Stem Cell Transplant vs CAR-T, with a Cannoli

If you read the title of this post and are now very confused, I'll explain below. 

But before I get to that, I want to remind everyone to take the Follicular Lymphoma Foundation's annual survey. The survey will be available until October 19, so you only have a few more days from when I am posting this. It's a chance to have your voice heard - the FLF shares results with oncology researchers and clinicians, so together, we can help them understand the things that think are important for them to know about patients. 

The survey is anonymous and shouldn't take more than 10 minutes to complete. Thanks for your help with this.

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Now, about the title of this post:

CancerNetwork is the web site for the medical journal Oncology, and they sponsor a series of recorded debates called CancerNetwork Face-Offs. In these events, cancer experts are divided into two teams. Each team takes one side of a particular controversy in oncology, and makes a presentation about it. The idea is make these events educational, but also "fun" -- as much fun as anyone can have in discussing cancer.

(To be clear, I am all for fun, even in discussing cancer. It's obviously a serious business, but I can appreciate that people who are around cancer patients all day might want to add a little levity to their jobs.)

Part of the fun is in coming up with team names. So, for instance, in one Face-Off, two teams of oncologists from Chicago debate about....well, let me just copy the description at the start of the web page: "Panelists discuss various aspects of lower-risk myelodysplastic syndromes, including trial results on erythropoiesis-stimulating agent timing and novel agents like luspatercept and imetelstat, treatment sequencing and timing debates, personalized approaches based on erythropoietin levels, and complex case management balancing immediate symptom relief with long-term strategies."

The fun part? One team is named after the Chicago Cubs, and the other after the Chicago White Sox, the city's two Major League Baseball teams.  

Now, back once again to the bog post title. Some of these Face-Offs include videos of the debates. But their most recent one included a transcript of the event, with the title "Boston’s Best Did Not 'Leave the Cannoli' in Battle of Lymphoma Top Trials."

This one caught my eye for three reasons. First, it was about Follicualr Lymphoma, at least partially. Second, the oncologists on the panels were all from Dana-Farber Cancer Institute in Boston (the city where I was born and raised). And finally, the teams were named after two well-known pastry shops in Boston, Modern and Mike's. So the "leave the cannoli" is related to the pastry shops, but also is a reference to a famous lime from the movie The Godfather.  It's one of my favorite films. So how could I not write about this?

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That's a long introduction to a post, I know. I suppose you want some details of the actual face-off.

The two teams debated whether or not CAR-T was "better"than Autologous Stem Cell Transplant. It isn't really about these two treatments going head-to-head, but rather about the two teams doing their best to present information in a way that is both fun and informative.

The teams discuss the results of some recent clinical trial updates, look at case studies of patients, and then whether ASCT or CAR-T is better.

First of all, I'm not sure this is a fair fight. The last time I wrote about Stem Cell Transplants in any serious way was almost 10 years ago, and even then, the subject was about whether or not they were still a good option.  And there has been so much progress in FL treatments since then, it's hard to imagine anyone could make a strong case for Auto SCT over CAR-T.

If you're fairly new to all of this, and don't know what a Stem Cell Transplant is, here's a quick description: Patients who receive a Stem Cell Transplant receive very aggressive chemotherapy, aggressive enough that it pretty much destroys their immune system. It can take up to 30 days for the body to recover that system. But that leaves the patients vulnerable to all kinds of problems, since they have no defense against even the weakest virus. So they are given a Stem Cell Transplant, putting immature immune cells into their bodies that can grow into immune cells quickly -- maybe within 7 days -- leaving them much less vulnerable.

There are two types of Stem Cell Transplants. An Autologous STC uses the patients own stem cells. Tey are removed from the body before the patient receives chemo and then put back in after the treatment. An Allogeneic SCT uses immune cells from a donor that are a match. The danger with an Allo STC is that the patient's body can reject someone else's cells. The danger with the Auto STC is that those removed cells might have some cancer in them. Auto STC is considered less aggressive, but Allo STC usually had a greater chance of a cure, when it was successful.

(A Bone Marrow Transplant is very similar to a Stem Cell Transplant. The same dangers apply.) 

You can see how an Auto STC could be compared to CAR-T. They both involve removing immune cells and then putting them back in later. But the CAR-T cells are changed in ways that help them to locate cancer cells and remove them them. The Auto STC cells are just going back to their job of being immune cells - they aren't necessarily targeting cancer cells.

It's an interesting debate overall, even if the Auto STC folks had the harder job.  

And to be clear, Stem Cell Transplants are still used. There's no definitive answer when it comes to Lymphoma treatment. Every patient's needs (including their financial situation) has to play a part in the individual decisions about treatment. CAR-T is great, but it's not the best choice for everyone.

Cancer Nerds will enjoy reading this transcript. And whether or not this is your idea of "fun," it is always interesting to me to see experts delve deeply into a topic, present some interesting data, show how it applies to real people, and help us stay informed.