Breakthroughs in Lymphoma and Other Blood Cancers Health Radio Network December 17, 2006 Andrew Evens, D.O. Introduction

Transcription

1 Breakthroughs in Lymphoma and Other Blood Cancers Health Radio Network December 17, 2006 Andrew Evens, D.O. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio Network, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction Good morning wherever you may be around the country or on the Internet around the world. I am Andrew Schorr here every week helping you make smarter healthcare decisions. Every week we talk about very significant health problems, and what I try to do is take a look at when there are big medical conventions or conferences, which is where a lot of research gets presented. We the patients, and as our announcer Carline said, I m a 10-year leukemia survivor. I have no sign of the leukemia now because I got advanced care, and I was in a clinical trial, and we ll talk about that as we go along, but that cancer could rear its head again. What will be the right treatment for me? So that may be something that s discussed at one of these meetings because I want to know is there something better and what s optimal for me with the fewest side effects, the best chance of beating the cancer or certainly beating it back so I can go on with my life. We had such a medical meeting just in the last week. It s called the American Society of Hematology or ASH meeting, and that was down in Orlando, Florida at the big convention center there not far from Disney World, and with us today is a cancer expert who can help us understand what happened, and that expert is Dr. Andrew or Andy Evens. He s a hematologist/oncologist and assistant professor in the division of hematology/oncology at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Dr. Evens, thanks for being with us. Thanks. No problem Andrews. So you were down at the ASH meeting. Now I know that you re a specialist in lymphoma, and that s sort of the most common blood-related cancer, and then there are a number of leukemias that follow as well and multiple myeloma, and I d like to bring those in as well. First of all, the overall tenor of the meeting; there are about what 20,000 to 30,000 doctors who go? 1

2 That s right. It s a huge meeting down there, and it really is our big annual world-wide meeting where not just the U.S. but literally everyone from all over the world comes to Orlando and really shares research ideas but in a formal manner where there are oral presentations and you submit ahead of time your research, and really the best of the best or the most important and novel get accepted, and you present them in front of your peers, or we even have poster board presentations where you make a poster and stand by the poster and other doctors come through and you discuss it. I like to describe it as sort of the World Series of blood-related cancers. It really is. It s big. Now, there certainly are smaller meetings throughout the year, but this is kind of the as you said the World Series or the Superbowl of our hematology meetings. Let s talk about some of developments that have happened in years past. Now the big one was a few years ago. There was actually an anti-cancer pill, if you will, Gleevec. Some people may have heard of it. It was on the cover of all the big news magazines, and that s a pill that s allowed people with one sort of leukemia, CML or chronic myelogenous or myeloid leukemia, to take this pill and many people who otherwise would die to live and live a pretty normal life. So that was a, wouldn t you agree that was a major, major breakthrough that cancer specialists dream about? It was incredible, and I remember how many years now, it probably was eight years ago or nine years ago when it first came through clinical trials, and at the time that disease CML or chronic myelogenous leukemia, it usually is chronic but sometimes it can become very aggressive, and I remember at the time I was just finishing my training at the time of the clinical trials. There are different types of clinical trials called phase 1 that are at the first step where they re just trying to find a dose, and then once you find a safe dose phase 2, and usually in phase 1 you don t see that many patients necessarily getting into remission, but I remember that these were patients who were very sick, and at the time it was really the first of its kind, this targeted cancer therapy as a pill. At the time patients had been getting huge IV chemotherapy, big doses, or bone marrow transplants and coming in very sick. We d give them a pill, and they would come back two weeks later, unbelievable, feeling great and a few months later in complete remission. It really, really set the standard for not only oncology but I think all of medicine trying to really be more targeted. 2

