Time Magazine has a piece in this week's issue called "No More Chemo: Doctors Say It's Not So Far-Fetched." The focus is on targeted, molecular-based therapies, and the job they do of focusing on cancer cells instead of healthy cells. If you've been keeping up with things, none of this is news. Still, it's about as good an introduction to the current and future state of cancer treatment as you'll find online.
The article was prompted by another Time article from the week before, "New Drug May Be Best Treatment for Leukemia Yet," which focused on the use of Ibrutinib. This earlier article looks at a New England Journal of Medicine piece that reported on Ibrutinib's success with Chronic Lymphocytic Leukemia (CLL), a slower-growing version on leukemia. Of course, Ibrutinib is also being tested in a bunch of other blood cancers, including Follicular Lymphoma.
The more recent article focuses on cancer in general, and the ways shotgun-style approaches to treatment are on their way out (though certainly still around -- just not necessarily as a first option anymore).
I like the way Dr. George Demetri from Dana-Farber put it: "The field is moving toward using the right drugs at the right time in
the right patients."
As I said, nothing earth-shattering of you've been following cancer developments, but it's a good introduction to pass on to anyone who hasn't been.
Friday, June 28, 2013
Wednesday, June 26, 2013
Follicular Lymphoma Survival Statistics
The medical journal Blood, which focuses on, well, blood, has in its most recent issue an article called "Improvements in Observed and Relative Survival in Follicular Grade 1-2 Lymphoma over Four Decades: The Stanford University Experience." As the title implies, the study looks at survival statistics for Follicular Lymphoma patients at Stanford from 40 or so years, trying to determine what kind of progress we've made.
Apparently, we've made a bunch.
The study looked at four different time periods (or eras) of treatment of Follicular Lymphoma patients, tracking patients from each period, and comparing them.
Era 1 is the "Pre-anthracycline" Era, from 1960 to 1975. They looked at 180 patients from this period. Anthracycline is a powerful category of chemotherapy drugs that do a great job, but also cause some heart damage. For Follicular Lymphoma, CHOP is the most commonly used anthracycline-based treatment; specifically, it's the H in CHOP -- Hydroxydaunorubicin (Adriamycin). So Era 1 represents those years before we had CHOP, basically.
Era 2 is the "Anthracycline," Era, from 1976 to1986, when these treatments were most popular. They looked at 426 patients from this era.
Era 3, is the "Aggressive Chemotherapy/Purine Analogs" Era, from 1987 to 1996. They looked at 471 patients from these years. This era saw the popularity of Purine Analogues like Fludarabine. Really interesting concept: purine analogues mimic "purines," which is a substance that, among other things, makes up part of our DNA. So when a cancer cell divides, Fludarabine sneaks in and takes the place of a purine in the DNA, preventing the DNA from recombining and making a new cell. Unfortunately, Purine Analogues leave some nasty side effects: higher risk of infections, for example. And of developing leukemia.
Finally, there's Era 4, the "Rituximab" Era, from 1997 to 2003 (and, arguably, up to today, though that's changing pretty rapidly). They looked at 257 patients from this era.
In some ways, the different eras aren't all that significant, though I think that look at our treatment history is kind of fascinating.
Here's the important stuff:
Median Overall Survival (that is, death from any cause, not from FL specifically) was about 11 years in eras 1 and 2. But it jumped to 18.4 years in era 3. As for era 4? A median still hasn't been reached. Too many people still alive. That's a good thing. I think we can assume it will be higher than 18.4 years.
If you look at the Wikipedia page for Follicular Lymphoma, the prognosis section says that the median Overall Survival is about 10 years. I'm not going to link to it. It will only upset you. It certainly upset me when I was first diagnosed, and it upset a lot of my loved ones, to (because that's what we do when we don't understand something -- we Google it, and a Wikipedia entry is inevitably near the top of the results).
Ten years, especially to a 40 year old with 3 kids, is nothing. But 19 years (we're rounding up because we're optimistic)? That's a whole lot of time. Especially when you consider how rapidly we're progressing with treatments. Heck, we're probably on Era 6 by now.
