As cancer patients, we'll all need treatment at some point. As Follicular Lymphoma patients, we'll probably need more than one treatment. As an often slow-growing cancer, FL has a way of sticking around, or coming back, even after a successful first treatment. So second (and maybe third and fourth) treatments are common.
And, of course, all cancer treatments have side effects. Unfortunately, one of those long-term side effects might be that the treatment for cancer might actually cause a different blood cancer down the road. I remember discussing this with my oncologist years ago -- we talked about Fludarabine, a type of chemo, but rejected in because I was so young, and it carried a risk of the patient developing leukemia years later.
No one has done a large-scale study, though, that looked at the risks of secondary cancers (that is, developing a cancer other than Follicular Lymphoma) as a result of FL treatments.
Until now, of course. "Risk of Secondary Haematological Malignancies in Patients with Follicular Lymphoma: An Analysis of 1028 Patients Treated in the Rituximab Era" was published earlier this month in the British Journal of Haematology.
Researchers looked at 1028 patients from Finland and Spain who had been diagnosed with FL and treated between 1997 and 2016 (Rituxan was first approved in 1997, which changed everything for FL, and so that's why it's called the "Rituxan Era").
Patients were grouped on the type of treatment they received -- Anthraycline chemotherapy (probably CHOP), Bendamustine (also a chemo), other chemo (maybe CVP, which is CHOP without the anthracycline), radiation, surgery, or watch and wait.
They found that 14 out of the 1028 patients developed a second blood cancer -- about 1.1% after 5 years. They estimate that the number would be about 2.7% after 10 years.
For patients who had more than one treatment, the number was 0.5% after the first treatment, but rising to 1.6% after a second treatment.
Some of the risk factors associated with secondary cancers included having a high FLIPI score, having B symptoms at diagnosis, and having multiple treatments. Patients who had Anthracycline chemo (like CHOP) or "other chemo" had a higher risk for developing Myelodysplastic Syndromes and Acute Myeloid Leukemia (both blood cancers). There were no secondary blood cancers reported in patients who had Bendamustine as a first treatment.
The researchers conclusion is that, if more treatments increase the chance of secondary cancers, then FL patients should think about treatments that allow for long Progression-Free Survival -- longer times between treatments means fewer treatments. They also think there should be more emphasis on immunotherapy -- the newer treatments that are more focused on cancer cells, rather than traditional chemotherapy, which targets lots of healthy cells as well as cancer cells. Less chemo might mean fewer secondary blood cancers.
A few comments on this.
First, no cancer is a good cancer, and I wouldn't wish a second blood cancer on anyone. But I also think it's important to put the numbers in perspective. A 2.7% chance of a secondary blood cancer after 10 years means about 1 in 39 people will get one. That's a fairly small number, in my mind -- maybe worth the risk if a particular chemo (like CHOP) seemed to give me the best chance of survival. For most of us, there are probably lots of other choices for our situation, so maybe CHOP isn't the best choice. Like with anything, having an informed conversation with your doctor is so important. Be aware of your choices, and make sure you are satisfied with the choice.
Second, it would be really interesting to know more about the long-term effects of some of those immunotherapies they recommend. This study looks mostly at patients who were diagnosed before some of the more recent immunotherapies were approved, so we don't get any idea of the effects of treatments like CAR-T, or various inhibitors, or all of those newer monoclonal antibodies.
Finally, looking at both what kinds of treatments were studied, and what kinds weren't studied, I'm reminded of all of the options we have. There are lots of them, and lots more in trials, possibly being approved in the next few years. We're fortunate in that way. Choices can be overwhelming, but it also means there are probably more that fit our particular situation and our desires (for longer remissions, for greater Quality of Life, etc.). But that really does mean staying educated and having open conversations with a doctor who is willing to have them.