Published on July 13, 2020
Transcript | Treating Diffuse Large B-Cell Lymphoma
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Hello, and welcome to Patient Power. I'm Andrew Schorr. We're talking about Non-Hodgkin's lymphoma and specifically diffuse large B-Cell lymphoma, which is an aggressive lymphoma. And with us is an expert in that Dr. Jason Westin from MD Anderson in Houston. Dr. Westin, first of all, you've got a long title. We want to make sure we get it right. What is your title there at MD Anderson?
Sure. Hi Andrew. Thank you for having me today on Patient Power. I at MD Anderson am the Director of Lymphoma Clinical Research and the Section Chief for Aggressive Lymphomas.
Okay, let's talk about treatments. So in the world of treatments, first of all, somebody is going to say, "Well, Doctor is this curable?" So let's start there. Are there treatments that could lead to a cure?
The first thing that I like to emphasize with my patients, when we're getting to know the extent of their disease is that, although this is an aggressive cancer and that word is kind of a scary combination, aggressive and cancer together is not something anybody wants to hear. The good news about large cell lymphoma is that it is a potentially curable cancer. And the majority of patients are cured with their first treatment, in that there's no relapse that the cancer doesn't come back, that it's gone for good.
That is a wonderful thing to be able to say to somebody who's newly diagnosed, “but the good news is, we think we can take care of this.” Now, unfortunately that's not a one size fit all everybody gets that result. We don't want to be too confident or too promising things at the beginning, we have to be honest that there are patients who do not respond to initial treatments or could relapse, but there are other treatments in the relapse setting, which have potential for cure as well.
And so the majority of patients who are diagnosed today in 2020 with diffuse large B-Cell lymphoma can be cured with the combination of chemotherapy drugs. If relapse occurs, there are other curative options. So we've got multiple shots on goal, but research is still needed to find the best treatments for different subtypes and to find smart ways to incorporate new targeted therapies to further improve our cure rates and reduce toxicity of the treatments themselves.
All right, so you said often chemo is part of it. So if I'm sort of a standard, a diffuse large B-Cell lymphoma patient, and you feel that standard approach is going to work, what would that be? What would my expectations, will I be getting infusions? Will I be able to work? Will I lose my hair? I already have, what happens?
The standard treatment for the vast majority of patients with diffuse large B-Cell lymphoma has been a combination called R-CHOP for about the past 20 years. For about 20 years before that it was just CHOP without rituximab (Rituxan). So that's a long time we've had this standard therapy. And the reason it's been around for quite a long time is that it works in the majority of patients and subsequent attempts to try and improve upon it or to replace it haven't been able to show a significant advantage.
And so the vast majority of patients who are diagnosed today, if they're going to be treated off of a clinical trial, if there's no research that's available, R-CHOP and usually for six cycles, is going to be the standard approach. That's an intravenous treatment. Each of the letters represents a different medication, is given by vein, usually every three weeks for a total of six cycles, 18 weeks.
So it's a decent amount of time that somebody is going to be getting treatments. To your questions about the side effects of those treatments. This is chemo, it's legitimate chemotherapy, and it's going to have some side effects in terms of potential for nausea. Although that's usually very well controlled with medications. Fatigue, which is managed by staying active by trying to continue to fight against fatigue on days that you don't feel too poorly. And risk of infections, because we're targeting the immune cells that have gone awry. The immune cells that have turned cancerous.
Unfortunately, the normal immune cells that help the cousins of the bad guys are inadvertently targeted and they can be knocked down to a level where infections can occur. Hair does come out for the vast majority of patients. I don't recommend my patients go out and get the clippers one day after treatment, because sometimes it doesn't come out or it doesn't come out very much, but the majority of people will lose their hair temporarily during therapy.
But all this is in the phase of side effects that we don't like, but that many people are able to tolerate, especially with the idea that better days are ahead and potential for cure is a realistic possibility.
How do you know whether the treatment has worked? Do you have some sort of scan? What do you do to say, "Okay, Mr. Jones, you've gone through these weeks of treatment. Let's take a look."