I've said plenty of times that I avoid numbers, but I break that rule when the numbers are good.
And these are good.
Apparently, we've made a bunch.
The study looked at four different time periods (or eras) of treatment of Follicular Lymphoma patients, tracking patients from each period, and comparing them.
Era 1 is the "Pre-anthracycline" Era, from 1960 to 1975. They looked at 180 patients from this period. Anthracycline is a powerful category of chemotherapy drugs that do a great job, but also cause some heart damage. For Follicular Lymphoma, CHOP is the most commonly used anthracycline-based treatment; specifically, it's the H in CHOP -- Hydroxydaunorubicin (Adriamycin). So Era 1 represents those years before we had CHOP, basically.
Era 2 is the "Anthracycline," Era, from 1976 to1986, when these treatments were most popular. They looked at 426 patients from this era.
Era 3, is the "Aggressive Chemotherapy/Purine Analogs" Era, from 1987 to 1996. They looked at 471 patients from these years. This era saw the popularity of Purine Analogues like Fludarabine. Really interesting concept: purine analogues mimic "purines," which is a substance that, among other things, makes up part of our DNA. So when a cancer cell divides, Fludarabine sneaks in and takes the place of a purine in the DNA, preventing the DNA from recombining and making a new cell. Unfortunately, Purine Analogues leave some nasty side effects: higher risk of infections, for example. And of developing leukemia.
Finally, there's Era 4, the "Rituximab" Era, from 1997 to 2003 (and, arguably, up to today, though that's changing pretty rapidly). They looked at 257 patients from this era.
In some ways, the different eras aren't all that significant, though I think that look at our treatment history is kind of fascinating.
Here's the important stuff:
Median Overall Survival (that is, death from any cause, not from FL specifically) was about 11 years in eras 1 and 2. But it jumped to 18.4 years in era 3. As for era 4? A median still hasn't been reached. Too many people still alive. That's a good thing. I think we can assume it will be higher than 18.4 years.
If you look at the Wikipedia page for Follicular Lymphoma, the prognosis section says that the median Overall Survival is about 10 years. I'm not going to link to it. It will only upset you. It certainly upset me when I was first diagnosed, and it upset a lot of my loved ones, to (because that's what we do when we don't understand something -- we Google it, and a Wikipedia entry is inevitably near the top of the results).
Ten years, especially to a 40 year old with 3 kids, is nothing. But 19 years (we're rounding up because we're optimistic)? That's a whole lot of time. Especially when you consider how rapidly we're progressing with treatments. Heck, we're probably on Era 6 by now.
I've said plenty of times that I avoid numbers, but I break that rule when the numbers are good.
And these are good.
Monday, June 24, 2013
Follicular Lymphoma: Revlimid + Rituxan
Lots of reports in the last few days about a successful phase 2 trial that looked at Rituxan and Revlimid (sometimes known as R + R) in previously untreated Follicular Lymphoma patients. The results look very promising.
There's no need, I assume, to introduce about Our Old Pal Rituxan. I've written about Revlimid before, but it's worth a reminder:
Revlimid (also known as Lenalidomide) is kind of cool -- it works in a bunch of different ways, so it can potentially be used for lots of different cancers, both liquid and solid. It works, for example, by messing with cancer cells' ability to grow by keeping stromal cells from growing in the bone marrow. These cells are necessary for the cancer cells to grow -- no stromal, no cancer. It can also inhibit new blood vessels from growing, which cuts off a source of food for cancer cells.
This is a treatment with lots of potential.
And apparently, when combined with Rituxan, that potential is reached even more. The study looked at 54 patients (a pretty small sample, but it is a phase 2 study, after all), and a whopping 92.6% (50 out of 54) had a response to the treatment. 72% achieved a complete response.
Those are pretty darn good numbers. Absolutely worth making this a larger phase 3 trial.
