Does It Matter How You Were Diagnosed?

I have communicated with many patients with Follicular Lymphoma over the years, and read many more patients' stories. I'm always struck by how heterogeneous this disease is -- how differently it presents itself in different people.

I know I'm fortunate to have a version of this disease that started slow and has mostly remained that way. So many others I have spoken to have had a very different course for their disease.

One of the places where we have different experiences is in how we were diagnosed. Some of us had very obvious symptoms -- swollen nodes, night sweats, weight loss, for example. Others of us had no symptoms at all, and were diagnosed almost accidentally, maybe because a routine blood test turned up an issue, or an unrelated surgery or scan found some hidden swollen nodes. My experience is kind of in between -- I had a persistent swollen node near my hip, but I didn't have any other symptoms, and I was otherwise healthier than I had been in a long time.

Some of us might have asked a question related to this -- does it matter how I was diagnosed? Is an "accidental" diagnosis with no symptoms somehow better than a diagnosis that came because of some very obvious symptoms?

Some researchers from the Mayo Clinic had that same question, and published their results in the Blood Cancer Journal. The article is called "Incidental vs. symptomatic diagnosis of follicular lymphoma: implications of earlier detection." They essentially want to know if a patient is better off being diagnosed before there are obvious symptoms. The logic is that such a diagnosis must be early, and an early diagnosis must be better. 

The results are interesting, and depend on how you define "better." To me, as someone who has been reading about FL for a long time, they aren't really very surprising.

The researchers looked at the medical records of 908 patients who were newly diagnosed with FL between 2002 and 2015. They looked at how they were diagnosed -- because of obvious lymphoma symptoms, or "incidentally." They found that 259 (or 28,5% of their sample) had an incidental diagnosis. 

They looked at some of the characteristics of the two groups. The incidental group was more likely to be diagnosed with "early" disease -- stage I or II. This makes sense to me. They also found that this group had normal LDH levels. Most of you probably know what LDH (lactate dehydrogenase) is, or have at least heard of it. It's an enzyme found in tissues, and high LDH is often present when FL is advancing. I know it's one of those blood test components that my oncologists always point out ("LDH looks good."). So those in the "Incidental" group had normal LDH levels -- again, not surprising.  

Those are the differences. It's the similarities between the groups that are so interesting.

comparing the "incidental" and the "symptomatic" groups, there was no difference in Event Free Survival (EFS), Lymphoma-Specific Survival (LSS) or Overall Survival (OS).

In other words, whether the patients in the study were diagnosed early or later, they tended to go about the same amount of time before they needed treatment. There was no difference in how long they lived because of their lymphoma. In fact, there was no difference in how long they lived, period.

As I said, as someone who has been reading about FL for a very long time, this did not surprise me. It takes a lot to improve Overall Survival in Follicular Lymphoma. Watching and waiting versus immediate treatment? Not much difference in OS. Maintenance versus no maintenance? Not much difference in OS. Traditional chemotherapy versus nob-chemo treatment? Not much difference in OS.

And that matters.

It would be wonderful to have some breakthrough in FL that vastly improved our Overall Survival. In general, our OS has improved quite a bit since I was diagnoses 17 years ago. It was still unofficially 8-10 years back then. Now, it's closer to 15-20 years. No one knows for sure for a really great reason -- FL patients keep living so long that they can't measure the upper end of their survival. That's an excellent thing.

But all of this really matters most to me because it should ease our minds just a little.

The disease is heterogeneous -- we all experience it just a little bit differently. One implication of that is that there is no real "right answer" when it comes to treatment. If all FL was the same, we'd be able to say "start with treatment X. If you need treatment again, go with Y. And then Z." But we don't have that clear path. 

And that means lots of decisions to make, and lots of doubt that the decisions were the right ones.

