October is coming to a close, and that means Breast Cancer Awareness Month is ending.
I've always had a funny relationship with Breast Cancer Awareness Month, or "Pinktober" as it is sometimes called. On the one hand, I really hate all of the pink that comes with it. My kids' old school did a "Pink Day,"and my town painted one of its police cars pink. Plus there are all of the pink-wrapped products at the grocery store.
Part of it is jealousy. I'd love it people cared about Lymphoma as much as they seem to care about Breast Cancer.
But I also recognize that there is some good that comes with "awareness."
I wrote about this is a piece I had published on The Mighty a few days ago. It's called "What the Rest of Us (Cancer Patients and Survivors) Can Learn from Pinktober." I invite you to take a few minutes to read it.
Ultimately, the lesson for all of us is that if we want others to be "aware" of our cancer, then we have to be the ones to make it happen. And that means being open about what we experience, encouraging people to do things to prevent cancer, to get themselves tested (and to do self-exams), and, if they are unfortunate enough to get a cancer diagnosis, to educate themselves about their disease.
So if you are like me, and you got a little frustrated at all of the pink from the last month, try to see some good in it. There are absolutely people who exploit Pinktober for their own gain, and that's a shame. But -- big picture -- talking about cancer is better than not talking about it.
I'm looking forward to another month of learning and writing.
Tuesday, October 31, 2017
Saturday, October 28, 2017
Follicular Lymphoma: Changes in the Treatment Landscape
Thanks to William, who sent me the link to an hour-long video from OncLive. I thought it was a compilation of some shorter videos, and I was going to ignore it, but I'm glad William alerted me to it. It features some great Lymphoma specialists, and is worth watching.
The video is aimed at oncologists, to give them a sense of the state of the art when it comes to treating Follicular Lymphoma. It's called "Follicular Lymphoma: Changes in the Treatment Landscape," and it features Dr. Bruce Cheson of the Georgetown Lombardi Comprehensive Cancer Center, Dr. Nathan Fowler of MD Anderson Cancer Center, and Dr. Anas Younes of Memorial Sloan Kettering Cancer Center.
That's some serious Lymphoma Rock Star stuff.
[I might go back to my idea from a few years ago of creating trading cards with Lymphoma Rock Stars on them. You'll get a free pack with every Rituxan infusion. Trade with your friends!]
The Rock Star Doctors cover a lot. From my perspective as a Cancer Nerd, it's all fascinating to me. Their subject is how treatments are changing, so they go into a lot about specific treatments, and the clinical trials that they were involved in, so it can kind of technical. But I'm OK with that.
Aside from being Cancer Nerd, though, I'm also a cancer patient, and that's different. It's one thing to gaze lovingly at a video, and another to think about how it all affects my actual life as someone with Follicular Lymphoma.
So these are the things that stood out for me as a patient:
First, they open the discussion by talking about some of the "scoring systems" that are used to measure prognosis. these are things like FLIPI and FLIPI-m7. The problem with these scoring systems, as they point out, is that they tell us a lot about groups of patients (they were created by looking at data from large groups), but don't say anything about individual patients.
Sometimes, as patients, we look at "scores" like FLIPI, and the numbers seem so definite, that we assume they will predict our futures. They won't. They can't. It's just not what they are meant to do. I'm happy that these three make that point -- and I hope that message gets through to oncologists who may use those numbers without explaining their significance to patients.
Another topic that thrilled me as a patient was their discussion of Subcutaneous Rituxan. All of them were thrilled with the amount of time that subcutaneous Rituxan cuts out from the patient's visit. It can go from about 6 hours (roughly how long my first Rituxan infusion took) to about 10 minutes. That's a huge improvement on Quality of Life. Dr. Cheson asked an important question -- how accepted will this be? He hinted that some doctors might stick with the IV version if Rituxan, because it might generate more revenue. That would be pretty horrible, putting profits ahead of patients. It's great that this discussion was being aimed at working oncologists. I think some of them can use the reminder that our Quality of Life matters, especially if some of us will be living with FL for years and years.
I'm happy that the good doctors made that point to lots of other doctors who might watch.
Another interesting exchange: the possibility of a cure. Dr. Fowler first brings this up, and Dr. Cheson asks if he "used the 'C' word" (and then makes it clear that it was he who has encouraged Dr. Fowler to think in those terms). The two are clearly more open to the idea of an eventual cure for FL than Dr. Younes, as least at this point.
But I like that, too -- that mix of optimism from Fowler and Cheson, balanced with a little skepticism from Younes. I think that's about the right mix -- 2/3 optimism about our future and all the great stuff that is happening in the FL treatment landscape, with 1/3 reminind ourselves that there's a long way to go.
Which isn't to say that Fowler and Cheson are blindly optimistic, or that Younes isn't also enthusiastic about things. Because there is plenty enthusiasm and plenty of realism from all three of them.