Yeah. The PET-CT scan, or if the CT scan of a PET-CT is not available, is the tool that we use to best decide if the treatment's working.
However, we usually know the answer before we ask the question, the question is not really, is it working or not? It's more often, how well is it working? Let's say a patient shows up with the symptoms that we described of a mass or a pain, that's a pretty good barometer of that mass or that pain began to reduce over the first or second cycle of treatment that the treatments are working.
If the symptoms were worsening, same thing, that you would get a scan to confirm what you've kind of already know. So, because this disease is usually a symptomatic disease, a patient reported disease, not a serendipitous finding disease. Usually the scans are done to get confirmation of what's already strongly suspected, but it's critical to get that data.
And so we often will get a scan during treatment, so-called interim scan, usually after the second or third cycle. And that helps us to feel more confident that the treatments are working well. That scan is important. However, the most important scan is the one at the end of treatments, usually about three or four weeks after the final round of treatments, that's done to decide the final response to therapy.
As you mentioned, not everybody gets the celebratory response. And so what do you do then?
If we have a scan that we don't like, either at the end of therapy, or when we're in the surveillance follow up period after therapy, the first step should always be to try to get another biopsy. And the reason for that is that scans sometimes don't tell us what we think they tell us, there can be false positives, meaning that something could appear to be a recurrence, and then if we biopsy then we find it's a benign condition or inflammation or healing cells that look abnormal on a scan, but are not cancer.
So getting a biopsy, I think is absolutely essential, both at diagnosis initially, as well as at concern for relapsed disease. If a repeat biopsy is done and shows that the disease is still there, diffuse large B-Cell lymphoma didn't go away, and we see it again on a repeat biopsy, then there are many treatment options to consider.
But the first fork in the road that we consider is how aggressive can we be for a relapsed disease? About half of the patients with relapsed large cell lymphoma are eligible for aggressive treatments, and there's something called an autologous STEM cell transplant. It's usually considered the next therapy to try, about half of patients are not fit or not eligible for that because of their age, their comorbidities, their organ dysfunction, because they're not able to tolerate really aggressive treatments.
And there are other treatments to try for those patients. So that's usually the first fork in the road after the biopsy is done is, how hard can we attack the cancer knowing that the damage to the patient might be some times more than what a patient would be able to tolerate?
Again, you said there's a great deal of hope for the newly diagnosed patient. So some people, many will do well with initial treatment, if people need to go to the second line, is there still hope that they can be cured?
Yeah. So in the second line for diffuse large B-Cell lymphoma, there is still hope for cure. However, the odds have declined. The odds are not as good. If the cancer has already shown itself to be resistant to the first line of treatments, sometimes that resistant trick that it had up its sleeve might apply to the second line or beyond.
And so our best chance for cure is by in a way, the first line. And that's why I mentioned before, that clinical trials are still a very good idea for people with newly diagnosed diffuse large B-Cell lymphoma. You don't want to get to second line or third line, you want to try and get rid of this on the first shot, and so clinical trials in that space are critical. If somebody is in the second line, curative options include autologous STEM cell transplant or potentially CAR T-cells, which I think we'll talk about in a few moments.
But right now there are three large clinical trials evaluating in a randomized fashion, autologous STEM cell transplant, which has been the standard for nearly 30 years versus the new kid on the block CAR T-cells in a head to head one versus one randomized clinical trial to see what is the best second treatment for relapsed large cell lymphoma that we're treating with an aggressive intent.
So things here in 2020, our currently standard answer is transplant, but that may change in the coming years as we get new information from these trials, both of which we hope have potential for curing patients.
A hopeful story. A positive story. Dr. Jason Westin from MD Anderson and a lymphoma specialist, thank you for explaining this to us, and your work in moving research forward so that the options that can help people continue to grow. Thanks for being with us.
Thank you for having me, it’s my pleasure.
I’m Andrew Schorr, remember; knowledge can be the best medicine of all.
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