Research like this should ease your mind. The decisions that you and your doctor make -- about when to start treatment, which treatment to try, and what to prioritize -- in the end, those decisions probably won't affect your survival. You don't need to say "Maybe I should have tried a different treatment" or, more to the point of this study, "Maybe I ignored that symptom too long and I would have been better off if I had been diagnosed earlier."

Forgive yourself. You made the right decision, no matter what it was. 

As I said, I'd love to see some research that tells us the right thing to do, with no doubts or questions.

But research like this is second best -- it tells us that whatever it was that we did, it was OK.

Take care, everyone.

Princess Catherine and Survivorship

Catherine, Princess of Wales, spoke a few days ago about her post-cancer life. It happened as she was visiting patients at a hospital. It seems like it was prompted by her dropping out of an event (the Royal Ascot, a horse racing event) that the Royal Family traditionally attends each year.

In the interview, she talked about the struggles she has had since finishing her cancer treatment. It is remarkable in the way she covers most of the issues that are related to survivorship.

I won't go through everything she said, but it amounts to this:

After successful treatment, everyone, including yourself, can think that everything is OK.  During treatment, she said, "you put on a sort of brave face." But when treatment is over, it can be "really difficult."

Part of the difficulty is physical -- your body is still recovering from the side effects of treatment. As she said, "You're not able to function normally at home as you perhaps once used to."

And part of the change is psychological. After treatment is over, "then it's like 'I can crack on, get back to normal'." But "the phase afterwards is really difficult, you're not necessarily under the clinical team any longer."And without that team that you were working with, there's some element of fear that comes with it. All of this lines up pretty much exactly with the recent survey results that I wrote about a few weeks ago.

One of the patients she talked with agreed: "It can be very discombobulating, in that time when you've finished active treatment."

I think all of this is a great reminder that survivorship isn't easy. As she said, "It's life-changing for anyone, through first diagnosis or post treatment and things like that, it is a life-changing experience both for the patient but also for the families as well....You have to find your new normal and that takes time... and it's a rollercoaster it's not one smooth plane, which you expect it to be. But the reality is it's not, you go through hard times."

And in a weird way, that should be comforting. If you're post-treatment and struggling, whether it's physical or emotional or spiritual -- you're not alone. I'm sure Catherine is getting the best treatment and post-treatment care possible, and she's struggling anyway. Cancer doesn't much care whether or not you have a crown on your head.

The lesson, of course, is to seek help if you feel like you need it. See if your cancer center has a survivorship program. If not, ask your oncologist of there are services available -- physical therapy, or a social worker or other mental health counselor, or a nutritionist, or something else (the Princess apparently found acupuncture very helpful).   

I appreciate Princess Catherine being willing to speak out about this. I remember when her diagnosis was first announced, there was little detail given, and I defended her right to keep things private. We all need to deal with our diagnosis and treatment in whatever way makes most sense to us and helps us. I would love it if every famous person was completely open about everything. But that's not their responsibility. They owe no one anything, except themselves and their loved ones.

So Catherine speaking out about survivorship is a wonderful thing. I hope it brings some comfort to a lot of patients and survivors.

Primary Extranodal Follicular Lymphoma

The journal Hematological Oncology just published an article called "Primary Extranodal Follicular Lymphoma: A Retrospective Survey of the International Extranodal Lymphoma Study Group (IELSG)." It actually doesn't affect most of us directly, but I think the bigger picture is probably important to us all.

The study described in the article looks at Primary Extranodal Follicular Lymphoma.

Extranodal FL means FL that exists outside the lymph nodes, and other organs related to the lymphatic system like the spleen and bone marrow. It's fairly common for FL to move out of the lymph nodes and into the spleen or bone marrow -- that's the very definition of stage 4 for FL, and about a quarter of FL patients are diagnosed with that stage. 

And if the lymphoma starts in the lymph nodes and then moves somewhere else, it's called secondary extranodal FL.

This article looks at primary extranodal FL -- it starts in some part of the body other than the lymph nodes.  