In fact, one of the really great things about the video (I'm speaking as a Cancer Nerd again) is the way they consider the many clinical trials and treatments that they look at -- with enthusiasm and realism. They're all hopeful about the future, but they know there's a way to go. These treatments are going to help a lot of people, but we're not there yet.
Another Cancer Nerd thrill for me: at the end of the discussion, they discuss how the community can try to prioritize certain treatments or combinations of treatments. there are, for example, a fairly large number of BTK inhibitors. It's an excellent target, but maybe putting resources into other targets would be good, too. There's certainly a patient aspect to this as well -- there are only so many patients who are willing to participate in trials, so a better focus would be more more efficient. Also, doing more to consider the safety of some combinations would also be good. And for that matter, maybe greater incentives for patients to participate in trials would help a lot.
[And for my CAR-T friends, going back to a discussion we had a few weeks ago in the comments -- certainly seems like CAR-T is going to be focused on patients who have had 4 or 5 previous treatments already. Cost and toxicity are the issues for now, though maybe that will change.]
So, once again, this is really great video, with some Rock Star panelists. (I'm too much of a Fanboy, I know, but this was like watching Glengarry Glen Ross or Doubt -- a bunch of Oscar winners and nominees doing their thing.)
The video is aimed at oncologists, to give them a sense of the state of the art when it comes to treating Follicular Lymphoma. It's called "Follicular Lymphoma: Changes in the Treatment Landscape," and it features Dr. Bruce Cheson of the Georgetown Lombardi Comprehensive Cancer Center, Dr. Nathan Fowler of MD Anderson Cancer Center, and Dr. Anas Younes of Memorial Sloan Kettering Cancer Center.
That's some serious Lymphoma Rock Star stuff.
[I might go back to my idea from a few years ago of creating trading cards with Lymphoma Rock Stars on them. You'll get a free pack with every Rituxan infusion. Trade with your friends!]
The Rock Star Doctors cover a lot. From my perspective as a Cancer Nerd, it's all fascinating to me. Their subject is how treatments are changing, so they go into a lot about specific treatments, and the clinical trials that they were involved in, so it can kind of technical. But I'm OK with that.
Aside from being Cancer Nerd, though, I'm also a cancer patient, and that's different. It's one thing to gaze lovingly at a video, and another to think about how it all affects my actual life as someone with Follicular Lymphoma.
So these are the things that stood out for me as a patient:
First, they open the discussion by talking about some of the "scoring systems" that are used to measure prognosis. these are things like FLIPI and FLIPI-m7. The problem with these scoring systems, as they point out, is that they tell us a lot about groups of patients (they were created by looking at data from large groups), but don't say anything about individual patients.
Sometimes, as patients, we look at "scores" like FLIPI, and the numbers seem so definite, that we assume they will predict our futures. They won't. They can't. It's just not what they are meant to do. I'm happy that these three make that point -- and I hope that message gets through to oncologists who may use those numbers without explaining their significance to patients.
Another topic that thrilled me as a patient was their discussion of Subcutaneous Rituxan. All of them were thrilled with the amount of time that subcutaneous Rituxan cuts out from the patient's visit. It can go from about 6 hours (roughly how long my first Rituxan infusion took) to about 10 minutes. That's a huge improvement on Quality of Life. Dr. Cheson asked an important question -- how accepted will this be? He hinted that some doctors might stick with the IV version if Rituxan, because it might generate more revenue. That would be pretty horrible, putting profits ahead of patients. It's great that this discussion was being aimed at working oncologists. I think some of them can use the reminder that our Quality of Life matters, especially if some of us will be living with FL for years and years.
I'm happy that the good doctors made that point to lots of other doctors who might watch.
Another interesting exchange: the possibility of a cure. Dr. Fowler first brings this up, and Dr. Cheson asks if he "used the 'C' word" (and then makes it clear that it was he who has encouraged Dr. Fowler to think in those terms). The two are clearly more open to the idea of an eventual cure for FL than Dr. Younes, as least at this point.
But I like that, too -- that mix of optimism from Fowler and Cheson, balanced with a little skepticism from Younes. I think that's about the right mix -- 2/3 optimism about our future and all the great stuff that is happening in the FL treatment landscape, with 1/3 reminind ourselves that there's a long way to go.
Which isn't to say that Fowler and Cheson are blindly optimistic, or that Younes isn't also enthusiastic about things. Because there is plenty enthusiasm and plenty of realism from all three of them.
In fact, one of the really great things about the video (I'm speaking as a Cancer Nerd again) is the way they consider the many clinical trials and treatments that they look at -- with enthusiasm and realism. They're all hopeful about the future, but they know there's a way to go. These treatments are going to help a lot of people, but we're not there yet.
Another Cancer Nerd thrill for me: at the end of the discussion, they discuss how the community can try to prioritize certain treatments or combinations of treatments. there are, for example, a fairly large number of BTK inhibitors. It's an excellent target, but maybe putting resources into other targets would be good, too. There's certainly a patient aspect to this as well -- there are only so many patients who are willing to participate in trials, so a better focus would be more more efficient. Also, doing more to consider the safety of some combinations would also be good. And for that matter, maybe greater incentives for patients to participate in trials would help a lot.
