Cancer Newsletter

I spend a  lot of time reading about cancer, as you probably know (or you can probably tell). 

I get lots of stuff in my email inbox about cancer, some of which I asked for, and some of which I did not. (I was contacted by a public relations aggregator years ago. They send press releases to journalists and bloggers, and they asked if I wanted to be included. I said yes, so about 20 times a day I get an email from someone pushing a product or a story related to "health" in some way. Very occasionally, it's something useful. Mostly it isn't anything that I want to write about. But I do enjoy knowing what is being pushed when it comes to "health."

One thing that I did receive that has been useful and interesting is a newsletter called Breaking Cancer News. That title sounds fake, to be honest. I fully expected it to be a newsletter full of stories about one product that was really questionable. But the first time I received it, I spotted a name that let me know it was legitimate. 

The name was Jamie Reno, who is the editor of the newsletter. He's also a long-time journalist who used to write for Newsweek and Healthline and a whole lot of other publications. I know the name because he has also been diagnosed with Follicular Lymphoma about 22 years ago. He wrote a book called Hope Begins in the Dark, which tells the story of 50 patients who were diagnosed with Lymphoma. And if my memory is correct, he was an early user of RadioImmunoTherapy (RIT).

So if it's cancer-related, and Jamie Reno's name is on it, I feel like I can trust it.

I signed up to get Breaking Cancer News sent to me once a week, and I am enjoying it (as much as someone can enjoy reading about cancer). The stories are written with a general audience in mind, so they're easy to understand (unlike most of the stuff I link to in this blog). And the stories deal with current issues, as the name of the newsletter suggests. Not necessarily about things like FDA approvals or clinical trials. More about issues that affect all patients, caregivers, and advocates.  

For example, in this week's issue, there's a short commentary from Jamie Reno about how politics is keeping a cancer funding initiative from being passed in Congress. Then there's a story on multi-drug resistance -- how cancer cells can find ways to survive multiple treatments, and what researchers are trying to do about it. And finally there's a story on some of the latest developments in cancer prevention and detection. 

None of this is about Follicular Lymphoma, specifically, but it does provide some interesting context on the larger issues that affect cancer patients and researchers. I like the big picture it provides me.

The header on the newsletter says it was developed in partnership with the organization Teen Cancer America, which focuses on helping young people who have been diagnosed. And the newsletter's tag line is "Plain talk about what's hot and hopeful in the cancer arena -- for young people and anyone else who's listening." But don't be fooled -- there's good stuff in there for all of us.

I don't have any affiliation with the newsletter or the organization that sponsors it. I've been reading it for a few months now, and it seemed like something worth sharing. I hope you'll find it interesting.

Improved Outcomes for Transformed FL

The journal Cancer Medicine  published a very interesting article lest month called "Outcomes of the transformation of follicular lymphoma to diffuse large B-cell lymphoma in the rituximab era: A population-based study." It describes a large research study that compared the outcomes for patients who were diagnosed with Diffuse Large B Cell Lymphoma (DLBCL), an aggressive type of Lymphoma, with those who were diagnosed first with Follicular Lymphoma and whose disease then transformed to DLBCL. There's lots of interesting data here, but the most important is this -- in the last 20 years, outcomes for FL patients with transformed lymphoma are greatly improved.

It is important to note that this is a "population study," meaning the researchers didn't look at individual patients. Instead, they looked at a large database called the SEER (Surveillance, Epidemiology, and End Results). You're probably in it -- oncologists upload anonymous data into the SEER database so this kind of large study can be done. Population study look at trends, rather than individual patients. But because they are looking at large numbers of patients, the results can be very interesting.

For this study, the researchers were interested in patients with transformed FL who were diagnosed between 2000 and 2020. This time period is known as "The Rituxan Era." Rituxan was approved by the FDA in 1997, and there were big improvements in FL patient outcomes once Rituxan started getting mixed with traditional chemo, and then with other treatments. As the researchers note, small studies focused on transformed FL are inconsistent in what they reveal, so they thought a large study like this would be helpful.

And it is indeed large. The researchers found 50,332 FL patients in the database who were diagnosed in that 20 year period, along with 95,933 patients who were diagnosed with primary DLBCL (in other words, they didn't have FL first). Of those 50,000+ FL patients, 1631 had disease that transformed. 