In other news from the same company, Revlimid was combined with R-CHOP for patients with Diffuse Large B Cell Lymphoma (a more aggressive type). Similarly excellent results: 98% response rate, with 74% achieving a complete response. It's not Follicular Lymphoma, but I always like to keep an eye out for anything that can help with transformed FL.....
Read about the two studies in stories from Benzinga and PharmaTimes Online.
Good stuff.
There's no need, I assume, to introduce about Our Old Pal Rituxan. I've written about Revlimid before, but it's worth a reminder:
Revlimid (also known as Lenalidomide) is kind of cool -- it works in a bunch of different ways, so it can potentially be used for lots of different cancers, both liquid and solid. It works, for example, by messing with cancer cells' ability to grow by keeping stromal cells from growing in the bone marrow. These cells are necessary for the cancer cells to grow -- no stromal, no cancer. It can also inhibit new blood vessels from growing, which cuts off a source of food for cancer cells.
This is a treatment with lots of potential.
And apparently, when combined with Rituxan, that potential is reached even more. The study looked at 54 patients (a pretty small sample, but it is a phase 2 study, after all), and a whopping 92.6% (50 out of 54) had a response to the treatment. 72% achieved a complete response.
Those are pretty darn good numbers. Absolutely worth making this a larger phase 3 trial.
In other news from the same company, Revlimid was combined with R-CHOP for patients with Diffuse Large B Cell Lymphoma (a more aggressive type). Similarly excellent results: 98% response rate, with 74% achieving a complete response. It's not Follicular Lymphoma, but I always like to keep an eye out for anything that can help with transformed FL.....
Read about the two studies in stories from Benzinga and PharmaTimes Online.
Good stuff.
Saturday, June 22, 2013
Education of a Cancer Nurse
I read an excerpt today from a new book called I Wasn't Strong Like This When I Started Out: True Stories of Becoming a Nurse, by Laura DeVaney, a four-year head-and-neck cancer nurse. The excerpt is, as one 20-year nurse says in the comments, "one of the most honest portrayals of nursing I've read."
So be warned -- it's a little bit graphic. Know that before you click.
But it did remind me of how great most of the oncology nurses I know have been. They're compassionate, but realistic. That's just what I want in my cancer nurse.
I've always wondered just what makes someone go into oncology nursing. I don't think this excerpt really answers that question. I'm sure it's different for everyone, but I suspect they've been touched by cancer, and want to do their best to make it go away -- or make it go a little easier, because they know what it's like.
I had a student once who was studying nursing. She was great -- smart, articulate, worked very well with other students in the class. I thought she'd make a great oncology nurse. On the last day of class, I asked her what kind of nursing she wanted to go into.
"Well," she said, "I really hate being around sick people. So, probably dermatology. Or plastic surgery."
I was disappointed -- I'll be honest. It certainly wasn't the first time. I have lots of students who want to be nurses. A great many of them don't seem to care about anything -- studying, other people, whatever -- and I really want to tell them, "You know, I deal with a lot of nurses. I wouldn't want you to be my nurse."
That's not really fair to them. Just like it wasn't fair of me to think my student should go into oncology, rather than plastic surgery.
After all, how many people can really handle cancer? Heck, even I don't want to spend too much time in my oncologist's office.
So consider this a loving tribute to all of those oncology nurses who do so much for us. Even those who aren't so nice sometimes.
So be warned -- it's a little bit graphic. Know that before you click.
But it did remind me of how great most of the oncology nurses I know have been. They're compassionate, but realistic. That's just what I want in my cancer nurse.
I've always wondered just what makes someone go into oncology nursing. I don't think this excerpt really answers that question. I'm sure it's different for everyone, but I suspect they've been touched by cancer, and want to do their best to make it go away -- or make it go a little easier, because they know what it's like.
I had a student once who was studying nursing. She was great -- smart, articulate, worked very well with other students in the class. I thought she'd make a great oncology nurse. On the last day of class, I asked her what kind of nursing she wanted to go into.
"Well," she said, "I really hate being around sick people. So, probably dermatology. Or plastic surgery."