[And for my CAR-T friends, going back to a discussion we had a few weeks ago in the comments -- certainly seems like CAR-T is going to be focused on patients who have had 4 or 5 previous treatments already. Cost and toxicity are the issues for now, though maybe that will change.]
So, once again, this is really great video, with some Rock Star panelists. (I'm too much of a Fanboy, I know, but this was like watching Glengarry Glen Ross or Doubt -- a bunch of Oscar winners and nominees doing their thing.)
Sunday, October 22, 2017
Awesome Video on the Importance of Educating Yourself
I want to recommend another great Lymphoma video for you. This one is great because of the star -- me!
WEGO Health asked me to make a video about the importance of doing research and educating yourself -- definitely something that I'm in favor of. The video is being used to introduce a WebMD slide show about a side effect of Hodgkin's Lymphoma treatment. (Yes, it's not the same as Follicular Lymphoma, but that's OK -- as I say in the video, doing research is important no matter what lymphoma subtype you might be living with.)
You might remember that WEGO Health are the folks that sponsor awards for online health advocates, and I was nominated for a couple of them (best blog and best kept secret). Alas, I didn't win, or even make the final five for either category. But that's fine -- it was nice to be nominated, and be listed among all of those great online health advocates. Thanks to those of you who voted for me.
I know some of you voted for me just so you could go to the page and see my picture. Well, here's your chance to hear my voice, too.
If you've been reading the blog for a while, my message in the video will be familiar.
There were 3 things I wanted to make sure I said: 1) There is a lot of information online, and it's important to find good information that is evidence-based, backed up by science; 2) Cancer is an emotional disease as well as a physical one, and doing research can help with that, too; and 3) doing research gives me a feeling of control over things that seem uncontrollable. I'm happy I was able to get all three of those messages in.
And I think I seem waaaaay more serious in this video than I usually am in real life. But that's because I did this in about 30 takes (I went too long, or the dog would make noise, or I'd forget what I was going to say, etc, etc. There are lots of frustrated bad words in the blooper reel). So by the end, I was focusing really really hard on just getting it right. That's not me being serious so much as just really focused.
The video is on the WEGO Health Facebook page. You can watch it even if you don't have Facebook.
The full video is here:
https://www.facebook.com/36556179253/posts/2000787863501222
The short version (just the invitation to click the link to the slide show) is here:
https://www.facebook.com/36556179253/posts/2000790436834298
(For some reason, the shorter version is way more popular. I guess people get sick of listening to me. I'm used to it -- I have three kids.)
It was fun making the video. I might do more of it soon. Thanks, WEGO Health, for the opportunity.
WEGO Health asked me to make a video about the importance of doing research and educating yourself -- definitely something that I'm in favor of. The video is being used to introduce a WebMD slide show about a side effect of Hodgkin's Lymphoma treatment. (Yes, it's not the same as Follicular Lymphoma, but that's OK -- as I say in the video, doing research is important no matter what lymphoma subtype you might be living with.)
You might remember that WEGO Health are the folks that sponsor awards for online health advocates, and I was nominated for a couple of them (best blog and best kept secret). Alas, I didn't win, or even make the final five for either category. But that's fine -- it was nice to be nominated, and be listed among all of those great online health advocates. Thanks to those of you who voted for me.
I know some of you voted for me just so you could go to the page and see my picture. Well, here's your chance to hear my voice, too.
If you've been reading the blog for a while, my message in the video will be familiar.
There were 3 things I wanted to make sure I said: 1) There is a lot of information online, and it's important to find good information that is evidence-based, backed up by science; 2) Cancer is an emotional disease as well as a physical one, and doing research can help with that, too; and 3) doing research gives me a feeling of control over things that seem uncontrollable. I'm happy I was able to get all three of those messages in.
And I think I seem waaaaay more serious in this video than I usually am in real life. But that's because I did this in about 30 takes (I went too long, or the dog would make noise, or I'd forget what I was going to say, etc, etc. There are lots of frustrated bad words in the blooper reel). So by the end, I was focusing really really hard on just getting it right. That's not me being serious so much as just really focused.
The video is on the WEGO Health Facebook page. You can watch it even if you don't have Facebook.
The full video is here:
https://www.facebook.com/36556179253/posts/2000787863501222
The short version (just the invitation to click the link to the slide show) is here:
https://www.facebook.com/36556179253/posts/2000790436834298
(For some reason, the shorter version is way more popular. I guess people get sick of listening to me. I'm used to it -- I have three kids.)
It was fun making the video. I might do more of it soon. Thanks, WEGO Health, for the opportunity.
Thursday, October 19, 2017
CAR-T Approved for Lymphoma
More good news for us -- the FDA has approved a CAR-T treatment for some Follicular Lymphoma patients.