That in itself is very significant to me. When I was diagnosed (in 2007), I read in many places that as many as 50% of FL patients would end up with transformed disease, which was alarming to me. Over time, in the small studies that I read, the numbers would usually come as closer to 15 or 20%. That's slightly less worrisome. But in this large study, only 3.2% of FL patients transformed to DLBCL. That is, obviously, a significantly smaller number. 

(I'm not suggesting the old research was wrong, or the new research is wrong, or that transformation is no longer a big deal. Just that the smaller number is very surprising to me.)

In fact, it's important to note that one of the things the researchers make clear is that transformation has a serious impact on Overall Survival. For patients with transformed disease, the OS rate at 10 years was 56.6%, with a median survival of 137 months (a little over 11 years), with a range of 2 months to 21 years. For patients who did not have transformed disease, the 10 year OS was 64.8%,  with a median survival of 194 months (about 16 years), with the same range of 2 months to 21 years. So clearly, transformation is still a big deal.

But the larger point they're trying to make still holds true --  compared to the time before Rituxan, outcomes for transformed FL are better. 

A few other interesting bits:

• Patients who had received Radiotherapy or who Watched and Waited had better outcome after transformation than those who received traditional chemotherapy or a combination of chemo and radiation. (they don't get into why this might be so, but my guess is that it has less to do with the treatment itself and more to do with how aggressive the disease was before transformation. FL patients who watch and wait tend to have less aggressive disease; those who get chemo tend to have more aggressive disease. All of that is entirely my own, non-expert guess.)
• Patients whose disease transformed soon after their FL diagnosis (within 18 months) tended to do better than those with later transformation (after 18 months). I wonder if this had to do more with how long it took to discover the transformation, rather than the actual transformation. Again -- my non-expert guess.
  
• There are more options now for treating transformed FL, obviously. The recommendation used to be a Stem Cell Transplant. That's still an option, but no longer automatic, especially as more FL patients have traditional chemo "reserved" as a later possibility.

It's fascinating to me that, even 16 years after I was first diagnosed, we still have lots of unanswered questions about transformation -- and about so many other aspects of Follicular Lymphoma.  But despite the lack of answers, we are still seeing overall improvement as a group. And that's worth celebrating.

Patient-Derived Lymphoma Spheroids

That post title is a lot, but it's the subject of some very cool recent research on Follicular Lymphoma that might be a big help to us someday.

The Blood Cancer Journal just published an article called "Patient-Derived Follicular Lymphoma Spheroids Recapitulate Lymph Node Signaling and Immune Profile Uncovering Galectin-9 as a Novel Immunotherapeutic Target." There's a lot of science in that title, and even more in the article, but as I said, it's very cool research.

The article describes the use of something called a Lymphoma Spheroid. As the "sphere" in the name implies, it's kind of a ball of lymphoma cells plus some other things. And here's why it's important.

Before a cancer treatment can be tried out on people in a phase 1 trial, it needs to go through a whole bunch of "pre-clinical" steps. After a possible treatment is developed (and there's whole bunch of steps to go through with that, but that's another post), the next step is come up with a target for treatment, and then figure out if the new treatment will work on that target. This is usually done "in a test tube," mixing the treatment with some cancer cells.

But it's much more complicated than that. Think about it -- if I put some cancer cells in a test tub and then added some gasoline, the gasoline would almost certainly kill the cancer cells. But that's not helpful -- you wouldn't want to put gasoline into your body. It would kill all of your cells, not just your cancer cells. So you need a treatment that will work on the cancer cells but do minimal damage to healthy cells. That's a little bit more of a challenge.

Even then, it gets complicated. A treatment can work fine in a test tube, but then fail when it's given an actual patient. Why? A big reason is the microenvironment for the cell. This is everything that physically surrounds the cell. And the microenvironment plays a huge role in cancer cells surviving. People (you may have noticed) are not just individual cells; we are complex systems. Change one thing in a person, and you're likely to change a bunch of other things. You bang your toe, and soon your back hurts, because you're walking differently. With a sore back, you don't sleep well. Without sleep, you need more coffee. This makes you jumpy and you can't sit for long. this makes your sore back worse. 

You get the idea. Works the same for cancer cells. You try to kill a cancer cell, and something else gets in the way -- an immune cell, an enzyme, a protein. If it was easy to kill cancer cells, you wouldn't be here reading this.

