(All the articles published in past are available at www.shyamhemoncclinic.com)
Question: Dr. Chiragbhai, thank you very much for helping us summarize this complex topic. In last part we covered diagnostic advances for multiple myeloma and lymphomas.
Ans: Now let us continue with advances in treatment, which have changed cure rates for these cancers from nearly 0 few decades ago to over 80% in many cases. This is a remarkable field where research and collaborative work has increased cure rates gradually but steadily over decades.
1. CML – chronic myeloid leukemia – biggest recent advance in last decade is in CML – the targeted therapy known as Imatinib. A simple tablet taken once a day, with few initial precautions, has been so effective by targeting BCR-ABL kinase specifically that it has replaced even Transplant as first line therapy. Before 2001, Transplant was first line treatment for CML, and still remains the only curative treatment. But now all patients, including children, are treated with imatinib first, due to its marked convenience and safety. NOW THERE IS NO ROLE FOR HYDROXYUREA ALONE AS FIRST TREATMENT IN CML. About 80% patients can have long term disease control with imatinib, but need to be taken lifelong. New trials have shown possibility that some patients can be taken off this drug safely, however their follow up period is still short. Cure is still not known with imatinib. Patients who progress on imatinib can be offered transplant or second line tyrosine kinase inhibitors like dasatinib or nilotinib. These two medicines are also approved as first line therapy, as they seem to be more effective, at least in short term, than imatinib. But their long term safety is not known. New medicines are also on horizon.
However about 10-20% patients fail all these medicines, and must be treated by transplant, the only currently known curative option. Transplant in CML provides cure in about 70% patients. Also, CML is the best example of how a new transplant related modality, DLI – donor lymphocyte infusion, works by use of immunity to control or cure disease, without use of medicines.
2. CLL – chronic lymphoid leukemia: this is a disease with wide variation in outcome, with some patients not requiring any treatment for many years, and some with rapidly progressive disease. There are predictive markers to help determine what treatment to choose first. Chlorambucil tablet has been traditional first choice, especially in elderly patients. However, a combination of chemotherapy and immunotherapy FCR has shown excellent results and should be first line treatment in younger or fit older patients. It provides much longer disease control, including over 10 years in a sizeable minority. There is a lot of excitement in this field with a new targeted oral therapy, Ibrutinib, and it seems like it may become first line option. However cost will be prohibitive for Indian patients, at least for few years. Lenalidomide and rituximab combination, without any chemotherapy, also seems to be a good option, in early studies at least, for elderly patients.
Allogeneic transplant is an option for patients with poor prognostic markers, and for those who have failed current treatment options.
3. Hodgkin Lymphoma: Possibly the cancer with highest cure rates, over 80-90% in many cases. One of the first cancer with established combination chemotherapy. Results are so good in early stages, that for last over a decade most research has focused on how to reduce short and long term side effects. ABVD is the most common combination used. One major advance with use of PET-CT scan is early ability to predict favorable disease, which allows reduction in chemotherapy cycles from 6 to 4 or sometimes even 2 cycles only. Brentuximab is a new medicine in this cancer with very good results. But for all relapsed and initially resistant Hodgkin, Autologus transplant (using one’s own stem cells) remains the main curative option, with cure rates of about 50% in these difficult cases as well.
June 13th, 2014.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com