Tag: chemotherapy

ASCO 2013: Impact of Interval Between Diagnoses and Initiation of Curative Chemotherapy on Survival of Patients with Diffuse Large B-cell Lymphoma

peter martin photoBy Peter Martin, MD

A common question arising among patients with newly diagnosed DLBCL is how soon to begin treatment. While it is generally considered more appropriate to start chemotherapy sooner rather than later after diagnosis, the exact impact of this time interval on treatment outcomes is unknown. At the recent Annual Meeting of the American Society of Clinical Oncology in Chicago, Dr. Kevin A. Hay from the University of British Columbia presented the results of a retrospective study evaluating the association of patient outcomes with time to initiation of treatment.

Dr. Hay retrospectively divided 793 patients with DLBCL and at least one cycle of R-CHOP into four groups based on the amount of time between initial diagnosis and beginning of therapy. A total of 25% of respondents received R-CHOP within 2 weeks of diagnosis, 31% in 2-4 weeks, 37% in 5-8 weeks, and 7% at longer than 8 weeks. Interestingly, there was no statistically significant difference in survival between the groups. The authors concluded that the timing of chemotherapy initiation appeared to be related to clinical factors (i.e., sicker patients were treated sooner) rather than medical system or socioeconomic barriers. While detrimental outcomes were lacking in those patients who began treatment after 8 weeks, they recommended beginning chemotherapy as soon as possible after an initial diagnosis of DLBCL.

Lymphoma and Infection: Do I Need to Take Medication to Prevent Infection?

By Jessica Lewis, PA

In some instances, patients may be started on medicines to prevent or minimize infection. Infection in patients with impaired immune system function (due to lymphoma or treatment of lymphoma) can be life threatening. Ultimately, your doctor will determine whether to start such medications, but some current literature helps medical providers make this decision. The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance between 21 different cancer-treating centers within the USA. Research generated from physicians in these institutions is used to develop evidence-based recommendations to help guide healthcare providers. The American Society of Clinical Oncology (ASCO) is a not-for-profit group of physicians, who focus on patient-oriented clinical research, education, prevention, and delivery of patient care.

The NCCN and ASCO provide summaries of factors that predict a lymphoma patient’s risk of developing fever and infection. These factors include age, performance status, type of cancer, status of disease (remission vs. active disease), type of treatment, the presence of a low infection-fighting white blood cell count (neutropenic), and prior episodes of fever with chemotherapy treatment. Patients with lymphoma are generally classified as having intermediate risk, although some patients with CLL or T-cell lymphoma may be considered high risk.

Prevention of bacterial infections: Common prophylactic medications include levofloxacin or ciprofloxacin. Prophylaxis is recommended for intermediate or high-risk patients, including patients that are expected to have neutropenia. There have been few randomized-controlled trials that have investigated the use of antibiotics to prevent development of fever and infection in lymphoma patients that are receiving chemotherapy. The largest randomized-controlled study, by Cullen et al in 2005, included 1,565 patients with solid cancers and lymphomas treated with chemotherapy that would lower the white blood cell count.  In this study, patients were randomly assigned a placebo or levofloxacin. The authors found a decrease in the incidence of fever and decreased rates of probable infection and hospitalization. However, patients who received levofloxacin did not have a statistically significant decreased rate of severe infection (including lethal infections). As per 2012 NCCN and ASCO guidelines, the use of levofloxacin prophylaxis is only recommended for patients with neutropenia that lasts longer than 7 days.

Prevention of fungal infections: Medications to prevent fungal infections are not usually needed in lymphoma patients. ASCO guidelines recommend considering prophylaxis only for patients with profoundly low white blood cell counts (ANC <100) longer than 7 days. Additionally, patients should limit exposure to construction or demolition sites, and quit cigarette smoking to reduce risk of fungal infections.

Prevention of viral infections: Antiviral medications may be recommended. If you have been exposed to hepatitis B infection, you may be started on medication to prevent this from becoming an active infection. If you had the chicken pox as a child you are at risk of developing shingles, and you may benefit from preventative medication. Patients with lymphoma should not receive the shingles vaccine.

PCP prevention: Some patients are at risk of developing pneumonia, caused by Pneumocytus jirovecii (also referred to as PCP). You may require preventative medication, typically with TMP-SMX, if you are on steroids for a prolonged period of time (>1 month), or are receiving treatment with alemtuzumab or purine analogs (i.e., fludarabine).

Other preventative measures: ASCO 2012 guidelines recommended all patients who are receiving cancer treatment to receive the seasonal flu vaccine, along with their family and household contacts. Guidelines from the Centers for Disease Control (CDC) include administration of a pneumococcal vaccine in all patients with lymphoma.

Investigator-Initiated Trial: Sequential Regimen of Intensive Chemotherapy Followed by Stem Cell Transplant for Refractory Lymphoma

Update: this study is closed to enrollment. 

The Weill Cornell Hematologic Malignancies & Bone Marrow Transplant Program is now enrolling men and women with relapsed or refractory lymphoma (non-Hodgkin or Hodgkin) and who are in need of a stem cell transplant for an investigator-initiated clinical trial. The principal investigator is Tsiporah B. Shore, M.D. For more information about the study, please call June Greenberg, RN at (212) 746-2651, e-mail June at jdg2002@med.cornell.edu, or call the Bone Marrow Transplant Program at (212) 746-2119.

Study Details

This clinical trial is for men and women whose lymphoma (non-Hodgkin or Hodgkin) did not respond to treatment or has returned after responding to previous therapy, and who are in need of a stem cell transplant.

The purpose of the study is to test the safety and effectiveness of giving the drug Bendamustine, followed by high dose chemotherapy, within two weeks prior to a stem cell transplant for lymphoma that has not achieved a complete response to salvage chemotherapy (treatment used for relapsed disease).

Bendamustine is FDA-approved for the treatment of Chronic Lymphocytic Leukemia. Although Bendamustine has been used in stem cell research studies, the timing and combination of Bendamustine and the conditioning regimen BEAM (carmustine, etoposide, cytarabine arabinoside, and melphalan) prior to transplant is not approved by the FDA, thus the combination therapy used in this research study is considered experimental.

Autologous stem cell transplants refer to stem cells that are collected from an individual and given back to that same individual after high dose chemotherapy. With this type of transplant, the person’s stem cells are obtained prior to high-dose chemotherapy, frozen, stored-if necessary, and then given back afterward. Allogeneic stem cell transplantation refers to stem cells that are collected from a donor.

Treatment Plan

Study participants will receive Continue reading “Investigator-Initiated Trial: Sequential Regimen of Intensive Chemotherapy Followed by Stem Cell Transplant for Refractory Lymphoma”