3 Right and the magic bullet, and I have a friend Jane, and she was a sick puppy, and they were wondering would she need a bone marrow transplant, and she takes those Gleevec pills. Now there is one approved successor or a medicine to help with people who didn t respond for some reason to Gleevec, and there is another one coming. That s right. I know there is more research even to look at what they called the, is it the multikinase inhibitors, but looking at were there yet other developmental medications that can round this out so that more people with these conditions can be helped. So I know that s pretty exciting. Okay well let s talk about some of the, now that was kind of a big on the Today Show on every news magazine kind of news. It was huge. Yes it was literally a home run. Yes, that was a home run. We wish that that could happen every year in our fight against cancer. That wasn t this year, but just as an overall tenor of it, was the meeting upbeat? I think so. It was, and yes it s hard because we want every new drug to be a home run, but usually in most situations it s a lot a singles; maybe in a few doubles here and there; but yes, I think with this meeting it was positive. There was really nice progress made in multiple areas. I pay a little bit more attention to the lymphoma but keeping an eye out on some of the leukemias and multiple myeloma really just across the board I think nice progress has been made. Now I ll just give my personal example and how this applies. So my doctor, I was in a clinical trial, is a fellow named Michael Keating who has devoted his life to a condition called chronic lymphocytic leukemia. So as you know there was a pill that people took that was marginally effective called chlorambucil or Leukeran, and people took it around the world. Right. 3

4 And then they tried a single-agent chemotherapy, fludarabine, and that did better, and then they said well let s combine that with Cytoxan, another drug used a lot in breast cancer, and then they did better and that research at a program like this at the ASH meeting, and then they said let s add a monoclonal antibody, a kind of nonchemotherapy, targeted therapy Rituxan, and for me at least being in a clinical trial over almost 6 years now that continues to have worked. So the monoclonal antibodies have been exciting and remain a very important area of research right? Absolutely. That one in particular was called rituximab, and that targets B-cells, which CLL is; it s a malignant B-cell disease, and most of lymphomas are B-cells, and thankfully right we ve learned that this rituximab works in many different lymphomas, different kinds of lymphoma, and also in this CLL, and that s really the future. The future of oncology is finding targeted medicines hopefully with not a lot of toxicity and certainly along with that hopefully high remission rates. Well it worked for me, and the treatment that I received is what many people receive nationwide and some worldwide now. When we come back after the break Andy, what I want to do is discuss lymphoma since that s really the most common blood-related cancer and what s going on there. Welcome back to Patient Power live on HealthRadio Network. Andy we were talking about this American Society of Hematology meeting that ended just about a week ago in Orlando, and you being sort of our news reporter on what happened, and your special area is lymphoma, and that is I guess the most common blood-related cancer. So that s what 40,000 to 45,000 new cases a year? Is that right? A little bit more, and it s that lymphomas probably are going to near 70,000. It s right around 66,000, and that s including Hodgkin lymphoma, which used to be known as Hodgkin s disease, which accounts for about 8,000, and then the non-hodgkin lymphoma, which is right around 60,000. That s one thing where we re dedicating research because it still is increasing in the United States and elsewhere, the incidence. We get asked that a lot; what causes it, why; and the honest answer is still we don t know. We have some theories, but it s still a really active area of research as well in addition to treating the disease. 4

