Over a four-year span, the Lymphopath Network, a national hematopathology expert network in France that reviews lymphoma cases prior to therapeutic decision, reviewed over 30,000 samples from patients with newly diagnosed or suspected lymphoma. Researchers found that a change in diagnosis from original referral to expert review occurred in almost 20 percent of patients, and the change was significant enough to potentially impact care in over 17 percent of patients.
Diagnostic discrepancies were greater in patient samples sent with a provisional diagnosis than in those sent with a formal diagnosis, meaning that when referring pathologists were confident about the diagnosis, they were typically correct. Although most discrepancies were due to misclassifications of lymphoma subtypes, some patients were referred with benign conditions that were deemed lymphomas after pathologic review.
The study implies that frequently, in order for patients to receive optimal care, their diagnoses are best determined in collaboration with expert pathologists – especially in the current age of personalized medicine.
“As doctors who take care of people with cancer, so much of what we do is dependent on having a precise diagnosis,” said Peter Martin, Chief of the Lymphoma Program at Weill Cornell Medicine and NewYork-Presbyterian. “My bias is to meet people early on so that I can help direct the diagnostic evaluation, minimize unnecessary testing, and work with our experts in radiology, surgery, and pathology to arrive at the correct diagnosis as rapidly as possible. Importantly, the findings from the Lymphopath Network study highlight that even when a diagnosis has already been made, a second opinion regarding pathology can be important, particularly when there is any diagnostic uncertainty.”
As part of our mission to deliver precise, individualized care to as many patients as possible, expert hematologists and oncologists at the Weill Cornell Medicine and NewYork-Presbyterian Lymphoma Program collaborate with our team of world-class hematopathologists to provide collective assessment of all individual cases, working our hardest to secure an accurate diagnosis before proceeding with the appropriate therapy.
Citing a pattern of intensive mantle cell lymphoma (MCL) treatment regimens, Dr. Peter Martin – who co-chaired the OncLive State of the Science Summit on May 4, 2017, along with Dr. John Leonard – proposed that physician-researchers become more mindful of patient preferences when determining treatment regimens. He noted that some patients might prefer to receive more broadly accessible treatments and that those decisions may not significantly impact outcomes.
High-dose cytarabine followed by an autologous stem cell transplant, for example, is an effective treatment regimen for patients with MCL, at times inducing remission durations of 10 years. But people with MCL, who tend to be in their mid-sixties, are rarely keen to take the requisite six months away from work in order to receive treatment. Because fewer than 25 percent of MCL patients are eligible for intensive regimens, more practical treatment strategies are needed.
Dr. Martin also stressed the need to find a way to help patients who are destined to have poorer outcomes due to the presence of multiple risk factors as defined in the combined Mantle Cell Lymphoma International Prognostic Index (MIPIc). These factors include: age, white blood cell count, performance status, lactate dehydrogenase (LDH), and Ki67, a marker of tumor cell proliferation.
In a comparison of two clinical trials from the European Mantle Cell Lymphoma Network, one in which patients less than 65 years of age were treated intensively with an autologous stem cell transplant, and another wherein a set of older patients received R-CHOP or fludarabine-based therapy followed by rituximab maintenance, Dr. Martin pointed out that patients with similar MIPIc scores had similar outcomes no matter their treatment regimen.
Dr. Martin highlighted that multiple clinical trials are underway to determine the best drug to combine with the MCL treatment backbone of bendamustine rituximab, to investigate ibrutinib combinations in the relapsed setting, and to evaluate the necessity of intensive treatments like stem cell transplantation.
Watch this OncLive clip for more of Dr. Martin’s thoughts on patient preference:
In an interview recorded during the 2016 American Society of Hematology Annual Meeting, Dr. Peter Martin discussed results from a phase 2 trial where researchers from the Fondazione Italiana Linfomi found that the addition of intermediate-dose of cytarabine to the first line treatment of rituximab and bendamustine led to a 91% response rate in elderly people with mantle cell lymphoma. This chemotherapy combination is known as RBAC500.