Friday, May 6, 2016

Some Articles on Follicular Lymphoma

If you're enough of a Cancer Nerd that you like reading medical journal articles, then the most recent issue of Blood is just what you have been waiting for. They have a special section that reviews Indolent Lymphomas, including Follicular Lymphoma. There is one article devoted to FL, and another that looks at Stem Cell Transplants, which also focuses a lot on FL (along with other slow-growing lymphomas).

If you're not enough of a Cancer Nerd to read medical journal articles, then I'll try to hit some highlights for you.

The Review Series starts off with an introduction called "The Paradox of Indolent B-Cell Lymphoma."

A Paradox is something that seems to contradict itself, even though both parts of it are true. Like watching and waiting: we don't actively treat our cancer, but we might be better off doing nothing. That's a paradox -- everyone knows that not getting aggressive treatment for cancer isn't good, and yet....

Follicular Lymphoma is full of paradoxes. Sometimes I think about them, or try to explain them to people, and I realize just how messed up and weird a cancer it really is. Like
  • It's a slow-growing disease, and maybe doesn't need to be treated for a long time, maybe never. Which is good. But it's also incurable. Which is bad.
  • It's a quiet disease, so quiet we can almost forget about it. That's good. But that quiet can be a problem if it transforms, and you're not paying close attention to it. That's bad.
  • We have a good bunch of treatments that work well, with more on the way. That's good. But there are so many treatments that work well, we don't have an protocol that we agree on. Some oncologists say to watch and wait, while others, for the same patient, might suggest Bendamustine, or CHOP, or even CVP. No agreement. That's less good.
  • Treatments often work for a long time. That's good. But they can work for so long, and there are so many options, that it's hard to construct any kind of clinical trial that looks at sequencing of treatments -- comparing how well a large group of patients do when trying a certain treatments after other treatments. That's not as good.
Isn't it fun to be part of such a weird disease, gang?

But even with all of those paradoxes and contradictions, we're still doing OK. The Introduction article says our median overall survival is probably greater than 12-15 years. When I was first diagnosed in 2008, Wikipedia said it was 8-10 years. So something is going right for us.

(I'm pretty sure that something is Rituxan....)

And that's kind of the theme of the main review article for FL, "Follicular Lymphoma: Evolving Therapeutic Strategies." It's a review article, meaning it is reviewing what we know about FL -- not really adding anything new. It discusses what we know about the Biology of FL, and how gene mutations lead to Follicular Lymphoma; and how the microenvironment (the stuff that surrounds the cancer cells, noy just the cancer cells themselves) play a role in FL growing and thriving; the kind of prognostic tools used to evaluate it (various FLIPIs, including the m7-FLIPI for more aggressive FLs). And it finally looks at transformation, the Big Monster We Fear. Good news there -- recent studies have shown a longer Overall Survival -- more than 5 years -- than we had previously thought.

The article then looks at some of the treatment options available for FL patients at different stages. It is summarized in this neat graphic:

It's a nice flow-chart, maybe something worth thinking as you consider different options. But be warned -- it's not a substitute for a conversation with your oncologist, and it doesn't really mention specific treatments. It certainly doesn't mention treatments available in clinical trials. We don't want to leave them out, do we?

The article does get into some more specifics of different treatments, their effectiveness, and what they might be good for. So you might be forced to read this article anyway.

Finally, the Blood issue has an article called "The Role of Autologous and Allogeneic Stem Cell Transplantation in the Management of Indolent B-cell Lymphoma." Like the FL article, this is a review article, looking at what we already know about SCTs, rather than offering anything new. I wrote about Stem Cell Transplants last month, and the basics remain the same: Auto SCTs are safer, but not always as effective. Allo SCTs might offer a cure, but can have some dangerous side effects like Host-vs-Graft Disease. The article goes into more detail about what we know and don't know.

What I know is this: We have a weird, messed-up cancer. But in all of those paradoxes, even if we say something is bad, or less than good, there is still plenty of good -- for many of us, it's a disease without symptoms that allows us to live our lives (at least our physical lives) in a fairly normal way, and we have lots of treatment options to try. And that's all good.

So we can keep our focus on that until we need to think about the less-than-good stuff.