June 29, 2013 - "Time, Time, Time Is on My Side, Yes It Is"

OK, this is really good news. A study of the survival rate of follicular lymphoma patients is showing a significant and steadily growing improvement since the 1960s.

The study results are published in an article, “Improvements in observed and relative survival in follicular grade 1-2 lymphoma over four decades: The Stanford University experience,” in Blood, June 18, 2013.

I don’t have follicular lymphoma — the small cells in my “B-cell, diffuse mixed large and small cell” grading evidently don’t display the same shape under a microscope as do follicular cells — but both are small-cell indolent lymphomas, treated more-or-less the same way. So, I take this good news to apply to my situation as well.

I’ve known this for years — that survival rates are getting better and better, as new treatments are steadily being rolled out — but it’s good to see some actual numbers, as part of a long-term historical study.

The study conducted at Stanford University identifies four historical eras:

Era 1, pre-anthracycline (1960-1975)
Era 2, anthracycline (1976-1986)
Era 3, aggressive chemotherapy/purine analogs (1987-1996)
Era 4, rituximab (1997-2003)

I’m off the chart in this study — a member of Era 5 — because I received my R-CHOP chemo (three chemo agents including anthracycline, plus the steroid prednisone, plus rituximab) in early 2006. So, my odds ought to be as good as, and probably better than, the era-4 patients.

Median overall survival rate steadily improved from approximately 11 years in eras 1 and 2 to 18.4 years in era 3. It’s not yet been reached for era 4 — because too many people in that cohort are still alive for researchers to have established their median age at death.

OK, so pre-rituximab follicular lymphoma patients are surviving for an average of 18.4 years after treatment. Rituximab-era patients up through 2003 are presumably doing much better than that (although the researchers can’t say, yet, by how much, because the numbers still aren’t in). I’m in the 15-year cohort beyond even that, that still hasn’t closed.

Even if the Era 4 numbers were to surprise everyone and reflect only a very modest gain (say, a 20-year average overall survival rate), that would peg the typical life expectancy of people who were treated at age 49, as I was, at age 69. Yet, because of the revolutionary impact of rituximab, the Era 4 group’s survival rate will likely prove to be much higher than that.

The news gets better. I’m not in Era 4. I’m in the yet-to-be-studied Era 5. Projecting the Stanford researchers’ steady increase into the future, that would push the average overall survival rate for patients from my era higher still.

I’m aware that I’m basing this speculation on the abstract, rather than the full article (which requires a subscription to the journal, Blood, to read online). I’m also aware that, once we get out of Era 3 (the latest one for which an actual median overall survival rate can be measured), we’re dealing in some very soft — and in the case of my Era 5 — even non-existent numbers. But, the trends look good.

“So teach us to count our days that we may gain a wise heart” (Psalm 90:12). I’m pretty sure the psalmist is talking about remaining aware of just how soon one’s own death may be coming. Does numbering our days in the opposite direction make us less wise?

I don’t know, and I don't much care. I’ll take the good news, all the same.

June 14, 2013 - Another Testimony for Radioimmunotherapy

A recent news article reports on another research study singing the praises of radioimmunotherapy (RIT), as an alternative to a stem-cell transplant. In RIT, radioactive isotopes are bonded to particles of rituximab (Rituxan), which just so happens to be the drug I received in conjunction with my R-CHOP chemotherapy in 2006. The radiation, which is delivered directly to the cancer cells by the rituximab, makes RIT a one-two punch that is proving to be very effective in enhancing long-term survival.

The two leading RIT drugs are Bexxar and Zevalin.

It does require doctors to think outside the therapeutic box, because practitioners must have one foot in each of two different treatment areas - oncology and radiology - that are usually the province of different medical specialists. While RIT treatments are very expensive, typically patients need to receive just one (as compared to multiple rounds of chemotherapy or traditional targeted-beam radiation, or the vastly more expensive - and more risky - stem-cell transplantation option).

VANCOUVER, British Columbia — In patients with refractory or relapsed aggressive lymphoma, immunoradiation combined with high-dose chemotherapy is associated with better progression-free and overall survival than chemotherapy alone when used in advance of autologous stem cell transplantation.

The BEAM chemotherapy consists of BCNU, etoposide, cytarabine, and melphalan.

"We started adding immunoradiation to BEAM about 9 years ago," said Tzila Zwas, MD, professor of nuclear medicine at Tel-Aviv University in Israel. "It was the hematologists' idea, because BEAM alone extended patients' lives by a few months only. The prognosis was very grave."

When Y-90 ibritumomab tiuxetan (Zevalin) was added to high-dose chemotherapy, "it was so successful — extending lives by over 2 years — we decided to conduct a multicenter trial," she explained....

The Z-BEAM approach improved overall and progression-free survival, "which is critical in hematology," said Dr. Zwas. The researchers also found positive effects in elderly patients. "This is very good news because we are dealing mostly with elderly patients. Refractory or relapsed aggressive lymphoma is not as common in the young age group. If elderly patients can achieve quality of life with low toxicity, it's unbelievably beneficial to them," she added....

Dr. [Norman] LaFrance said he hopes to see radioimmunotherapy combined with chemotherapy in earlier stages of disease and in other indications. "It's an evolution that hasn't occurred quickly enough, but I think it will," he explained. Medical oncologists are not trained to deal with radiation therapy, and there could be issues of reimbursement. "It's complicated, it's multifactorial, but I think it's turning the corner that people think combining radioimmunotherapy with chemotherapy is the right thing to do."

- Excerpted from "Radioimmunotherapy Improves Lymphoma Survival," by Jim Kling, Medscape Medical News, Jun 14, 2013.