I was disappointed -- I'll be honest. It certainly wasn't the first time. I have lots of students who want to be nurses. A great many of them don't seem to care about anything -- studying, other people, whatever -- and I really want to tell them, "You know, I deal with a lot of nurses. I wouldn't want you to be my nurse."
That's not really fair to them. Just like it wasn't fair of me to think my student should go into oncology, rather than plastic surgery.
After all, how many people can really handle cancer? Heck, even I don't want to spend too much time in my oncologist's office.
So consider this a loving tribute to all of those oncology nurses who do so much for us. Even those who aren't so nice sometimes.
Wednesday, June 19, 2013
Follicular Lymphoma: Idelalisib
Kind of a quicky, because I'm busy with work:
A phase 2 study of Idelalisib (formerly known as GS-1101) shows good results in patients of Follicular Lymphoma and other indolent (slow-growing) lymphomas.
The trial looked at 125 patients, focusing particularly on those who refractory to Rituxan and certain chemos. Those enrolled had a median of 4 previous treatments. (Basically, these are folks who are starting to notice the quiver is getting a little light on arrows, if I can use a comparison I'm fond of.) This is a fairly under-represented group, so it's nice to a see a trial that focuses on them.
Idelalisib is another kinase inhibitor --one of those newer treatments that targets pathways that are necessary for B cells to survive. As such, they tend to have fewer horrible side effects than traditional chemo (though are still some side effects).
In this trial, 53.6% of participants achieved a response, and it lasted just a shade under a year. 89% of patients achieved at least some shrinkage in lymph node size.
The study was led by Dr. Salles, who was featured in a video with Dr. Cheson that I posted just a few days ago, discussing this very treatment (and other topics). As Dr. Salles said then, these treatments work pretty decently on their own, and seem to also increase the effectiveness of more traditional chemo.
There are a few people in my support group who are being given Idelalisib. Not sure if they are in this trial, specifically, but they seem to be generally happy with the results.
I assume we'll be seeing more of this in the months and years to come.
A phase 2 study of Idelalisib (formerly known as GS-1101) shows good results in patients of Follicular Lymphoma and other indolent (slow-growing) lymphomas.
The trial looked at 125 patients, focusing particularly on those who refractory to Rituxan and certain chemos. Those enrolled had a median of 4 previous treatments. (Basically, these are folks who are starting to notice the quiver is getting a little light on arrows, if I can use a comparison I'm fond of.) This is a fairly under-represented group, so it's nice to a see a trial that focuses on them.
Idelalisib is another kinase inhibitor --one of those newer treatments that targets pathways that are necessary for B cells to survive. As such, they tend to have fewer horrible side effects than traditional chemo (though are still some side effects).
In this trial, 53.6% of participants achieved a response, and it lasted just a shade under a year. 89% of patients achieved at least some shrinkage in lymph node size.
The study was led by Dr. Salles, who was featured in a video with Dr. Cheson that I posted just a few days ago, discussing this very treatment (and other topics). As Dr. Salles said then, these treatments work pretty decently on their own, and seem to also increase the effectiveness of more traditional chemo.
There are a few people in my support group who are being given Idelalisib. Not sure if they are in this trial, specifically, but they seem to be generally happy with the results.
I assume we'll be seeing more of this in the months and years to come.
Monday, June 17, 2013
ASCO: Do Scans Actually Help?
Another one of those reviews of the ASCO conference that I expected would be helpful -- this one from Dr. Anne Blaes from the University of Minnesota, called "Symptoms, not surveillance, as effective at detection of relapse in some cancers."
Dr. Blaes works with cancer survivors, and was particularly interested in some of the ASCO presentation on imaging -- the use of CT and PET scans, especially in helping to discover relapses. Most survivors want to know just how often they'll be scanned after they've had a response to treatment. (I know I do.)
She describes two particular lymphoma studies, one for Diffuse Large B-Cell Lymphoma patients and the other for Hodgkin's patients. In the DLBCL study, 500 patients were followed, and given follow-up scans every 6 months for 2 years (which is standard). Only 1.5% of those scans actually detected a relapsed lymphoma. In the Hodgkin's study, a similar result was shown: little benefit for routine follow-up scans so frequently.