(As usual, when it comes to CAR-T news, Ben beat me to the news. I just learned that he is a fan of the New York Yankees -- rivals to my beloved Boston Red Sox. I still like him anyway, and I'll keep sending you to his blog for everything you want to know about CAR-T and Lymphoma.)
The treatment is called axicabtagene ciloleucel, or axi-cel, though it will probably known to patients as Yescarta (to help you remember: Yes! CAR-T! Ahhhhhh!). The approval came from the results of the ZUMA-1 clinical trial, which involved patients with refractory aggressive B cell lymphomas.
That's important to remember. For now, anyway, the approval is for a very specific group of Follicular Lymphoma patients -- those with Transformed FL. There are other types of aggressive B cell lymphomas, too, who meet the approval criteria. But it's a big step for all lymphomas.
As a reminder, CAR-T stands for Chimeric Antigen Receptor T cell therapy. In the procedure, a patient has T cells removed from her blood. T cells are a type of white blood cell, part of the immune system, whose job is to attack invaders like viruses and bacteria. But they don't attack cancer cells. With CAR-T, after the T cells are removed, they are genetically engineered so that, when they are put back into the patient, they do recognize the cancer cells as invaders, and they attack. T cells have a memory, so if the cancer cells come back, they should be able to find them and attack again.
The ZUMA-1 trial involved 101 patients with several types of aggressive B cells lymphomas, including Transformed FL. The results were great -- 82% had a Response, including 54% who had a Complete Response. Six months after treatment, 36% were still in remission.
There are some side effects, of course, though researchers are looking into ways to recognize the most dangerous ones early and control them.
But there may be some other problems with this treatment (which I have seen coming up since the approval news).
The first will be the cost. This is an expensive treatment -- about $373,000. Granted, it's a personalized treatment -- each patient will have her own cells removed, manipulated, and put back, so it's not like it can be manufactured in large quantities. But it's still a lot of money.
The second will be the limited number of patients who have conditions that it has been approved for. It's pretty clear that only certain patients are approved for this (as is the case with any FDA approval). But Dr. John Leonard had a good point on Twitter last night. He said "I expect MDs to spend much more time explaining to lymphoma patients why they are not CAR-T candidates than managing the very few who are." This is likely to get a lot of attention (which it deserves), but won't be able to help a lot of patients -- yet. The manufacturer is developing CAR-T treatments for other types of solid cancer. The ZUMA-2 trial is looking at this treatment in Mantle Cell Lymphoma patients. ZUMA-3 is for Acute Lymphoblastic Leukemia patients.
It keeps going. ZUMA-5 is the trial for indolent (slow-growing) lymphoma patients, like those who have Follicular Lymphoma. It will look at 50 patients with indolent lymphoma whose disease has relapsed within two years of initial treatment, or had a second (or greater) treatment stop working, or who relapsed after a transplant. The first patient to get treatment in that trial got it in August.
We have a lot to look forward to.
(And I don't just mean next spring, when baseball starts up again for some of us.)
(As usual, when it comes to CAR-T news, Ben beat me to the news. I just learned that he is a fan of the New York Yankees -- rivals to my beloved Boston Red Sox. I still like him anyway, and I'll keep sending you to his blog for everything you want to know about CAR-T and Lymphoma.)
The treatment is called axicabtagene ciloleucel, or axi-cel, though it will probably known to patients as Yescarta (to help you remember: Yes! CAR-T! Ahhhhhh!). The approval came from the results of the ZUMA-1 clinical trial, which involved patients with refractory aggressive B cell lymphomas.
That's important to remember. For now, anyway, the approval is for a very specific group of Follicular Lymphoma patients -- those with Transformed FL. There are other types of aggressive B cell lymphomas, too, who meet the approval criteria. But it's a big step for all lymphomas.
As a reminder, CAR-T stands for Chimeric Antigen Receptor T cell therapy. In the procedure, a patient has T cells removed from her blood. T cells are a type of white blood cell, part of the immune system, whose job is to attack invaders like viruses and bacteria. But they don't attack cancer cells. With CAR-T, after the T cells are removed, they are genetically engineered so that, when they are put back into the patient, they do recognize the cancer cells as invaders, and they attack. T cells have a memory, so if the cancer cells come back, they should be able to find them and attack again.
The ZUMA-1 trial involved 101 patients with several types of aggressive B cells lymphomas, including Transformed FL. The results were great -- 82% had a Response, including 54% who had a Complete Response. Six months after treatment, 36% were still in remission.
There are some side effects, of course, though researchers are looking into ways to recognize the most dangerous ones early and control them.
But there may be some other problems with this treatment (which I have seen coming up since the approval news).
The first will be the cost. This is an expensive treatment -- about $373,000. Granted, it's a personalized treatment -- each patient will have her own cells removed, manipulated, and put back, so it's not like it can be manufactured in large quantities. But it's still a lot of money.