As I said, this doesn't apply to most of us, but I have communicated with a few readers over the last couple of years who have had their FL present in this way. Maybe some of you are still reading.

The research was conducted by the International Extranodal Lymphoma Study Group (IELSG), made up of Lymphoma experts who are specialists in these types of Lymphomas. Keep in mind that "Lymphoma" is a very broad term, and there are as many as 90 different types of Lymphoma, depending on who is doing the counting. About 30 of them are Extranodal types.

This research looked specifically at Primary Extranodal Follicular Lymphoma. This seems much less common than other types of Extranodal Lymphomas. I say "seems" because, as the authors note, extranodal FL "has not been extensively described." So they set out to find as much as they could by surveying specialists about cases that they had documented. They looked at "605 pathologically reviewed cases from 19 different countries" so they could compare the clinical features at diagnosis and their outcomes, and compare them to nodal FL.

What they found was that the two most common sites for Extranodal FL were the skin (334 of the 605 they looked at) and the gastrointestinal tract (72 of 605). More importantly, those two subsets were very different from nodal FL and had different Overall Survival patterns. After a median follow-up of 5.5 years, the cutaneous (skin) FL had an 89% 10 year OS, and the gastrointestinal FL had a median 10 year OS of 79%. For those gastrointestinal FL that presented in the duodenum (the first part of the small intestine), the OS was 95%. Other extranodal FL sites were similar to nodal FL. 

I think this is all good news for those of you with Primary Extranodal FL.

The bigger picture, though, is what interests me more. The researchers conclude by saying "These findings support the identification of specific primary FL localizations as distinct entities with particular clinical and biological characteristics." In other words, not all FLs are the same.

In some ways, that's really obvious. FL has a reputation for being heterogeneous -- it seems like we're all a little bit different. That was the conclusion of one of the ASCO presentations that I reviewed a couple of weeks ago. 

And yet, as obvious as it seems, we're still all kind of lumped in together as "Patients with Follicular Lymphoma." I think this goes back to not so many years ago, when diagnosis was done mostly by microscope. On the surface, all FL cells look very alike. As diagnostic tools, and our understanding of genetic features, becomes more sophisticated, it gets easier to see the differences. So some of us are probably still close enough to be a patient with FL, and to follow the same treatment recommendations as everyone else.

But that greater recognition that not every FL is the same will have significant implications in the future. We already know that, for example, grade 3B FL isn't really like other FLs. And POD24 FLs aren't really the same as others. But the more researchers can recognize specific features of different subtypes, the better off we will all be when it comes to diagnosis and treatment.

So that's my takeaway from all of this. It seems like very positive news for those of you for with Primary Extranodal FL. And for all of us, it's at least a small step toward making FL a little more manageable by identifying the things that make it heterogeneous. 

And those small steps are what move us forward.

 

Survivorship and Lymphoma

I've written a lot lately about the idea of "survivorship" -- what happens after treatment is over. It's an important issue for al cancer patients. Very often, health professionals are focused on making us better, and there isn't time or resources or expertise to deal with what happens after that. 

That's changing somewhat, and more and more cancer centers are focusing on survivorship, sometimes by having a dedicated office or clinic for patients who are no longer "patients," but who are still dealing with the physical and emotional effects of cancer, months or years later. That's certainly not the case for every cancer center, though.

I bring this up again because JCO Oncology Practice recently published an editorial on the topic, specifically on survivorship for Lymphoma patients.

I'll get to that, but first I want to look at the article that the editorial was responding to. It was aso published in JCOOP, in February. It's called "Perspectives of Lymphoma Survivors and Oncology Care Providers on Survivorship Care: A Qualitative Study." The article presents research based on in-depth interviews with 32 Lymphoma patients and 13 oncologists. This is what a "qualitative" study is, as opposed to a "quantitative" study. Rather than giving a survey to a large number of patients and presenting the results as numbers, it looks at a smaller number of patients and looks for themes and patterns in their words. (Both types of research can be valuable.)