The costs for scans are high, in emotionally (anxiety, false positives), physically (all that radiation), and financially (in one of the studies, detecting just one relapse cost about $600,000, and that's not calculating what happens after the detection).
As Dr. Blaes points out, those scans, while they cause some anxiety, also make us feel good -- we have proof that things are OK (or that things aren't OK). But maybe they aren't worth what we get out of them.
Just as effective? Regular blood work, physical exams, etc.
This kind of study makes me more and more pleased with my own beloved Dr. R, who won't do a scan unless he has a reason, all part of his larger "Do No Harm" philosophy. I would think that just an approach would even more important for Follicular Lymphoma and other indolent cancers, where (hopefully) problems aren't going to pop up too quickly.
There's a balance that takes a while to come to a Follicular Lymphoma patient -- a need to stay vigilant with a need to be able to just let it go -- but it does come. We learn to know our bodies, and to recognize when something just isn't right. When we learn to trust that sense, and our doctor's knowledge, the things get easier.
(Not easy -- just easier. Let's not get carried away....)
Dr. Blaes works with cancer survivors, and was particularly interested in some of the ASCO presentation on imaging -- the use of CT and PET scans, especially in helping to discover relapses. Most survivors want to know just how often they'll be scanned after they've had a response to treatment. (I know I do.)
She describes two particular lymphoma studies, one for Diffuse Large B-Cell Lymphoma patients and the other for Hodgkin's patients. In the DLBCL study, 500 patients were followed, and given follow-up scans every 6 months for 2 years (which is standard). Only 1.5% of those scans actually detected a relapsed lymphoma. In the Hodgkin's study, a similar result was shown: little benefit for routine follow-up scans so frequently.
The costs for scans are high, in emotionally (anxiety, false positives), physically (all that radiation), and financially (in one of the studies, detecting just one relapse cost about $600,000, and that's not calculating what happens after the detection).
As Dr. Blaes points out, those scans, while they cause some anxiety, also make us feel good -- we have proof that things are OK (or that things aren't OK). But maybe they aren't worth what we get out of them.
Just as effective? Regular blood work, physical exams, etc.
This kind of study makes me more and more pleased with my own beloved Dr. R, who won't do a scan unless he has a reason, all part of his larger "Do No Harm" philosophy. I would think that just an approach would even more important for Follicular Lymphoma and other indolent cancers, where (hopefully) problems aren't going to pop up too quickly.
There's a balance that takes a while to come to a Follicular Lymphoma patient -- a need to stay vigilant with a need to be able to just let it go -- but it does come. We learn to know our bodies, and to recognize when something just isn't right. When we learn to trust that sense, and our doctor's knowledge, the things get easier.
(Not easy -- just easier. Let's not get carried away....)
Saturday, June 15, 2013
ASCO Sum Up
As I said last week, I figured someone would do a summary of the good stuff from ASCO, and now Medscape has just such a summary, featuring Lymphoma Rock Star Dr. Bruce Cheson and Dr. Gilles Salles, who's pretty darn good himself (and who was featured in a Patient Power video about ASH that I linked to recently). The two discuss some of the take-aways about lymphoma (in general, not just Follicular Lymphoma) from the ASCO conference.
They say there are four pretty noteworthy trends:
1) Chemo has disappeared. There are no new traditional chemotherapies being developed for lymphoma, and I can't imagine there will ever be anymore ever again. The old stuff (Bendamustine and CHOP, for example) will hang around for a while, but with so much immunotherapy, biological treatments, kinase inhibitors, etc. etc. being developed, the "shotgun" approach of chemo is pretty much a thing of the past. Chemo will hang around, like a used car with a tape deck, because we all have the high school mix tape still sitting under the front seat; but from here on out, we're all mp3, folks. Metaphorically speaking, of course.