5 Advantages of Targeted Therapy Okay. Now I have a friend, Tim. I won t give his last name, but Tim was diagnosed with non-hodgkin s lymphoma gee I want to say eight or ten years ago, quite a long time ago, and he s had different courses of therapy and one; you have various acronyms for things, and I know he had what s pretty common, CHOP therapy, and maybe you can tell us what that is; but then along the way this drug Rituxan that I mentioned, this sort of targeted monoclonal antibody, sort of cruise missiles, and as you said they re used to get at those cancerous B-cells and knock them out, and it certainly did with my related condition, chronic lymphocytic leukemia, and it s worked for Tim. So now you re increasingly using Rituxan earlier with those chemotherapies with good results, right? We are, and it is somewhat like a smart bomb so to speak because what chemo, and chemo still works, and chemo has been around for many, a good 50 years, many years, but the problem with chemo is it kills every cell in your body in other words including your normal cells. Certainly you hope it kills more cancer than your own cells whereas these targeted drugs like rituximab and some others that we ll probably talk about are targeting right to the cancer and really because of that we see much less side effects. You don t see the hair loss like you see with chemotherapy and nausea/vomiting and some of those unwanted, undesired side effects with chemotherapy. Now we d like to cure cancer, and in some cancers now we have been curing it, but in lymphoma it s been tough, and certainly in my CLL it s tough. So can these less toxic or minimally toxic therapies like rituximab or others of these sort of cruise missiles or smart bombs if you will, that go after the cancer cells and don t really affects others, can they be reused because I think that what s Tim s getting. He s getting what some describe as maintenance Rituxan. Every few weeks I think it is he goes in for another infusion and then he feels well, and he goes about his work. He is in the insurance business, and he just goes on with his life. Yes, you can. Part of it though also Andrew really depends on the kind of lymphoma because even with the syndrome or the disease, non-hodgkin lymphoma, there actually are many different types, and believe it or not under the microscope there are 30 different kinds of non-hodgkin lymphoma, but we put those into categories, and there are some and actually your cancer - CLL, chronic lymphocytic leukemia - falls into the one general category called indolent or chronic. Those are ones that, and it sounds like your friend has that, where it is more of a chronic disease and where patients will receive a treatment, go into remission hopefully for many years, it will come back, they will get another treatment 5

6 and go into remission whereas other of the lymphomas are much more aggressive. In fact the most common of the 30 non-hodgkin lymphomas is called diffuse large B-cell lymphoma, and that s one that actually is very aggressive, and untreated it is 100% fatal, but the good news is chemotherapy <inaudible> and when you add rituximab on to it, it is curable. In other words it goes away and it never comes back, but it really in those types of lymphomas is an all or none. Rituximab has not only helped remission rates with that, but it actually has increased the actual cure rate of that specific type of lymphoma. So going back to the ASH meeting then and we talk about lymphoma, what looks to be I guess we d say a incremental or you called it singles or maybe some doubles, but what looks encouraging? Well, a couple of different things. We are learning how to combine. The rituximab is one thing and because many drugs, and I think we ll talk about clinical trials of little bit later, but usually you ll test it just by itself but what we ll often learned is okay it works good by itself and as you mentioned Andrew let s combine it with other drugs and make it work even better, and so there are some new kids on the block, somewhat like rituximab but different mechanisms, but they are targeted drugs. For example one is called bortezomib, which is called Velcade, and that s FDA approved for multiple myeloma, and it just got its FDA approval about 10 days ago for mantle cell lymphoma. That s an aggressive lymphoma, and that s somewhat of a concept that we see a lot where these targeted drugs get approved and first find its niche for a certain blood cancer or even a solid tumor and then we test it in three or four other cancers and will find out wow it works there as well. So were doing that a lot with a lot of these drugs where they are approved in certain conditions and then finding out it works in others. Now if you have chemotherapy typically it might work, you have a certain result for a while, and then kind of peter out or have high toxicities, and you would just be weakened. Now we re developing these more targeted therapies, you mentioned rituximab, I want to say it right, bortezomib I think, but Velcade That s right. I think of it as its trade name, familiar with it in multiple myeloma and maybe more coming. So the idea is that these could be reused or combined for sort of a bigger hit right, and that is what you re always working on is how do you combine them, and which 6

