Update on treatment options for lymphoma on World Lymphoma Awareness Day 2015
By Dr Brian Healey Bird
Lymphoma is a cancer of the smart white cells that fight disease. It is nearly always treatable and frequently curable.
Last year, I wrote on this website about developments in treatments of lymphoma to mark World Lymphoma Awareness Day.
Clinical trials, laboratory work and Irish research aimed at understanding the challenges long term survivors of lymphoma face have all improved how doctors treat and understand lymphoma and empathize with their patients.
PET adapted therapy for Lymphoma
PET scans use a radioactive sugar called FDG to ‘light up’ high grade lymphomas which are hungry for sugar to fuel their rapid growth.
It is now normal practice to do a PET scan before and after completing chemotherapy for Hodgkin lymphoma (HD) and Diffuse large B cell lymphoma.
With 80% of patients cured of Hodgkin lymphoma, our goals are to increase cure and minimize side effects.
Several Hodgkin trials are looking at if doing a PET after two months of chemotherapy can help doctors decide whether to continue the same treatment, escalate to tougher chemo or de-escalate to gentler chemotherapy.
This 'interim PET scan’ will help us reserve tougher chemotherapy for patients whose disease is not responding to standard approaches and may allow us to use gentler treatment for those having a great response.
With eight out of ten patients cured of Hodgkin lymphoma, our goals are to increase cure and minimize side effects.
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Interim PET scan with resolution of disease: The brain is burning the black radioactive sugar in both scans.
Patients with early stage Hodgkin lymphoma are frequently treated with four months of ABVD chemotherapy followed by radiotherapy.
The recently-reported EORTC H10 trial showed that the one in four patients whose disease was still lighting up on PET after two months of ABVD chemo did much better when switched to tougher chemotherapy (91% of patients who got tougher treatment post ‘hot’ interim PET alive and free of disease at 5 years vs. 71% who continued standard treatment) .
Unfortunately in the 75% of patients with ‘cold’ interim PET dropping radiotherapy led to twice the rate of disease recurrence.
This trial and others will help us tailor treatment to best help patients.
Take the brakes off the immune system to better fight lymphoma
Cancer hides from our immune system in many ways.
New drugs may help us ‘unmask’ the cancer and unleash the immune system to attack lymphoma. These drugs are called immune checkpoint inhibitors. They unleash good T cells to recognize and kill tumour cells. Read more (external link)
They are already used to treat melanoma and are coming into use in many other cancers.
Their side effects include autoimmune diarrhoea and lung inflammation – the activated immune system can attack good host cells as well as cancer cells.
We still can’t reliably predict which patients will benefit from these treatments.
Early clinical trials in a small number of patients whose Hodgkin Lymphoma recurred after lots of treatments are very encouraging.
An immune therapy pembrolizumab which targets the PD1 protein on T cells preventing tumour cells from switching the T cells off caused shrinkage of disease in a majority of cases. (external link)
A clinical trial for this therapy is expected to begin in St James’s Hospital Dublin in October. Hopefully the small minority of HD patients whose cancer recurs even after stem cell transplant will benefit from this approach.
ICORG (Irish Clinical Oncology Research Group) and the University of Queensland, Australia are planning a biomarker trial in the commonest high grade Non Hodgkin lymphoma (NHL), Diffuse large B cell lymphoma (DLBCL).
This trial will look at how DLBCL hides from the immune system. The aim of this trial is to better predict which patients will be cured by standard chemotherapy (R-CHOP) and who needs different treatment.
We hope that it we will learn from this trial which DLBCL patients should be treated with immune checkpoint inhibitors and other novel drugs.
Dr Colm Keane, an Irish graduate now working in Queensland, believes that patients whose immune system is activated to ‘mop up’ residual cancer cells left behind by chemotherapy are the ones who are cured but patients with a ‘dormant’ immune system are more likely to have residual disease which will relapse.
Dr Richard Flavin will lead crucial work in the department of histopathology in St. James’s Hospital looking at better ways of classifying DLBCL.
This collaborative approach where Irish patients are closely followed using state of the art genomic technology will put Ireland on the map as a centre for lymphoma trials.
I am writing the final protocol with Dr Verena Murphy ICORG.
Survivorship research in Cork
This year Dr Rebecca Holland and I presented work based on a survey of Cork survivors of high grade lymphomas.
These patients were in follow-up in Bon Secours hospital Cork and Cork University Hospitals. I am indebted to my colleagues in CUH who helped with this research and allowed us to contact their patients.
Our patient population had good quality of life, emotional and physical function when compared with larger American groups of lymphoma survivors.
There was a decrease in quality of life around year 4-5 which resolved in later years. I speculate that anxiety around the “magic five years” may be responsible.
High grade lymphoma survivors are usually followed closely for 5 years and are aware that if they make it that far they’re probably cured. Read more (external link(
Dr Eileen Maher and I looked at cardiovascular follow-up of Cork lymphoma survivors.
We cure a lot of patients but some of the vital drugs (anthracyclines) can cause long term heart damage which worsens with age.
The key to avoiding early heart failure is minimizing other 'insults' to the heart – excess alcohol, cocaine, smoking, high blood pressure and cholesterol.
The good news was that nearly all patients (98%) had baseline heart scans prior to receiving chemotherapy – a marker of good care.
It was disappointing that only one in three of patients in follow up were screened for diabetes and one in four for high cholesterol.
In the patients who had their cholesterol checked it improved over time. We speculate that knowledge leads to lifestyle changes and use of cholesterol lowering drugs. Guidelines vary and there is not a great deal of evidence that close cardiac follow up actually saves lives in patients treated with modern chemo and radiotherapy.
However I ask my patients to check blood pressure and cholesterol yearly with their GP. I also repeat heart scans (ECHO) every 5-10 years post treatment.
World Lymphoma Awareness Day takes place on Tuesday 15 of September 2015. If you have any questions about Lymphoma you can contact the Cancer Nurseline on Freefone 1800 200 700 and speak to specialist nurse or see our cancer information pages on lymphoma.
Dr Brian Bird is a Consultant Oncologist with the Bon Secours Hospital in Cork. Find out more about his work on his webpage. You can also follow him on Twitter @DrHealeyBird.
