No More Bone Marrow Biopsies?

Interesting research from the Journal of Clinical Oncology about Bone Marrow Biopsies (BMB). Some strong evidence that maybe we don't need them anymore (at least not as often).

I probably don't need to explain Bone Marrow Biopsies to any of you, but just as a reminder, when a patient is diagnosed with Follicular Lymphoma, they are put through a bunch of tests to determine the disease stage (how widespread the disease is) and grade (how aggressive it is). One of the tests is a Bone Marrow Biopsy.  It's different from a lymph node biopsy. With a BMB, a sample of bone marrow is taken from the bone. If there is FL present, it's likely a sign of advanced stage disease -- stage 4. The bone marrow is where immune cells are created, so cancer cells in the marrow means things have progressed pretty far.

(Though, as another reminder, stage 4 FL is different from stage 4 for other cancers. Still serious and advanced, but easier for treatment to get to the cancer cells and do its job than it is for many other stage 4 cancers.)

I won't get into the details of how BMB works. Most of you have been there, and the rest of you don't want to hear about it. It's not a fun procedure (and it's still pretty fresh in my memory, many years later).

The JCO article is called "Relevance of Bone Marrow Biopsies for Response Assessment in US National Cancer Institute National Clinical Trials Network Follicular Lymphoma Clinical Trials." 

It looks at a very particular use of BMBs, but it has some bigger implications.

Specifically, it looks at the use of BMBs in clinical trials. For many trials, a Bone Marrow Biopsy is a requirement. At the beginning of the trial, before the treatment is given, patients have a BMB to see if they have any FL cells in their bone marrow. That's common for many of us -- to get a BMB at diagnosis. However, many trial participants also get a BMB at the end of the trial, to make sure the treatment worked all the way into the bone. And some will even have one or more in the middle of the trial to kind of see how it's going.

It's a lot like getting a PET scan at the beginning, middle, and end of treatment. It's a way to check on things. But, as unpleasant as a PET scan is, a BMB is even more invasive and unpleasant. If there is a way to get rid of them, I'm all for it. 

The research in the article provide some evidence that maybe we can indeed get rid of BMBs.

The researchers looked back at two clinical trials that took place from 2008 to 2016. The first one looked at 580 FL patients, and found that only 5 of them had a positive BMB at the beginning of the trial. That's less than 1%. In the second trial, 5 out of 385 patients had a positive BMB (1.3%). The researchers conclusion was obvious -- if less than 1% of patients even need a BMB, why are they putting the other 99% through it -- multiple times? 

When they dug a little deeper, they found that the BMBs really didn't add anything to the analysis. Not every patient in the trial had multiple BMBs, so they could compare patient outcomes. They found that there was not any difference -- patients who had multiple BMBs didn't have a longer Progression Free Survival or Overall Survival. In other words, the BMB did catch anything early, or find cancer cells that weren't found by some other means.

Even though the focus of the research was on BMBs in clinical trials, the researchers are making bigger recommendations. First, they think BMBs should be eliminated from clinical trials. They don't add anything, and they put patients through unnecessary pain and cost. But they go further -- they think BMBs should stop being part of standard diagnostic testing for Follicular Lymphoma, except in special circumstances, like confirming limited stage disease (stage 1 or 2), or assessing cytopenias (low blood cell counts). 

For many (maybe most) of us, those things don't matter, or there are other ways to find them out. Liquid Biopsies, for example -- as I discussed in my last post -- might do a better job of all of this. Better in that (maybe soon) they will be just as accurate, but will not affect quality of life the way an invasive test like a BMB does.

This is all part of a larger trend in Follicular Lymphoma research, and in cancer research in general. Examine the way we do things, and don't just say "that's the way we've always done it." If we can't find a cure, then we can at least find ways to make the experience less unpleasant, whether it's treatment side effects or tools for diagnosis.

It's a small study, but an important one, with some potential implications for making our lives just a little bit easier.