The research found three main themes. I don't think any of them will surprise you. The first is that Lymphoma patients often have a "profound fear of recurrence" and anxiety after treatment is finished. Patients wanted more information about signs and symptoms that their cancer might return, and more reassurance from their cancer team. 

The second is had to do with which doctor to see after treatment was "finished." Some wanted to continue to see an oncologist. Some were forced to see a primary care physician instead. Others saw the value of seeing a PCP but had trouble finding one. It's a complicated issue, and one that came up during the Follicular Lymphoma Foundation webinar that I spoke at earlier this month.  

Finally, during the interviews, it became clear to the researchers that formal survivorship programs were necessary, and that they needed to include psychosocial support, wellness services, and assistance with financial and employment programs to help survivors transition to their different lives. 

That last sentence was a hard sentence to write -- I tried "go back to their old lives," but there's really no going back. Then I tried "their new lives" but that's not right either, because it kind of implies that everything is OK after treatment is over, and it's not. So I went with "different lives," which I'm also not satisfied with, but which is probably more accurate than "old" or "new." And that pretty much sums up why survivorship is such a complex topic, doesn't it?

And I also recognize that "survivorship" is different Follicular Lymphoma survivors. That first one, the fear of recurrence, might be worse for us. If you're like me, you've been told since diagnosis that it's incurable, and we can expect to to come back. So maybe it's better, not worse, since many of us just accept that recurrence is inevitable and we can prepare ourselves for it?

 Like I said -- it's a complex topic. And it affects each of us a little differently. 

Which brings us to the more recent piece from JCOOP, published a couple of weeks ago, in response to the qualitative research above. It's called "Bridging the Gap: The Essential Role of Lymphoma Clinicians in Guiding the Transition From Lymphoma Treatment to Survivorship." 

As the authors of this piece note, one of the big issues related to survivorship is the lack of information that Lymphoma patients receive about what their lives will be like after successful treatment. That's certainly a factor in the fear that patients feel in that first theme. And its a factor in the second one, too, in the confusion about seeing an oncologist vs seeing a PCP -- will a PCP know enough about Lymphoma to be useful? Ideally, the type of information that patients receive would be personalized, since each of us does deal with survivorship in our own way.

Given that JCOOP is a medical journal for oncologists that work with patients, the recommendations from the authors are aimed at Lymphoma clinicians -- the oncologists that work most directly with Lymphoma patients. But they have lessons for us as patients, too.

Their first bit of advice for oncologists is to Prepare -- to start conversations with patients early, and continue them over time. Since patients tend to be focused on the present, it helps to gradually and repeatedly introduce the idea of survivorship over time, to let it all sink in. They suggest the use of Survivorship Care Plans -- a written record of your treatment and symptoms, including emotional symptoms, and how you'd like your concerns to be addressed. That's an excellent idea for us as patients -- consider creating one even if your oncologist doesn't suggest one formally.

The second bit of advice is to Acknowledge and Assess -- for the oncologist to ask questions about emotional well-being and fears, and to recognize that they are valid. As patients, we can help here by bringing them up even if the oncologist does not. I think it's also important to be prepared to have an oncologist that may dismiss them ("You have nothing to be worried about") or downplay them, or just not know how to deal with them. I like to think that someone in oncology would be well-aware of patients' fears, but I know that isn't always the case. Be open about it anyway. If nothing else, it will be a good education for the oncologist.

The third piece of advice for oncologists is Connect -- to be aware of survivorship services and help patients make contact with them. Again, as patients, we can ask questions about these kinds of services. They are often available, even if some oncologists don't know that. Pushing for information might make a less-informed oncologist seek out the information. And a well-informed oncologist will be able to pass on that information to you.