The second will be the limited number of patients who have conditions that it has been approved for. It's pretty clear that only certain patients are approved for this (as is the case with any FDA approval). But Dr. John Leonard had a good point on Twitter last night. He said "I expect MDs to spend much more time explaining to lymphoma patients why they are not CAR-T candidates than managing the very few who are." This is likely to get a lot of attention (which it deserves), but won't be able to help a lot of patients -- yet. The manufacturer is developing CAR-T treatments for other types of solid cancer. The ZUMA-2 trial is looking at this treatment in Mantle Cell Lymphoma patients. ZUMA-3 is for Acute Lymphoblastic Leukemia patients.
It keeps going. ZUMA-5 is the trial for indolent (slow-growing) lymphoma patients, like those who have Follicular Lymphoma. It will look at 50 patients with indolent lymphoma whose disease has relapsed within two years of initial treatment, or had a second (or greater) treatment stop working, or who relapsed after a transplant. The first patient to get treatment in that trial got it in August.
We have a lot to look forward to.
(And I don't just mean next spring, when baseball starts up again for some of us.)
Sunday, October 15, 2017
EJM: New Paradigms for FL
Let's keep this theme going. The European Medical Journal published an edition that looked back at the European Hematology Association conference from last June. In all of my reading about Follicular Lymphoma, it seems like the kinds of research that gets done in the U.S. is the same as in other parts of the world, more or less, but I enjoy getting a different perspective on things.
One section of the journal is called "Shifting Treatment Paradigms in Non-Hodgkin Lymphomas," and in that section is a piece called "Follicular Lymphoma: Strategies in the Era of New Targeted Therapies." [The link should take you right to the article on FL, but if it doesn't, scroll to page 36.]
The FL article is written by Professor Dolores Caballero from University Hospital Salamanca in Spain. She gives a sense of the current state of treatment and its results. In a nutshell:
The median Overall Survival for FL is about 15 years. [Remember "median" means half of patients will survive less than that, and half will survive more. Also remember that most FL patients are diagnosed in their 60's; the media OS for younger patients is much longer than 15 years.] Common options are watching and waiting, straight Rituxan, and immunochemotherapy (usually Rituxan + CHOP, CVP, or Bendamustine.) Patients with no symptoms often get W & W or Rituxan; patients with a higher tumor burden often get R + chemo. Some benefit from Rituxan Maintenance. Some more aggressive approaches seem to improve Progression Free Survival (how long it takes until the disease starts to get worse), but don't improve Overall Survival.
That about sums it up, right?
Prof. Caballero continues: While something like R-CHOP might increase PFS, it also comes with side effects that affect Quality of Life. Traditional chemotherapy attacks healthy cells as well as cancer cells. What we need (and what we have) are treatments that focus on the cancer cells and leave everything else alone. This should result in fewer side effects. And since FL is a heterogeneous disease -- it's a little bit different for everyone -- it would be good to have a bunch of options.
And that's what we have. Prof. Caballero gives a brief discussion of some of the targeted options available, and how well they have performed in trials. These include Obinutuzumab (combined with chemo, it had a higher 3 year PFS than Rituxan + chemo), Idelalisib (a PI3K inhibitor, which seems to work best with patients who are high risk and have had several prior treatments), Ibrutinib (a BTK inhibitor with high response rates), and Lenalidomide.
Lenalidomide gets the most discussion here (it's not a long article, but it gets about 4 paragraphs). An immunomodulatory agent, it has been combined with Rituxan to create "R-squared" (Lenalidomide also goes by the name Revlimid). It's a combination that has had lymphoma specialists very excited for a few years.
Dr. Caballero finishes by pointing out that next generation treatments will combine biologic and targeted agents, in ways that are based on individual patient needs. But we need to learn more about biomarkers -- those clues that help predict which patients will respond to which treatments even before they try them.
So, looking at the trends here, and comparing what a European expert is excited about to what American experts seem excited about, I'd say Lenalidomide is near the top of everyone's list. More targeted treatments like inhibitors are also up there. And there's plenty of buzz about CAR-T.
The big lesson I'm taking away is that we have a lot of options, and more on the way. And if you think about some of the combinations that are being tested, that's even more still.
The future looks bright, on both sides of the world.
One section of the journal is called "Shifting Treatment Paradigms in Non-Hodgkin Lymphomas," and in that section is a piece called "Follicular Lymphoma: Strategies in the Era of New Targeted Therapies." [The link should take you right to the article on FL, but if it doesn't, scroll to page 36.]
The FL article is written by Professor Dolores Caballero from University Hospital Salamanca in Spain. She gives a sense of the current state of treatment and its results. In a nutshell:
The median Overall Survival for FL is about 15 years. [Remember "median" means half of patients will survive less than that, and half will survive more. Also remember that most FL patients are diagnosed in their 60's; the media OS for younger patients is much longer than 15 years.] Common options are watching and waiting, straight Rituxan, and immunochemotherapy (usually Rituxan + CHOP, CVP, or Bendamustine.) Patients with no symptoms often get W & W or Rituxan; patients with a higher tumor burden often get R + chemo. Some benefit from Rituxan Maintenance. Some more aggressive approaches seem to improve Progression Free Survival (how long it takes until the disease starts to get worse), but don't improve Overall Survival.