7 patient is which combination right for, and I think you talked about targeted therapy when we talked about Gleevec. It would be great if there was one pill that works for everybody or one infusion that works for everybody, but a lot of it is figuring out which approach is right for which person, right? That s right, and I think that s somewhat of a whole other area. It s related where not just finding drug A and targeted drug A and B that work really good, but if we could even take the next step and find out okay, who exactly, who are the best patients. Instead of just taking the first 100 patients who walk through the door and it works in 40 or 50% go into remission can we figure out who are those 40 or 50% beforehand? It s a little bit earlier in lymphoma in that, but I think for the future that s something we want to use, but we re definitely making progress. And it s important to mention that we ve been doing that in other areas of cancer. In breast cancer now they re looking at the tumor type and actually the cells, and they are trying to determine is chemotherapy important and which chemotherapy might be likely to work best. We are going to take another break on Patient Power. We re visiting with Dr. Andrew Evens. He s an oncologist/hematologist at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago. We ll talk with Andy more on the latest in blood cancers right after this. Stay with us on Patient Power. Thanks for tuning in to HealthRadio Network were listening to our replay online on or I m Andrew Schorr, a 10-year chronic lymphocytic leukemia survivor. I m based in Seattle, which is pretty cold today and a lot of people without power from a windstorm that we had just a couple of days ago, Thursday night. It was terrible, like 70-mile-an-hour winds, and I live where there are a lot of trees, so we may be without power for about a week, but you know every day that I m alive, power or no power, I celebrate medical technology and great providers that have helped me get the best care, and that was a combination of a targeted therapy, a monoclonal antibody, kind of a cruise missile for the cancer type that I have, in my case a drug called rituximab which is also used in lymphoma as we ve been hearing, and then two other drugs, fludarabine and cyclophosphamide also known as Fludara and Cytoxan. They have acronyms, these cancer specialists, for all these combinations. That one s called FCR, and I think the data, Dr. Andrew Evens from Northwestern, continues to look good that that s been an advance for many people hasn t it? It really has, and it somewhat makes sense that if you combine more drugs it s better, but ultimately we want to make sure because there are a little more side effects as you could imagine than if you used one drug by itself, but yes, it looks that the overall remission rate is higher if you use all three together. 7

8 Determining Goals of Treatment Now in some of these chronic conditions we always wonder well is it not only better for you today but it will change your survival. With the chronic conditions where somebody was probably going to live a pretty long time anyway it takes awhile to find out, and that s always the question. Does it offer what you all call a survival advantage, and the jury is still out on that right? I think that s huge, and every new patient we see that s one of the first things we talk about because you have to say okay what are my endpoints in treating this cancer, and as we spoke before there are some that are curable meaning go away and never come back, and then there are of some that are what we say treatable; in other words you can put it in remission but it s not curable; and then there is a level in between even where okay it s not curable but we can at least extend survival and make you live longer, whereas there are other conditions where yes you can put it in remission, but it actually does not affect survival. So it s important going in to know okay should I take this extra toxicity? What am I doing it for? What is my endpoint? I think that s always fair for patients to ask their doctors okay what are our goals? Are we just trying to get in remission, which is good, or is this going to be curative and/or extend survival? The way I looked at it was, because we haven t known about extending survival is, can I go back to a pretty normal life and feel good? Can I be productive? Can I be with my family? Can I put the cancer worry in the background for however long it lasts? The other thing, and I think this relates to these targeted therapies is, can I buy time? If you will, can I live better and hopefully live longer but live better and put my cancer in such a low state that not only can I live well but so I can be around for when the next big breakthrough comes along? Absolutely, and that s not only getting in a remission but hopefully staying there longer. I can tell you just one example we talked about this group of the low-grade lymphomas, and really for 50 years we knew it was treatable, but when we looked at the survival for 50 years it wasn t changed, but I can tell you at the ASH meeting and in the last year in our journals and publications we re finally seeing that we re actually prolonging survival, and so it s exciting. It s really the first time in low-grade lymphoma that paper after paper after paper is starting to show that, and so we re pretty excited about that. And that s my friend Tim. He s living well. He is working. He has the low-grade lymphoma. Also there are more kind of big gun treatments like bone marrow transplant, which 8

