal limits. 6 month follow up!
I'll be checking your blog regularly! Thank you!

Rodrigo Carvalho said...

Hey anonimous. What a great new!

Anonymous said...

Hi Bob, I am fairly new to your sight and love the way you present the info! It was 12 years ago today that I was diagnosed with stage IV follicuar NHL with a conglomerate mass that showed as indolent on the pathology but was acting aggressive. I underwent R-chop for 8 cycles with a good response. After 11 years it became active again, I have been watch and wait for the past yr even though it is stage IV but the last CT showed significant growth and it became time to treat. We decided to go with Revlimid plus Rituxin and I was accepted into a phase III clinical trail for it that I started yesterday. The comment made in the article you posted here now has me concerned in that he say it is not as effective as initially thought, do you have any background or links regarding were that information came from?

Lymphomaniac said...

Hi there. First of all, congratulations on your 12th diagnosiversary. That's amazing, and an inspiration to all of us.
Second, I know you're in a vulnerable place now, and it's easy for me to tell you not to worry to much about what was in that article, but let me say this: Revlimid has a good chance of working for you. Early research on R-squared involved a small number of people, and lots of them responded very well. When they expanded to include more people, the numbers went down, which was something they were prepared for. It doesn't mean R-squared doesn't work as well on each individual, it just means it doesn't work as well on the larger population. My guess is that your oncologist thought you would benefit from it, and that's why you're in the trial.
There have been a lot of research reports on R-squared, and it's one of the treatments that gets specialists most excited. They think it will be a big part of our future. And it certainly does work very well for lots of people. There is someone in the online support group that I belong to who has had FL for a number of years, like you, and has tried a number of treatments, with mixed success. The last one he had was R Squared, and so far, he has been in remission.
So don't give up hope. And good luck with the treatments. Let us know how you are doing.