That about sums it up, right?
Prof. Caballero continues: While something like R-CHOP might increase PFS, it also comes with side effects that affect Quality of Life. Traditional chemotherapy attacks healthy cells as well as cancer cells. What we need (and what we have) are treatments that focus on the cancer cells and leave everything else alone. This should result in fewer side effects. And since FL is a heterogeneous disease -- it's a little bit different for everyone -- it would be good to have a bunch of options.
And that's what we have. Prof. Caballero gives a brief discussion of some of the targeted options available, and how well they have performed in trials. These include Obinutuzumab (combined with chemo, it had a higher 3 year PFS than Rituxan + chemo), Idelalisib (a PI3K inhibitor, which seems to work best with patients who are high risk and have had several prior treatments), Ibrutinib (a BTK inhibitor with high response rates), and Lenalidomide.
Lenalidomide gets the most discussion here (it's not a long article, but it gets about 4 paragraphs). An immunomodulatory agent, it has been combined with Rituxan to create "R-squared" (Lenalidomide also goes by the name Revlimid). It's a combination that has had lymphoma specialists very excited for a few years.
Dr. Caballero finishes by pointing out that next generation treatments will combine biologic and targeted agents, in ways that are based on individual patient needs. But we need to learn more about biomarkers -- those clues that help predict which patients will respond to which treatments even before they try them.
So, looking at the trends here, and comparing what a European expert is excited about to what American experts seem excited about, I'd say Lenalidomide is near the top of everyone's list. More targeted treatments like inhibitors are also up there. And there's plenty of buzz about CAR-T.
The big lesson I'm taking away is that we have a lot of options, and more on the way. And if you think about some of the combinations that are being tested, that's even more still.
The future looks bright, on both sides of the world.
Tuesday, October 10, 2017
NCCN Congress on Hematologic Malignancies
A few days ago, the NCCN Congress on Hematologic Malignancies took place in San Francisco. The NCCN is the National Comprehensive Cancer Network, a group of cancer research centers best known for their guidelines for cancer treatment. They have a number of meetings every year for different cancer specialists, to give updates on different sub-types. Of course, Follicular Lymphoma was one of the topics of discussion.
I wasn't at the Congress, but OncLive has a couple of articles (one with a video) describing the FL session. (OncLive has a whole series of pieces on the sessions for different blood cancer subtypes, and they posted them almost immediately. OncLive has always been good, but they are just nailing it lately. My thanks to them.)
(While I'm at it, I just want to say that I would love to actually be at all of these meetings, like ASH and ASCO and NCCN and the rest. I wish I had the time and money to go. Maybe some day after i retire.)
(And yes, even though I'm 15 or 20 years from retiring, I do plan to be around until then -- and longer after that.)
Anyway, both articles focus on Dr. Jane Winter from Northwestern University in Chicago. (I believe she was the expert who presented on Follicular Lymphoma.)
The first OncLive article gives an overview of the session. Some of the issues she covered:
So these articles aren't presenting anything brand new. And that makes sense -- they are reporting on a session that was meant to get oncologists up to date on a bunch of things. But it's always interesting to see what FL experts think is important enough to want to make sure all of their peers know about it. I hope we see more in the near future about that 20% of patients.
(And I'm serious about wanting to go to one of these conferences. If any of you is a kindly billionaire who grants wishes, my email is in the profile on the right.)
I wasn't at the Congress, but OncLive has a couple of articles (one with a video) describing the FL session. (OncLive has a whole series of pieces on the sessions for different blood cancer subtypes, and they posted them almost immediately. OncLive has always been good, but they are just nailing it lately. My thanks to them.)
(While I'm at it, I just want to say that I would love to actually be at all of these meetings, like ASH and ASCO and NCCN and the rest. I wish I had the time and money to go. Maybe some day after i retire.)
(And yes, even though I'm 15 or 20 years from retiring, I do plan to be around until then -- and longer after that.)
Anyway, both articles focus on Dr. Jane Winter from Northwestern University in Chicago. (I believe she was the expert who presented on Follicular Lymphoma.)
The first OncLive article gives an overview of the session. Some of the issues she covered:
- Stage 1 FL can sometimes be treated with radiotherapy -- traditional radiation. A PET scan can help identify if this approach will be helpful. Up to half of stage 1 patients can possibly be cured with radiotherapy. Unfortunately, fewer than 1/3 of patients who could benefit from this treatment actually get it. (Don't know why, but I suspect that the difficulty of diagnosing at stage 1 might be part of it -- for most of us, we don't actually notice symptoms until stage 3 or 4.)