The idea of a Lymphoma Spheroid is an attempt to deal with this challenge. It's been around for a few years, with some interesting research already being done with it.

Rather than just putting an FL cell in a test tube, the Patient-derived Lymphoma Spheroid attempt to create a 3D model of what's happening in the body -- recreating as best it can the microenvironment that the FL cell exists in. The researchers mixed together a formula with about 60% tumor B cells, and then added about 13% T cells that have the CD4 protein, and another 3% that have CD8. The researchers found that this mix kind of organizes itself into something that resembles what's happening in the patient's body, with the spheroid doing things like producing things like PD1 and CD3 that are already targets for treatments.

Just as important, it's showing that there are new targets for Lymphoma researchers to create treatments for, like CD39, a protein on the surface of the cancer cell. Some other research found that Obinutuzumab and Nivolumab, an anti-PD1 treatment, might be effective. 

The article from this week used Patient-Derived Lymphoma Spheroids to show that a protein called galectin-9 can lessen the effectiveness of Rituxan, and so they are proposing that galectin-9 would be a good target for future treatments. 

The most important thing with all of this is not just the "Lymphoma Spheroid" part of it, but the "Patient-Derived" part. Follicular Lymphoma is heterogeneous -- it shows up in very different ways for different patients. That's why there is no real agreement on what the best way to treat it is. But the Patient-Derived Lymphoma Spheroid takes cells from each patient. In other words, this isn't an attempt to study how FL behaves. It's an attempt to study how your FL behaves. We're all different, so recreating your personal microenvironment should, at least in theory, tell your doctor which treatments are likely to work best for you. that's what "personalized medicine" is all about.

Will this ultimately change things? Hard to say. Lots of cool things turn out to work less effectively than we'd hoped, once they get tested out on a large group of patients. But there's already a growing body of research that is showing some success. Time will tell.

But for me, getting (and sharing) a little bit more insight into the process for developing treatments is also the cool part. I often see (and share) research that is much farther along, and the closer it gets to the doctor's office, the more exciting it is. But there is a whole lot of work that goes into that journey from a test tube in a lab to an intravenous tube in a treatment room, and I like the reminder of that.

More good stuff to come. The ASCO abstracts are due out very soon....

2024 Social Health Awards

It's that time of year again -- voting for the Social Health Awards is now taking place.

The Social Health Awards as sponsored by Health Union, and they recognize online health advocates who represent patients with a wide range of health conditions. There are 10 categories for the awards, ranging from Rookie of the Year to Lifetime Achievement Award, recognizing efforts at caregiving, using social media, working as a team, etc. I have been blessed to have been nominated many times in the past (and thanks to those of you who have nominated me), and I was fortunate enough to have been a finalist twice. 

This year, I have been nominated in three categories (these are the descriptions from the awards website):

1) "Healthcare Collaborator: The Healthcare Collaborator category is for advocates who bridge the gaps between industry stakeholders and healthcare consumers. Whether speaking at conferences, consulting with healthcare companies, or using their experience to help change the healthcare industry, these Patient Leaders are impacting the healthcare landscape."

2) "Community Cultivator: A diagnosis can be life-changing, but fortunately, so can the support from an online community. The Community Cultivator category celebrates the online communities or forums that create an inviting space for newcomers while maintaining a safe place. Whether through online support groups, live events, or forum discussions, these leaders have mastered managing, moderating, and engaging their communities all to support others."

3) "Revolutionary Researcher: The Revolutionary Researcher category aims to celebrate the patients and caregivers who refuse to let medical jargon and data slow them down! The winner of this category stays up-to-date on the latest research, treatments, and clinical trials. This winner has a knack for transforming complex information into layman's terms for the greater community."

The nomination period is actually still going, and will continue until May 3.

But also happening now, and until May 3, is the voting.  

If you are interested in voting for me, you need to go to the voting page.  If you've done this in the past, the process is a little different this year. Instead of going to my profile and voting for me there, you need to go to the pull down menu for the category on the voting page. From there, scroll down the list of names until you find me: Bob McEachern (they should be alphabetical by first name, so look under "B.")

Be aware, though, that in order to vote, you need to provide an email address, and you'll be placed on Health Union's email list. That's not a bad thing -- check out their site Blood-Cancer.com, which I write for occasionally. Lots of good stuff there. But if you'd rather not share an email address and vote, that's fine. I appreciate your support in other ways, like reading the blog.