9 certainly have been perfected a lot and made less scary, but still it s a big deal, and these are people who might have otherwise gone to transplant who are not, right? I think so, yes it has. I mean all of these new therapies because at some point let s say 10 years ago before rituximab was here you had chemotherapy but at some point the chemotherapy stopped working and you started to resort to bone marrow transplants. They still have their role. There still are certain conditions where it s curative to get that, but there are other conditions where you can take a pill or take a Rituxan and not go through the extra toxicity, as you can imagine, many patients will choose that option. Latest Multiple Myeloma News Before we get to that break maybe we could just start for a minute. Another condition you mention not common but some famous people have it, Geraldine Ferraro who had been at vice presidential candidate, and Mel Stottlemyre who had been the pitching coach for the Yankees with multiple myeloma. How we doing there? You mentioned Velcade, and that s made a difference. How are we doing in multiple myeloma? What s the news there? Doing pretty good, and I think that s one too when we look back at our data 10 years ago when we just had chemotherapy we sometimes look at median survival or half way at what time point are 50% of patients alive, and when we just had chemotherapy it was only a year and a half, but now when we look at whether bortezomib or thalidomide or it s the new kid on the block lenalidomide, the median survival is four to five years, and so it just keeps getting longer and longer and longer. So I think very nice progress continues to be made and that disease as well. Are you encouraged Andy? I am. I really, really am, and I think what we re encouraged about are there are so many drugs and new agents out there. Now that s a good thing. The challenge is because unfortunately not every new targeted drug that comes through the laboratory works. In fact it s probably the minority, so it s a big, big task to figure out through good clinical trials which drugs work and work the best and in what combination, and that s a big challenge. So it s exciting that we have this opportunity to study all these new drugs, but it s important. They do have to be studied because if it doesn t work well we want to show it doesn t work and move on to the next one. 9

10 After the break you and I will talk about clinical trials in depth and also about maybe consulting with an academic medical center as well to see do they have clinical trials that you want to consider in your treatment options and where those should fit in your sort of continuum of care. We re talking with Dr. Andrew Evens from the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago on the latest on blood cancers, and we ll be back with more as we continue on Patient Power right after this. Welcome back to Patient Power. Andrew Schorr or hear it live on HealthRadio Network as I am most weeks, although next week we re going to have a replay, and that will be coping with anxiety, differences in anxiety disorders, and really helping you understand. That will have Dr. Mark Pollack who is at Harvard and Massachusetts General, and then Jerilyn Ross from the Anxiety Disorders Association of America, and also we ll have a woman on who dealt with anxiety for so many years and finally got the treatment she needed and deserved when she saw an article in the paper and heard about new treatments and got to the right practitioners, and it worked out. Advances Through Clinical Trials Today were talking about blood-related cancers and news from the American Society of Hematology meeting that just concluded about a week ago in Orlando where all the big cancer specialists go. One of them who was there is a lymphoma specialist from the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, that s Dr. Andrew Evens. Dr. Evens, so you mentioned before the break about the importance of research and helping patients and doctors come together to perfect treatment and that happens in clinical trials. So I know you re a big fan of clinical trials and you have many at Northwestern. I was in one that came out of M.D. Anderson Cancer Center in Houston, and I m so glad I did because in my case it did work out that I got sort of tomorrow s treatment today, the treatment most people get. That s not always the way it works out, but I certainly helped play a role in knowledge about what treatments could be effective in this case and maybe your spiel, if you will, about clinical trials and why you think it s so important and for people to ask about them. I think you re exactly right. It s something in cancer that we probably need to do a better job because as you said that is a way to make advances, and certainly things usually will start in a laboratory, but to really prove that it works to prove that it s a safe it is through good clinical trials, and it s tough because when we look at statistics in the United States in oncology specifically for pediatrics, for example, they ve actually done papers on this, approximately 50 to 60% of pediatric cancer patients go on a clinical trial whereas for 10

