Is Chemo Necessary Anymore?

Modern Medicine Network has a fun debate going -- "Can chemotherapy be eliminated in the treatment of Follicular Lymphoma?"

OK, maybe "fun" isn't the best word to describe it. But it's fun for me. We're in that dull period between ASCO (in June) and ASH (in December). Those times are when the internet is full of great research. But now I'm so desperate for good FL stuff. This is a solid debate. It's "fun" because I fi ally get to read something good.

There are two sides of this debate.

First we have Dr. Loretta J. Nastoupil from the MD Anderson Cancer Center. Dr. Nastoupil's side is "Yes—Chemotherapy Need Not Be Routinely Used." She argues that Overall Survival has increased for FL patients, but that has come from adding rituxan to chemotherapy, not from newer, or better, or more chemo. She also argues that some recent trials have shown the dangers of chemo, as much as they have shown the effectiveness of non-chemo. The treatments showing the most promise these days are not traditional chemo -- things like lenalidomide (especially combined with Rituxan, make the combo called R-Squared), lots of inhibitors (which stop the processes that cancer cells need to go through to grow and survive). In the end, until we have some better ways of predicting how FL will behave, we need to focus on balancing effective treatments with Quality of Life. And that means using less chemo.

On the other side, we have Dr. Paul Barr of the University of Rochester Medical Center. He says "No—Chemotherapy Remains an Essential Part of Therapy for Follicular Lymphoma." While Rituxan added to chemotherapy was responsible for increased Overall Survival, it was better chemo that started that upward trend. When patients are first treated with immunochemotherapy (usually Rituxan + CHOP, CVP, or Bendamustine), they can achieve long-lasting remission, with other non-chemo options available for later treatments. And while maintenance with something like Rituxan can be helpful, it can also cause problems -- the best benefit comes from the chemo that came before it. In the end, it is immunoCHEMO that has the best benefit.

Of course, if there was an easy answer, there wouldn't be a debate.

Here's what I think about it all.

(And I know you want to hear what I think. Who better to have an opinion than someone whose only training in this area was that he was a Biology major in college, 30 years ago, for one semester?)

But, really, as a patient and cancer Nerd who has been looking at research in FL treatments for about 10 years, I have noticed some things.

For what it's worth, I don't think we're getting rid of chemotherapy any time soon.

Probably the biggest reason is that we have years and years of data about the long-term effectiveness of chemo. We know that R-CHOP and R-Bendamustine are very effective over 10 years. We just don't have that data yet for R-Squared or some inhibitors. they just haven't been in regular use that long. Maybe 10 years from now, that will change.

I have noticed, too, that there are fewer and fewer new clinical trials involving chemotherapy. Most resources are going into things like inhibitors and immunotherapy. And that's the way it should be. Chemo has its place, but newer treatments are usually more targeted, and they promise to be effective with fewer side effects. There are some research reports that look at chemo, but they are usually long-term studies that started years ago.

So, yes, there is still a place for chemo. My guess, though, is that as we learn more about the long-term effects of newer treatments, and even better ones are developed, that chemo will become less common.

But that will be a long time from now.

For now, let's be happy that we have lots of options, including chemo, that we know are effective and pretty safe.