So thanks for considering voting for me in one or all three of the categories I've been nominated for. And thanks for reading.

 

Treatment Options for R/R Follicular Lymphoma (video series)

The ASCO Post, a kind of newspaper for oncologists, published a video series on treating relapsed/refractory Follicular Lymphoma. If you've been reading for a while, you know how much I enjoy watching video series like this one. I like listening to experts get excited about treatment options. 

For this series, the participants are Dr. Andrew M. Evens (Rutgers University), Dr. L. Elizabeth Budde (City of Hope Medical Center), and Dr. Carla Casulo (University of Rochester). What's especially interesting about this series is that instead of talking about treatments in general, they look at case studies of specific patients. That matters -- with a disease that can look really different for different people, it's interesting to see the kinds of factors that the oncologists consider when making treatment decisions. Of course, seeing the actual patient would be even better -- knowing their goals, their families, their histories, all of the things that make them people and not just "case studies." But even the few specific clinical details that are given are better in some ways than looking at statistics from a group of 100 patients in a clinical trial.

(By the way, each of the videos includes a transcript, in case you'd rather read or need to translate.)

The first video focuses on a patient who was diagnosed with grade 1/2 Follicular Lymphoma, and had successful treatment with Bendamustine and Rituxan. But the FL returned just 8 months later, making the patient POD24 (Progression of Disease within 24 months after receiving immuno-chemotherapy). About 20% of FL patients are POD24, and POD24 patients have a statistically lower survival rate than most FL patients. Reseachers have been payin special attention to this group, trying to identify biomarkers that could signal POD24 early on (right now, there's no clear way to predict it -- you just have to wait for it to happen).  The discussion in the video talks about what POD24 is, the types of treatments available, and whether Auto Stem cell Transplants (using the patient's own stem cells, not a donor's) is still happening these days (you don't hear much about SCT anymore).

The second video discusses a patient who had successful treatment with Rituxan, followed by Rituxan maintenance. This worked for about 4 years, but then he had some leg swelling that showed a return of the FL. More importantly, he had multiple comorbidities -- other serious health issues -- that needed to be taken into account when deciding on a second-line treatment. The conversation for this video focuses on the importance of biopsies and molecular testing to determine a stage and grade for FL that has returned, and how those comorbidities influence the treatment recommendation. (I'll let you guess which treatment they recommended, then watch the video and see if you are right. I was sort of right.)

Finally, the third video looks at a patient looks at a patient who was treated with R-CHOP (a chemotherapy), and then with B-R when he relapsed (a second chemotherapy), and then presented again with grade 3 FL. This is yet another different situation, as the patient is in a high risk category and has exhausted his chemo options. If you guessed that this third-line treatment decision comes down to choosing between CAR-T and bispecifics, then give yourself a gold star for paying attention to what's going on in the world of FL.

As I said, it's an interesting series, and the focus on actual individuals really emphasizes how different this disease can be. It highlights how important it is to have conversations with your oncologist. I'll speak for myself -- I consider myself lucky to not need treatment right now, and that has given me time to stay up on what my options are. Maybe more importantly, it's given me time to let my oncologist get to know me. When the time does come for additional treatment, it won't be a case of just looking at numbers. He'll have a sense (I hope) of what matters to me, what my treatment goals are, and who I am. I think that's important.

I hope you enjoy the series.

Is Accelerated Approval Successful?

 I know that title is a little click-baity, but I couldn't come up with something short that really captured the complexity of this issue.

The Journal of the American Medical Association published a study last week that looked at treatments that were given Accelerated Approval in the last 10 years. It's called "Clinical Benefit and Regulatory Outcomes of Cancer Drugs Receiving Accelerated Approval." The question they sought to answer (and this is quoted from the article) was "What is the clinical benefit of cancer drugs granted accelerated approval, and on what basis are they converted to regular approval?" In other words, how successful are cancer drugs that are given accelerated approval?

A little background, just so we're clear on what all of this means and why its important. The issue has been on my mind a lot lately, as a couple of posts that I wrote last month would indicate.