2) That said, there was still lots at ASCO on targeted-therapy combos: new treatments that home in on lymphoma cells, but combined with traditional chemo or monoclonal antibodies to increase their effectiveness. Kinase inhibitors are big among targeted therapies these days, especially GS-1101/Idelalisib and Ibrutinib. They seem less likely at the moment to give a Complete Response that lasts, so the combos are a better bet. The problem there: the companies that make them don't play nice together, and they cost a whole bunch of money.
3) How should we approach Follicular Lymphoma? Should we try for a cure? Or are we better just treating it as a chronic disease and accept that we should hold it in check for the rest of our lives? Dr. Salles thinks we shouldn't give up on a cure (and I agree), though treatments that hold things in check are a good idea. Still, he's not crazy about the idea of someone taking pills for his entire life (and Cheson implies that this would benefit drug companies more than patients, which is part of what makes him a Rock Star). But Gilles isn't convinced that, over time, we won't see more mutations of clone cells (that is, the cancer cells will find a way to change and thus resist the treatments), so he's not ready to throw out chemo just yet.
4) PETs were also a topic at ASCO. They are used for initial staging and response checks (and endpoints -- determining if a treatment really worked). Maybe we don't need repeated PETs, though, as checks between treatments? Other ways of checking might work as a way of measuring growth of the disease without so much radiation exposure. I'm with Drs. Cheson and Salles on this, and so is my own Dr. R; until a blood test or a physical exam shows a reason for a PET, I'm probably not getting one. (Though every now and then, I think I'd really like one, just to check that everything is OK with those deeper nodes that aren't so close to the surface.)
So, this isn't all necessarily about Follicular Lymphoma, but it's a pretty nice summary of some very up-to-the-minute trends from two guys who know what they're talking about.
Lots to look forward to in there.
They say there are four pretty noteworthy trends:
1) Chemo has disappeared. There are no new traditional chemotherapies being developed for lymphoma, and I can't imagine there will ever be anymore ever again. The old stuff (Bendamustine and CHOP, for example) will hang around for a while, but with so much immunotherapy, biological treatments, kinase inhibitors, etc. etc. being developed, the "shotgun" approach of chemo is pretty much a thing of the past. Chemo will hang around, like a used car with a tape deck, because we all have the high school mix tape still sitting under the front seat; but from here on out, we're all mp3, folks. Metaphorically speaking, of course.
2) That said, there was still lots at ASCO on targeted-therapy combos: new treatments that home in on lymphoma cells, but combined with traditional chemo or monoclonal antibodies to increase their effectiveness. Kinase inhibitors are big among targeted therapies these days, especially GS-1101/Idelalisib and Ibrutinib. They seem less likely at the moment to give a Complete Response that lasts, so the combos are a better bet. The problem there: the companies that make them don't play nice together, and they cost a whole bunch of money.
3) How should we approach Follicular Lymphoma? Should we try for a cure? Or are we better just treating it as a chronic disease and accept that we should hold it in check for the rest of our lives? Dr. Salles thinks we shouldn't give up on a cure (and I agree), though treatments that hold things in check are a good idea. Still, he's not crazy about the idea of someone taking pills for his entire life (and Cheson implies that this would benefit drug companies more than patients, which is part of what makes him a Rock Star). But Gilles isn't convinced that, over time, we won't see more mutations of clone cells (that is, the cancer cells will find a way to change and thus resist the treatments), so he's not ready to throw out chemo just yet.
4) PETs were also a topic at ASCO. They are used for initial staging and response checks (and endpoints -- determining if a treatment really worked). Maybe we don't need repeated PETs, though, as checks between treatments? Other ways of checking might work as a way of measuring growth of the disease without so much radiation exposure. I'm with Drs. Cheson and Salles on this, and so is my own Dr. R; until a blood test or a physical exam shows a reason for a PET, I'm probably not getting one. (Though every now and then, I think I'd really like one, just to check that everything is OK with those deeper nodes that aren't so close to the surface.)
So, this isn't all necessarily about Follicular Lymphoma, but it's a pretty nice summary of some very up-to-the-minute trends from two guys who know what they're talking about.
Lots to look forward to in there.
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