(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 treatment advances including some very exciting news for CML, CLL, Hodgkin’s.
Ans: 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.
1. NHL – Non Hodgkin Lymphoma – There are over 25 subtypes of NHL. However, broadly there are 3 categories: LOW grade lymphomas where cure is less likely except in very early stages, but disease can be controlled for many years, over 10 years in many cases. Some of them grow so slow that they can be left without any treatment initially. Commonest subtype follicular lymphoma is treated with milder chemotherapy and Rituximab (a non chemotherapy monoclonal antibody against CD 20 antigen. This drug is one of the biggest advances in field of NHL in last 15 years). Rituximab can also be combined with radioactive agents and given as a single dose which works for many years, but it is not available in India at this time. INTERMEDIATE grade lymphomas, have cure rates of about 60% depending on stage etc, and are treated with chemotherapy, most commonly CHOP. It is important to remember that IHC should be done and if CD 20 positive lymphoma, Rituximab should be added. This drug was costly earlier but now cost has reduced markedly and many companies provide support for poor patients to ensure that such important medicine is received by all suitable patients. HIGH grade lymphomas are treated with aggressive chemotherapy regimens and must be treated in experienced centers. Cure rates are high, in the range of 80%, but initial risks of tumor lysis syndrome and infection etc from aggressive chemotherapy needs to be managed to reduce early mortality.
AUTOLOGUS transplant should be considered as part of initial treatment in patients with Double Hit lymphomas and Mantle cell lymphoma. For almost all NHL subtypes who have relapsed after initial treatment, AUTOLOGUS transplant is the standard of care. In some cases, Allogeneic transplant is also considered.
Some subtypes of NHL need special consideration for treatment, such as Lymphoblastic, MALT, LGL, Mycosis fungoides, Hairy cell leukemia, Splenic marginal zone, Mantle cell, Waldenstrom’s, Hepatosplenic gamma delta. Although these are NHL, but are treated in varied ways.
2. Multiple Myeloma: Treatment of myeloma has changed remarkably from VAD chemotherapy which was given intravenous with hospitalization for 4 days, about 10 years ago, to now almost completely outpatient treatment. Almost all patients are now treated as outpatient by oral medicines like lenalidomide/thalidomide/dexamethasone with or without bortezomib (now given subcutaneously for last 3 years or so, not even requiring any intravenous access). Some patients need day care injection of liposomal doxorubicin, cyclophosphamide. All the newer agents are thus more convenient but also more effective than VAD chemotherapy, and hence survival has improved considerably.
One major additional advance is AUTOLOGUS transplant added to initial treatment, after 3-6 months of therapy as noted above. Once considered a disease with survival of only about 2-3 years, now most patients live beyond 5 years, and with transplant added, about 25% cross 10 years. New research points to the hope that some of these may actually be cured. This is why Multiple Myeloma remains number 1 indications worldwide for transplant. In USA alone, over 5000 transplants are performed every year for myeloma. Safety of this transplant is now 98%, and in younger patients below age 60, nearly 100%. There is minimal follow up or medicines required after discharge.
Transplant done as part of initial treatment allows reduction in number of chemotherapy cycles to half or more (only 3 to 6 cycles of chemotherapy, instead of 9 to 12 cycles), thus providing better quality of life, and overall much more treatment free period, and hence cost effective as well. Also, chemotherapy alone, without transplant, provides a shorter disease free period, hence requiring repeat chemotherapy earlier. August 10th, 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