Most treatments that get approval from the FDA use the results of a phase 3 clinical trial to provide data for the application. Phase 1 trials are usually very small, and their main purpose is to show safety -- they help determine the best dose of the treatment to be effective while being safe. Phase 2 trials focus more on effectiveness, and use a larger number of patients to show that the treatment actually works. Phase 3 trials are, ideally, randomized and double-blind, meaning the new treatment is given to half of the patients in the trial, while the other half gets the old treatment (the "standard of care" -- the one that patients would usually receive). This allows for a direct comparison between the new and the old, so the FDA can see that the new is more effective and/or safer than the old. 

With accelerated approval, the makers of a treatment can apply to have their treatment approved after the phase 2 trial. Accelerated approval is usually given for treatment classes that are brand new, allowing a potentially life-saving treatment to get to patients faster then if they went through the full trial process. This benefits patients because a treatment might get to them sooner. And it certainly benefits the maker of the treatment because they can start making money (and recouping the money they put into research) sooner. 

But part of the deal is that the clinical trial process has to continue. A "confirmatory trial" has to happen to show that the good results from the smaller phase 2 trial will actually hold up over time. If the trial is successful, then the treatment gets full approval. If not, then the treatment is withdrawn.

The JAMA article, then, wants to know just how successful those accelerated approvals are -- how many actually go on to get full approval.

The authors looked back at the 129 cancer treatments that were given accelerated approval by the FDA between 2013 and 2017, and then looked at the 46 of them that had follow-up data after 5 years. The results were not great, in terms of how many showed an improvement in survival or quality of life -- only 20 of the 46 (or 43%).

Despite that, 29 of the 46 (63%) went on to get full approval. Another 10 (22%) were withdrawn, and 7 of the (15%) were still in the confirmatory trial process.

Looking at those 29 that did get full approval, only 7 of them (24%) were shown to improve both overall survival and quality of life. Another 7 improved overall survival but not quality of life, and 6 improved quality of life but not overall survival. The remaining 9 did not improve either one.

Those number are very important, which is why I'm sharing them, but I also have to point out some limitations here. I'm not able to access the full article, so I'm not sure how they measuring "quality of life." Overall survival is easy enough to measure, but quality of life is harder, and I'm not sure every study uses the kinds of patient-reported quality of life measurements that I'm familiar with. I guess that's how they measure safety, looking at the side effects that patients experienced? That would be the standard measurement in a clinical trial. If that;s the case, I really do not like referring to it as "quality of life." That completely ignores a whole lot of things that should be included in a measurement of the quality of life. 

Aside from that, Overall Survival is a complicated measurement, too. There are certainly cancers that are so aggressive that new treatments are successful when they add months to a patient's life. Then there are others, like Follicular Lymphoma, that have OS measured in years. The measurement can be so long that the median OS hasn't been reached in 5 years. That's actually very common in FL treatment trials, which is why they use Progression Free Survival as a measurement instead. So without looking at the full article, I can't tell if they are counting something like that as improving OS or not improving OS.

This is what I meant when I said it was all kind of complex.

Ultimately, though, I'm not sure those details matter.

The authors of the study provide this conclusion: "Most cancer drugs granted accelerated approval did not demonstrate benefit in overall survival or quality of life within 5 years of accelerated approval. Patients should be clearly informed about the cancer drugs that use the accelerated approval pathway and do not end up showing benefits in patient-centered clinical outcomes."

I would hope that any conversation about treatment with an oncologist would include that information, and that any oncologist would take that into consideration before recommending it to a patient. But I also know, based on the kind of enthusiasm that lots of oncologists had for PI3K inhibitors, that they aren't going to wait for full approval before using them, and that even a preliminary OK from the FDA is good enough. And probably should be.

So, I'll ask the question again that I ask in my title -- Is Accelerated Approval Successful? 

By some measures, No, it isn't. If more than half of accelerated approvals don't result in a better experience for patients, then it seems like the system failed. On the other hand, if the goal is to get new improvements to patients more quickly, than it's a success. And if a large number don't get full approval, then that IS a success. Arguably, the system works -- the treatments that aren't doing the job don't last. If the FDA gave them early approval and then just forgot about them, that would be a problem. But the follow-up makes sure that they are as god as the smaller trial showed.

Of course, "success" isn't just about how well the system works. It's about the patients who get the treatments. Every confirmatory trial that failed means a bunch of patients who didn't get the treatment they had hoped for. And that hurts to think about. From what I can tell, a lot of the treatments get accelerated approval because they offer something that available, standard-of-care treatments can't offer. Think about something like a bi-specific. It works on cancer cells in ways that no other treatment works. If the confirmatory trial involves mostly patients who have tried everything else they could, and they have hope for this new thing that might work in a different way, then that's a success. Clinical trials are necessary, and trials need participants. 

