Sunday, October 2, 2016

Radiation + Chemo for Stage 1 or 2 FL

I've seen a bunch of news stories about this (like this one), so I thought it was worth discussing: last week, a presentation at the American Society for Radiation Oncology showed that adding chemo to radiation treatments can greatly improve Progression Free Survival for Follicular Lymphoma patients with stage 1 or stage 2 disease.

(I looked for the abstract in the ASTRO program online, but I just couldn't find it, so I'm going by the news stories that I've been reading.)

The study focuses on stage 1 and 2 Follicular Lymphoma. I'm sure most of you know which stage you were diagnosed at, and it was probably 3 or 4. Because FL patients usually don't have any symptoms, it doesn't show up until it has reached stage 3 or 4. Stage 1 or 2 means the disease is concentrated in one or two areas of the body, above the diaphragm. (See's explanation here.)

Because the disease is focused on only one or two areas, it can often be treated with radiation, the way some solid cancers can be treated. In this study, the researchers used Involved-Field Radiation Therapy (IFRT), which means radiation is used only on the immediate area where the cancer is found. (Extended-Field Radiation Therapy is also used on some cancers, but it covers a larger area of the body and can lead to more side effects, short- and long-term). Radiation is often used on stage 1 and 2 FL, because the cancer is in a small space. Some patients are even cured with radiation alone (one article I read says it might be 50% of them).

But that's not true for everyone who is stage 1 or 2. And for those folks, the study says that following up with chemo (specifically, CVP or R-CVP) will increase Progression-Free Survival, the time it takes until the cancer comes back or gets worse again. Of the patients in the study, the 10 year PFS for those in the radiation + chemo group was 59%. The radiation only, with no chemo, was 41%. Pretty good.

I think this is great for patients who are stage 1 or 2, and deserving of the attention it has been getting, but I have some thoughts:

  • First, this effects a pretty small number of FL patients. One of the articles says only about 2% of FL patients are diagnosed at stage 1 or 2; I've seen it as high as 15%. but either way, it's a small number of us. This is great news for those patients, but it isn't going to mean much for the great majority of us, since IFRT isn't appropriate for us.
  • Second, while the PFS saw a lot of improvement, there was no difference between the two groups in Overall Survival. It may take longer until the next treatment, but it won't affect how long the patient lives. So that's a mixed blessing. There are a lot of treatments in the same situation -- it's really hard to increase Overall Survival for FL patients.
  • Third, this was a really long-term study, so it used CVP (which is CHOP, but without the component that damages your heart). I see fewer and fewer new studies involving CVP, so I'm not sure how useful it's going to be compared to newer treatments that don't involve traditional chemo, but instead use those cool new targeted pathway treatments.

So, in some important ways, the study is limited. However, there are definitely some good things about the study, too:

  • This is a little bit of a stretch, but this might reinforce the idea that radiation is a useful treatment for FL patients, and maybe RadioImmunoTherapy is something we need to keep pushing for. IFRT and RIT are different in the details, but they share a similar approach -- zapping those darn cancer cells until they glow like Fenway Park during a night game. If you haven't done your part to help save RIT, then get to it.
  • The real value to this, I think, is that it was such a long-term study. They followed these patients for a median of 10 years (half of them longer than that). That's important. Our disease is a long-term disease, and it helps us to see how things work out long-term. there's a push now to approve treatments after a short term, maybe as short as 1 or 2 years. But studies that follow patients for a long time help us see how the treatments affected not only our PFS and OS, but our lifetsyles as well. So if this is an example of a long-term study that shows some good, maybe we'll see more of them.
For any of you that have stage 1 or 2 Follicular Lymphoma, I hope you see some good stuff here.

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