Finally, the last bit of advice for oncologists is to Evaluate and Document -- to ask patients how they are doing and make sure that their emotional well-being becomes a part of the permanent record. Again, we can help as patients by making sure that we bring up the subject ourselves. And it's not just emotional issues or concerns -- we should bring up physical issues, financial issues, anything that cancer has done to make our lives different.

As you can tell, I think the message to oncologists is interesting, but more importantly, I think the JCOOP piece provides an opportunity for us as patients. Some of us might be fortunate enough to be affiliated with a cancer center that has a survivorship program, and to have an oncologist that knows about it and intervenes early. Or maybe the opposite is true -- no program and an oncologist that isn't aware of the issues. Or maybe something in between.

Whatever the case, I think it's important for us as patients to be proactive. We need to be aware of our own needs, and unafraid to bring them up. If enough of us do so, it becomes a regular and expected part of our conversations with our doctors. That's good for all of us.

Stay well, and stay proactive.

FDA approval for Tafasitamab-cxix for R/R FL

The FDA has approved Tafasitamab-cxix (also known as Monjuvi) in combination with Lenalidomide (also known as Revlimid) and Rituxan for Relapsed/Refractory Follicular Lymphoma.

I wrote about this combination in November, just before the ASH conference. The results of a phase III clinical trial were being presented at ASH, and the website Fierce Pharma called the early results a "triumph." The makers of Tafasitamab had said immediately afterwards that they were going to seek FDA approval. And it came.

Tafasitamab had already been approved by both the FDA and the EU for use on R/R Diffuse Large B Cell Lymphoma, in combination with Lenalidomide.

Tafasitamab is a monoclonal antibody, like Rituxan. But Tafasitamab targets a different protein, CD19, on the surface of B cells (Rituxan targets CD20). The idea was that combining the two (along with Lenalidomide) would increase the chances that the treatment could find the cancer cells. That seems to have been the case.

The trial involved a direct comparison between Tafasitamab + Lenalidomide + Rituxan and a placebo + Lenalidomide + Rituxan. In other words, patients in the trial were going to receive either this new combination or just R-squared (Lenalidomide/Revlimid + Rituxan). Patients in the trial had already received at least one treatment for their FL already.

As Fierce Pharma said, the results were triumphant. After a median follow up of 14.1 months, the Progression Free Survival for the Tafasitamab combination was 22.4 months and 13.9 months in the other group. The Complete Response Rate was 49.9% for Tafasitamab and 39.8% for the other group, and the Overall Response Rate was 83.5% vs 72.4%.

The question with the combination was going to be about safety. Monoclonal antibodies like Tafasitamab and Rituxan work by eliminating B Lymphocytes, a kind of immune cell. They target both healthy B cells and cancerous B cells. So while having two antibodies targeting the same cells might mean it's more effective, it also means you're running the risk f having too many immune cells being disabled all at once, opening up the possibility of greater risk of infections.

And that did happen. In their announcement, the FDA points out that "serious adverse reactions occurred in 33% of patients" in the Tafasitamab group, including serious infections in 24% of participants.The announcement doesn't give a direct comparison to the other group in the trial, though the ASH presentation did -- 36% of the Tafasitamab group vs 32% for the other group (the FDA numbers are a little different because they were updated 6 months later). Also in the ASH presentation, it was noted that during the study, 15 patients in the Tafasitamab group died, 5 because of disease progression and 6 because of side effects, versus 23 in the other group (17 due to disease progression and 6 from side effects). 

It will be interesting to see how popular this combination becomes with oncologists. Will this become a substitute for R-Squared? Similar way of working, but more effective? Or will some patients still be given R-squared instead because it seems slightly less aggressive on the immune system? (Remember, I'm not a medical doctor -- these are just questions that are coming to me immediately after reading this). I look forward to reading more commentaries in the coming weeks and months.