11 adults in the US it s less than 5%, and it s hard because to really make that advance to answer the next question to say okay this works better or this doesn t work or this is the way to go, it s through a clinical trial, and so if there s one thing with all these new drugs it s becoming, there so many clinical trials, something more important we need to do is just to be more active, to be more involved as doctors and as patients in these clinical trials, and sometimes clinical trials for whatever reason get a negative stigma, but I think the key is to be well informed, and if there s an opportunity whether it s a totally new compound, new drug, or what it often is a clinical trial is it s just studying the combination like with you, the fludarabine/cytoxan/rituximab, they had all been out there. What the clinical trial was, was combining them together, and that s how we make advances. I want you to know that I did not consider going into a clinical trial lightly, and certainly there are all sorts of papers you sign and warnings. I was able to actually through a listserv, and I ll mention it, acor.org, Association of Cancer Online Resources. They have groups of patients with a variety of blood cancers in particular speaking with one another via . I did that, and then through that I then spoke to some people on the telephone and actually spoke to people who were in the clinical trial that I was considering, and they were a month, two months, three months further down the road, and I could talk about it as well as I talked to my local oncologist and then the university oncologist that I was consulting with. So you go into it with your eyes open. For me it was would this offer me the potential of a better treatment and would I also be helping others in the process? So I would recommend it to people to make that part of your treatment decision. Have clinical trials be part of the discussion. Bring it up with your doctor. It may be that it s available with your community oncologist, somebody at that freestanding cancer clinic down the street, or it may be that you ll go to a big cancer centers like the Lurie Cancer Center at Northwestern in Chicago, an NCI comprehensive cancer center. I would recommend if you have one of these blood cancers that you should probably get a second opinion. If you have lymphoma consult with somebody like Dr. Evens and say from your perspective what s on the table or are clinical trials something I can consider, and then you may have your local oncologist or maybe Dr. Evens, and you make that decision. Andy, does that sum it up pretty well? That s perfect, absolutely. I couldn t honestly have said it better, and that really should be part of the decision making, and it s understandably a little nervous sometimes for the patient. It s a lot of information, but it s really important. Okay, it s all about being a smarter patient or if it s your loved one with a cancer for you to get smart and then have these discussions with doctors who can help and advise you. We ll be back with some final comments on Patient Power on the HealthRadio Network right after this. Stay with us. 11

12 I really appreciate you joining us today on Patient Power. I want to mention again if you go to all our replays are there about almost 170 hours of programs and a number of them on cancer. This replay will be there later this week with Dr. Andrew Evens from the Lurie Cancer Center at Northwestern in Chicago. So it s all there. Also I have a blog, and you are welcome to comment on it. I really appreciate your comments. If you want to send me an anytime just send it to Andrew@patientpower.info and tell your friends this is the only program like it in the whole country or in the whole world I think. Dr. Evens as we wrap up you came back from this meeting of 30,000 of your closest friends and peers all working to move the ball forward in curing cancer or if it can t be cured to really make it chronic to the point where people like me can just go live our lives and hope for a long one. A final comment from you sir? I agree, and I think we are in an exciting time with the targeted therapies with multiple institutions working together on clinical trials, and I think we want to move on. We want to continue to progress and as you said if not cure it just find better, nontoxic therapies that will allow the patients to live their lives. Are you feeling upbeat? You know years ago being an oncologist I mean, and you decided to go in it, but it was a tough field. Many of your patients didn t survive, and the treatments were toxic, and you know it was tough. How are you feeling today? I think totally different. I think encouraged, excited, just a lot of opportunities, and when we see patients that s the exciting part is it s not just one option or two options. It s typically and often many options that we have to talk about, and that s the important thing is involving too, I should of mention on an aside, involving the patients. Not telling them, You re going to take this. It s Okay here are options 1, 2, and 3. How does this fit in your life and what are your preferences? It s very exciting. Dr. Andrew Evens from the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago. Andy thanks for being with us. We wish you and fellow hematology/oncology experts just all the best in working with us so that we can be around a long time, live well, and help other people in the future. Thanks for being with us Andy. That sounds great. Take care. 12

13 Okay, thank you for being with us on Patient Power. Have a great week. I hope I have my power back next week, and watch us on the news in Seattle. Remember knowledge can be the best medicine of all. Bye-bye everyone. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio Network, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. 13