- For many patients with stage 3 or 4 disease, watch and wait is still an option. The signals that it is time to treat? Symptoms start to show up, threats to organs [that's what happened with me -- swollen inguinal nodes started pushing on things], cytopenia or low blood counts, bulky disease, and steady disease progression. Right now, there is no evidence that watching and waiting results in a lower Overall Survival than treating right away.
- Maintenance Rituxan after a treatment does not offer a better Quality of Life than treating and then waiting for a reason to treat.
- Long-term follow up of patients who received R + Chemo shows that there is no one treatment that prolongs Overall Survival better than others.
- R-squared (Rituxan + Revlimid/Lenalidomide) continues to impress experts, enough that the results of a phase 3 clinical trial might be enough to recommend that the combination replace chemotherapy as the standard choice.
- Patients who receive R-CHOP and then have progressive disease within 24 months have a lower survival rate than other patients. This group accounts for about 20% of Follicular Lymphoma patients. One of the big challenges for FL researchers is figuring out how to identify these patients early, and how to treat them.
So these articles aren't presenting anything brand new. And that makes sense -- they are reporting on a session that was meant to get oncologists up to date on a bunch of things. But it's always interesting to see what FL experts think is important enough to want to make sure all of their peers know about it. I hope we see more in the near future about that 20% of patients.
(And I'm serious about wanting to go to one of these conferences. If any of you is a kindly billionaire who grants wishes, my email is in the profile on the right.)
Friday, October 6, 2017
Obinutuzumab vs Rituxan
The New England Journal of Medicine published an article yesterday on the results of the GALLIUM study that compared Obinutuzumab and Rituxan as part of an initial treatment for Follicular Lymphoma. Obinutuzumab came out ahead.
Or did it?
Obinutuzumab was in the news at the end of August, when it was given priority review by the FDA. The review will also be based on the GALLIUM trial results. Obinutuzumab is similar to Rituxan, in that they are both monoclonal antibodies that target the CD20 protein on B cells. But Obinutuzumab is considered a possible improvement over Rituxan, because it was created differently, to target B cells better, and to cut down on some of the side effects that come with Rituxan's being made from mouse cells (instead of Obinutuzumab's human cells).
The NEJM actually provides a really helpful video that explains the results of the trial. As shown in the video and the article, the GALLIUM study looked at how effective and how safe Obinutuzumab was when compared to Rituxan in FL patients who had not yet received any treatment. The trial involved 1202 patients. Half of them (601) were given chemotherapy+ Obinutuzumab, while the other half was given chemo + Rituxan. The chemo could have been Bendamustine, CHOP, or CVP. Patients who had a Complete Response or Partial Response were then given maintenance treatment for up to 2 years (361 for Obinutuzumab and 341 for Rituxan, or an 88.5% Response Rate for Obinutuzumab and 86.9% for Rituxan).
As you can see, there were slightly more patients who had a Response from Obinutuzumab + chemo than Rituxan + chemo. The study was stopped after almost 3 years when it was clear that Obinutuzumab had a better Progression Free Survival rate for 3 years -- 80%, vs. 73.3% for Rituxan. That number is considered significant enough to say that Obinutuzumab is more effective that Rituxan.
This is one of those stories that's getting lots of play in the oncology community. Rituxan has been around for 20 years, and there have been a bunch of attempts to find something that does the same job, but in a better way. Lots of stories online are suggesting that Obinutuzumab has done that.
But then, there are a few more stories that are looking at a second piece in the NEJM, an editorial called "Which Anti-CD20 Antibody is Better in Follicular Lymphoma?" In it, the authors raise some questions that should be raised, and that should make the "Obinutuzumab is better than Rituxan!" article writers slow down a bit. Not many of them did. Medscape was one -- their article reporting on the research is called "Obinutuzumab vs Rituximab in FL: 'Too Close to Call'."
The Medscape article points out some problems with the study that might make the results a little less simple than it might seem. The PFS is significant -- about 7% better for Obinutuzumab.
But there are some problems, too, as the editorial (and the Medscape article) point out.
For example, there is a dosage difference. Patients who received Obinutuzumab had a dose almost 3 times higher than the Rituxan dose. Those are both standard doses for the two, but it raises the question, if the two treatments are generally the same thing, would a higher dose for Rituxan have given better results?
Also, the Obinutuzumab had a higher incidence of adverse events -- things like low blood cell counts, nerve issues, infections, and infusion-related reactions. All of them were more frequent (for some adverse events, twice as frequent) in Obinutuzumab as in Rituxan. That raises the question -- if there is a higher Progression Free Survival, is it enough to make it worth the higher risk of adverse events?
Finally, the editorial authors point out that, while PFS is higher, there is no Overall Survival benefit. So people might go longer before they need another treatment, but they don't live longer as a result of taking Obinutuzumab instead of Rituxan. (I think, though, that's it's too early to measure that statistic.)