ASCO: Exercise and Cancer

A reader left a comment on my last post that I want to address here, rather than in the comment section:

Thank you for ASCO coverage. Seems ASCO's headline grabber this year was the "Structured Exercise Program Improves Survival Outcomes in Patients With Stage III or High-Risk Stage II Colon Cancer" story. Do you think this study translates to FL folks, especially in terms of recurrence and survival? I just noticed current Mayo study along the same lines for indolent NHL lymphomas CLL and MZL. Any "there" there?

I have been reading about this presentation, and I was considering writing about it (especially since there is so little to write about Follicular Lymphoma this year. 

My quick take on it is this -- it's a study that describes a very specific research project, and was reported with some headlines that make it seem to affect many more people than it actually does. It is both excellent research and a good lesson in reading carefully.

***************

Let me start off with one of the headlines that describe this study (from NBCNews.com, which shouldn't be so clickbaity): "Exercise may benefit colon cancer patients as much as some drugs."

Now, clickbait is a headline that is meant to get you to click on it and visit the page. If I'm being fair, the title I'm using for this blog post is kind of clickbaity, but that's the point -- the title doesn't fully represent what the content of the article says, exactly. There were a lot of articles that did something similar, speaking in very general terms about the study to make it more attractive to readers. It's a very common tactic in popular science writing. The NBC News headline makes it sound like exercise is a substitute for more traditional cancer treatments for anyone with colon cancer.

That's not the case. Exercise didn't cure anyone's cancer.

But that's not to say it isn't an important study. From what I read, when the presentation was finished, the oncologists in attendance actually gave a standing ovation. So what the study actually says is still pretty important.

The presentation is #LBA3510 "A randomized phase III trial of the impact of a structured exercise program on disease-free survival (DFS) in stage 3 or high-risk stage 2 colon cancer: Canadian Cancer Trials Group (CCTG) CO.21 (CHALLENGE)."

The study looked at 889 patients with colon cancer from Canada and Australia, median age 61. About 90% of the patients had stage III colon cancer, and the other 10% had high risk stage II. The patients all had surgery followed by adjuvant chemotherapy (that is, chemo that was meant to "clean up" any remaining cancer).

It's worth repeating this, given the headlines -- all of the patients had surgery and chemotherapy. Traditional cancer treatments played a huge role in making them cancer-free. Exercise did not cure or prevent their cancer, at least in this particular study.

After chemotherapy, patients were split into two groups. The first group was given Health Education Materials (the abstract calls this the HEM group) that promoted good nutrition and exercise. The second group was given a Structured Exercise Program (they are the SEP group), supervised by a Physical Activity Consultant, who met with them twice each month for three years. The specific physical activity was chosen by the SEP patient. It could have been working out in a gym or it could have been just walking for 45 minutes per day. But it was structured, supervised, and done regularly. 

The results were fascinating. With a median follow-up of almost 8 years, 93 patients in the SEP group had their cancer come back, compared to 131 in the HEM group. After 5 years, the disease-free survival (DFS) was 80% for the SEP patients and 74% for the HEM patients. The 8 year Overall Survival was 90% for SEP and 83% for HEM.

This was a fairly large stage 3 clinical trial, not just observations or reports from patients, and that's what makes it so impressive. The patients in the trial reported in with their consultant every two weeks for 3 years. All of this is enough to make it pretty clear that the difference in the two groups with the physical activity that one group performed. Exercise didn't cure anyone's cancer, but it might have helped keep 90% of the patients alive for 8 years.

Now, I want to be clear about something else -- the reader who left the comment wasn't implying that exercise alone was a replacement for conventional treatment. The reader is clearly reading carefully, even referencing another Mayo Clinic trial on blood cancer. That reader is being careful.

That said, I don't know the answer to their question, Do you think this study translates to FL folks, especially in terms of recurrence and survival? I just noticed current Mayo study along the same lines for indolent NHL lymphomas CLL and MZL. Any "there" there?

