Intermediate Risk FL: One Patient's Treatment

Targeted Oncology has another short video series featuring an oncologist discussing one patient's treatment history. Like the one they did a couple of weeks ago about a patient with high risk Follicular Lymphoma, this one highlights a single patient's story. It's not supposed to be a description for how everyone in her condition should be treated, but it is interesting to see how an oncologist makes decisions.

This one features a patient with intermediate-risk FL, and the oncologist doing the describing is Dr. Peter Martin from Weill Cornell in New York City. The link will take you to the first video in the series; the others are linked to the right of the video box.

The patient is a 57 year old woman. A scan showed activity in lymph nodes near her collar bone and groin (stage 3), and a biopsy showed grade 2 FL. She also had low hemoglobin (which carries oxygen in red blood cells), making her intermediate risk.

Dr. Martin points out that the PET scan at diagnosis is valuable as a base line in case there is a suspicion of transformation later on. [That's one of those things that I like about the Targeted Oncology series -- the oncologists who do them are very good about explaining their reasoning, something our own doctors don't always do.]

The patient was treated with Bendamustine and Rituxan initially. Again Dr. Martin discusses soem of the reasoning; he considers GELF criteria, which inolves looking at "organomegalies [enlarged organs], cytopenias [low blood counts], elevated LDH [Lactic Acid Dehydrogenase, which shows possible tissue damage], and the size and number of lymph nodes [pretty sure we all know what that means]." In this patient's case, the cytopenias and fatigue were enough to say she needed to be treated early (low red blood cell count).

Dr. Martin also discusses the uses and limitations of FLIPI scores.

They might be useful in giving a  general idea of "where a patient is headed," but it doesn't say anything about an individual patient's survival or how they might react to treatment.

Again, Dr. Martin provides some reasoning behind the decision to go with B + R. Another option might be straight Rituxan. Interestingly, he says the patient's age and the fact that is probablly still working would be a factor in using Rituxan only -- minimal disruption to her Quality of Life. He also discusses other possibilities, like R-CHOP, as well as the possibility of using either Rituxan or Obinutuzumab maintenance.

Four years later, Dr. Martin saw the patient again. She was experiencing fatigue again, and a scan showed that the nodes near he groin were large again. There were no other signs of transformation, so he didn't do a biopsy. They tried R-Squared (Rituxan and Revlimid/Lenalidomide), which worked well.

Again, Dr. Martin discussed the reasoning for the decision. The patient wanted something that would put her in remission for a while, but without too intensive a treatment (again, seems like a Quality of Life issue). One thing to consider for R-squared is how long to keep it up. Dr. Martin's preference is to not use it any longer than necessary.

Two years later, the patient again needed treatment. There was more activity throughout her body, though the scan didn't show evidence of transformation. She was given Idelalisib, a PI3-kinase inhibitor. Once again, Dr. Martin discusses his reasoning for the choice -- one consideration was that the inhibitor works in ways that are different from the first two treatments, which makes sense, given that the other two types stopped working. The decision also had, again, Quality of Life considerations -- as Dr. Martin says, "Idelalisib is an oral therapy, so it’s easy to do. It requires some blood monitoring and some clinical monitoring after that. But it doesn’t require a lot of intravenous infusions, doesn’t cause hair loss, is relatively easy to administer, and is easy to take, and as long as we’re cognizant of the potential side effects and looking for them and being ready to act on them, it’s something that can be done relatively easily."


So, once again, an interesting description of one person's treatment, with a nice description of the reasoning behind all of the decisions. It won't be the same for everyone, since everyone's disease will act a little differently. But it does give us a lot to think about.


I'm hoping they do a series now on low-risk FL, and it's basically 25 minutes of the oncologist talking about how boring the office visits are since the patient is watching and waiting and they just talk about baseball instead (which is what mine were like).


No, really, there are plenty of decisions to be made even for low-grade FL -- whether to treat or watch and wait, which treatment to try, and certainly what kinds of Quality of Life factors are important to the patient.


I'm looking forward to that one.