The Medscape article also looks back at the ASH session last year that first reported these results of the GALLIUM trial, that showed problems with Bendamustine and Obinutuzumab (and Bendamustine alone).
The Medscape article ends with some interviews with oncologists about whether or not Obinutuzumab will replace Rituxan. The responses were mixed. I can see why -- the study does raise some questions. And, as one doctor points out, the potential FDA approval will be for this very specific course of treatment -- Obinutuzumab plus chemo, followed by Obinutuzumab maintenance. That might not be the best choice for everyone.
My sense is, human nature being what it is, many doctors will continue to stick with what they know, and that means using Rituxan. And my guess (and it's only a guess) is that it will remain that way until there is a really big improvement in the numbers.
And finally, there is a lesson here for us as patients -- a reminder, really. Online stories about cancer are meant to be read, and that means sometimes making them sound better than they are. Most stories about this study didn't bother with the editorial, and the questions it raised. We need to all be careful (me included) to think carefully about what we see, and to make sure we're getting the full story.
Staying informed is the best way to have a voice in our treatment.
Or did it?
Obinutuzumab was in the news at the end of August, when it was given priority review by the FDA. The review will also be based on the GALLIUM trial results. Obinutuzumab is similar to Rituxan, in that they are both monoclonal antibodies that target the CD20 protein on B cells. But Obinutuzumab is considered a possible improvement over Rituxan, because it was created differently, to target B cells better, and to cut down on some of the side effects that come with Rituxan's being made from mouse cells (instead of Obinutuzumab's human cells).
The NEJM actually provides a really helpful video that explains the results of the trial. As shown in the video and the article, the GALLIUM study looked at how effective and how safe Obinutuzumab was when compared to Rituxan in FL patients who had not yet received any treatment. The trial involved 1202 patients. Half of them (601) were given chemotherapy
As you can see, there were slightly more patients who had a Response from Obinutuzumab + chemo than Rituxan + chemo. The study was stopped after almost 3 years when it was clear that Obinutuzumab had a better Progression Free Survival rate for 3 years -- 80%, vs. 73.3% for Rituxan. That number is considered significant enough to say that Obinutuzumab is more effective that Rituxan.
This is one of those stories that's getting lots of play in the oncology community. Rituxan has been around for 20 years, and there have been a bunch of attempts to find something that does the same job, but in a better way. Lots of stories online are suggesting that Obinutuzumab has done that.
But then, there are a few more stories that are looking at a second piece in the NEJM, an editorial called "Which Anti-CD20 Antibody is Better in Follicular Lymphoma?" In it, the authors raise some questions that should be raised, and that should make the "Obinutuzumab is better than Rituxan!" article writers slow down a bit. Not many of them did. Medscape was one -- their article reporting on the research is called "Obinutuzumab vs Rituximab in FL: 'Too Close to Call'."
The Medscape article points out some problems with the study that might make the results a little less simple than it might seem. The PFS is significant -- about 7% better for Obinutuzumab.
But there are some problems, too, as the editorial (and the Medscape article) point out.
For example, there is a dosage difference. Patients who received Obinutuzumab had a dose almost 3 times higher than the Rituxan dose. Those are both standard doses for the two, but it raises the question, if the two treatments are generally the same thing, would a higher dose for Rituxan have given better results?
Also, the Obinutuzumab had a higher incidence of adverse events -- things like low blood cell counts, nerve issues, infections, and infusion-related reactions. All of them were more frequent (for some adverse events, twice as frequent) in Obinutuzumab as in Rituxan. That raises the question -- if there is a higher Progression Free Survival, is it enough to make it worth the higher risk of adverse events?
Finally, the editorial authors point out that, while PFS is higher, there is no Overall Survival benefit. So people might go longer before they need another treatment, but they don't live longer as a result of taking Obinutuzumab instead of Rituxan. (I think, though, that's it's too early to measure that statistic.)
The Medscape article also looks back at the ASH session last year that first reported these results of the GALLIUM trial, that showed problems with Bendamustine and Obinutuzumab (and Bendamustine alone).
The Medscape article ends with some interviews with oncologists about whether or not Obinutuzumab will replace Rituxan. The responses were mixed. I can see why -- the study does raise some questions. And, as one doctor points out, the potential FDA approval will be for this very specific course of treatment -- Obinutuzumab plus chemo, followed by Obinutuzumab maintenance. That might not be the best choice for everyone.
My sense is, human nature being what it is, many doctors will continue to stick with what they know, and that means using Rituxan. And my guess (and it's only a guess) is that it will remain that way until there is a really big improvement in the numbers.
And finally, there is a lesson here for us as patients -- a reminder, really. Online stories about cancer are meant to be read, and that means sometimes making them sound better than they are. Most stories about this study didn't bother with the editorial, and the questions it raised. We need to all be careful (me included) to think carefully about what we see, and to make sure we're getting the full story.
Staying informed is the best way to have a voice in our treatment.
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