This is a good time to once again remind everyone that I am not a medical doctor, and the best person to ask about treatment and lifestyle choices is your own oncologist. 

But I will say, for what it's worth, as a non-expert, I think exercise is an excellent idea, whether you are watching and waiting, in active treatment, or post-treatment. Moving our bodies is always a good thing. 

One of the great details from this study is the range of exercise that the participants engaged in, and the fact that it was their choice. I've heard it said that the best exercise that you can do is the one that you enjoy enough to keep on doing it. Sometimes when we think of a "structured exercise program,"  we imagine going to a gym and having a trainer yell at us as we push large amounts of weight. If that's what you enjoy, keep doing it. But if a 2 mile walk every morning is your thing (as it is with my wife and me), then keep that up. And if you have physical issues that make that harder, then find something else -- a shorter walk, or chair yoga, or water aerobics. But keep moving.

The best part of all of this was the enthusiastic reaction of the oncologists in attendance. I hope this means there will be follow-ups -- more rigorous studies on the benefits of exercise, whether it's post-treatment or during treatment. 

So I certainly hope there is some "there" there. We'll know for sure when the results of the Mayo trial get presented or published.

In the meantime, I encourage you to do two things:

1) Read carefully.

2) Keep moving.

More soon. 

 

ASCO: Amulirafusp alfa

 As I have been saying, there really weren't a lot of presentations on Follicular Lymphoma at ASCO this year, and most of them have been focused on treatments that are already established.

But there is at least one presentation on a newer treatment. It's one that I haven't written about before. (To be clear, I'm not saying that I manage to write about everything FL-related. But this is definitely one that I haven't mentioned before.)

The presentation is Abstract #7051: "Phase II safety and preliminary efficacy of amulirafusp alfa (IMM0306) in combination with lenalidomide in patients with relapsed or refractory CD20-positive follicular lymphoma." I actually remember reading about this when I looked at abstracts from ASH in November and December, but for whatever reason, I decided not to write about it. The ASH presentation looked at phase 1 trial results. This one looks at phase 2 results.

In this research, a treatment called Amulirafusp Alfa is given in combination with Lenalidomide (also known as Revlimid, one of the Rs in R-Squared). Amulirafusp Alfa is a very interesting treatment. It worls in ways that are similar to a bispecific, but it isn't a bispecific (which attaches to a protein on a lymphoma cell, and to a protein on a T cell, a kind of immune cell, bringing them together so the T cell can elimiate the cancer cell).

Amulirafusp Alfa works by targeting two proteins on the lymphoma cell. One of them is CD20, the same protein that is targeted by Rituxan and by some bispecifics. But it also targets CD47, another protein on the cell. By attaching to CD47, it blocks something called SIRPα (Signal Regulatory Protein a). When CD47 and SIRPα interact, they send a "Don't Eat Me" signal to the immune system. When that interaction is blocked, the immune system can eliminate the lymphoma cell.

And just as a bispecific is an immunotherapy -- it allows the body's T cells to work against cancer cells -- Amulirafusp Alfa allows other (even more powerful) immune cells to work against the cancer cells, in this case Macrophages and NK/Natural Killer cells.

This phase 2 trial involves 34 patients with Relapsed/Refractory FL. All of them had a previous treatment with anti-CD20. In the study, 22 patients were evaluated; 10 of them had a Complete Response (45%), 8 had a Partial Response, making the Overall Response Rate 82%; 2 more had Stable Disease. As for safety, the side effects were considered "well-tolerated," with most pateints having descreased blood cell counts of different types, another 35% having an infusion-related reaction. About 65% of patients had a more serious (grade 3 or higher) side effect. 

It certainly seems like a promising treatment, one that works in ways that are different from what we have seen so far.  It will be interesting to see updated figures (only 22 of the 34 patients in the phase 2 trial were evaluated), and to see how this treatment goes in a larger phase 3 trial.

Definitely one to keep an eye on.