It's all so complex. 

In the end, I think Accelerated Approval has its place, and the authors are right -- being fully informed is key to it all. Talk to your oncologist about treatments, about clinical trials, and about anything else that concerns you. (But you knew that already, you smart, informed FL patients....)

Great Debates: Alternatives to CAR-T

There's a really interesting speaker series that happens every year in New York City called "Great Debates and Updates in Hematological Malignancies." Basically, a bunch of famous oncologists get together, two of them pick sides of a debate about blood cancer, each one speaks for a while, some others comment on what they said, and they move on to the next debate.

It's probably a little bit misleading to call them "debates." I'm not sure they really expect there to be winners and losers. It's more like they are exploring together, looking at issues that don't have definite answers, and offering there thoughts. It's really an alternative format for the kinds of "update videos" that I like to post every now and then.

Follicular Lymphoma seems like a natural fit for something like this, since there really aren't any clear answers when it comes to our disease. Usually at ASH or ASCO every year, someone makes a presentation that looks at the last 10 years or so of FL diagnoses in a database, and how the patients were treated. And the treatment choices will be all over the place -- some watch and wait, some Rituxan, some traditional chemo (some of them Bendamustine and some R-CHOP), some R-squared, plus a bunch of treatments in clinical trials. You see what I'm getting at, I'm sure. There is still no clear treatment path for FL that everyone can agree on. That's partly because FL patients present differently, but also because all of those treatments work, so oncologists just go with what they've always used.

So there's lots to debate, if two oncologists are looking to have a friendly debate.

At this year's "Great Debates" (which happened about a week ago), the FL debate feature Dr. Peter Martin of Weill Cornell and Dr. Caron Jacobson or Dana Farber. The debate centered on Relapsed FL and CAR-T. Dr. Martin's presentation was called "CAR-T Cells Should Be Rarely Used in Relapsed Follicular Lymphoma," while Dr. Jacobson's was "CAR-T Cells Should Be More Often Used in Relapsed Follicular Lymphoma." Pretty straightforward.

Unfortunately, I don't have access to Dr. Jacobson's talk, but I do have an interview with Dr. Martin, where he summarizes what he said at "Great Debates." It's an interesting talk, and worth the 5 minutes it takes to view it (or read the transcript, both of which you can find here.)

I'll give you a summary. Dr. Martin's role in this debate is to argue in favor of "all of the other treatments" besides CAR-T, which seems to me to be the easier side to take. But he focuses in particular on 3 treatment options (and remember, these are for relapsed FL, not for first treatment). Traditional chemotherapy is not one of the options -- "we're al moving beyond that," he says.

The first of the three is R-Squared, or Rituxan + Revlimid (also known as Lenalidomide). In its favor is the fact that we have data from two large trials now, so we know a lot about side effects and effectiveness. As he says, R-squared will work for between 2 and 5 years on average, and it's well-tolerated.  A good option.

Second is Tazemetostat, an EZH2 inhibitor. It works especially on B cells, keeping them from growing, which makes it very well-suited to FL. About 20% of patients have a mutation in EZH2 that makes Tazemetostat a very good option, and it has very few serious side effects. For patients who have the particualr mutation, t can be very effective, especially given the low side effects.

Finally, and "most exciting," according to Dr. Martin, are the bi-specifics. He compares them especially to PI3K inhibitors, saying bi-specifics are geared toward the same population as those who tried the PI3K inhibitors, but the bi-specifics are twice as effective. They can be tricky to administer, and their most serious side effect is Cytokine Release Syndrome. But bi-specifics are also (like Rituxan) open to combinations with other treatments, which could increase effectiveness. 

It's interesting to me that this once again comes down to bi-specifics vs. CAR-T, but that's not a surprise.

What's most important is this statement from Dr. Martin: "I think we're at a very fortunate time in the history of follicular lymphoma to have a number of excellent options."

That's absolutely true, and the most important take away from this "great debate." We do have some excellent options, and more likely on the way.

I'm going to keep an eye out for Dr. Jacobson's talk on why CAR-T should be used more often. She's great, and I'm sure it will be worth sharing. 

But for now, we can remember that we have some other options, and they're very good.