Tag Archive for: relapsed DLBCL

Dr. Nirav Shah: Why Is It Important for You to Empower DLBCL Patients?

Dr. Nirav Shah: Why Is It Important for You to Empower DLBCL Patients? from Patient Empowerment Network on Vimeo.

 How can diffuse large B-cell lymphoma (DLBCL) care providers empower their patients? Expert Dr. Nirav Shah of the Medical College of Wisconsin explains methods he uses to help patients gain confidence and to create a relationship of collaboration and trust with patients.

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Dr. Nirav Shah:

So when I meet a new patient with diffuse large B-cell lymphoma, whether it’s in the frontline or in the relapsed/refractory setting, my main goal is to develop a partnership with them. Yes, I am the expert and the person who has knowledge on how to treat the disease, but the patient is a person going through it. And so what I try to do is educate them, review the options, and then guide them and try to help them come to a decision as to what is that best treatment there is, but again, with my educated guidance. And often patients need to make that decision themselves, especially our older patients who may have other values about how they want their life to be in their seventh or eighth decade.

And so what I try to do is have this collaborative discussion where I review the options and sort of say, “Well, this is what I think is best.” Why do I think that’s important? I think that patients today have access to a lot of information, and they’re going to be able to read a lot of things, and I think it’s important to be honest and up front that often there is more than one option for their disease, whether it’s frontline or relapsed, and then help them understand why I’m choosing a particular pathway for them and giving them that ability to make that final decision about, this is the way that I want to proceed.

By empowering them, I think it makes them a partner in their care, in the care that you’re providing them, it creates trust in a relationship between an oncologist and a patient, which is just so important to have because without having that trust it’s difficult to ask these patients to sacrifice their health, sacrifice sometimes important family events to be able to do the treatments that we’re prescribing. And so that’s sort of my approach, is through good education, review of information, through guidance, but ultimately allowing them to make that decision as to what they think is the best path among the options that I presented. 

Treating Relapsed/Refractory DLBCL

Treating Relapsed/Refractory DLBCL from Patient Empowerment Network on Vimeo.

What are the options for DLBCL patients who relapse? Dr. Jane Winter shares treatment options for relapsed/refractory DLBCL and what is available for patients who have coexisting conditions or health concerns.

Dr. Jane Winter is a hematologist and medical oncologist at Robert H. Lurie Comprehensive Cancer Center at Northwestern University. More information on Dr. Winter here.

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Laura Beth:

Dr. Winter, if a DLBCL patient doesn’t respond to treatment or relapses, what happens next? Are there additional treatment options available?  

Dr. Winter:

Absolutely, but we have some very new treatments and some new data that’s just been within the last year. So, I had mentioned earlier with regard to follicular lymphoma this CAR T-cell therapy. So, CAR T-cell therapy is now approved for certain patients who relapse. So historically, in the past, patients who were young enough and robust, healthy enough to consider what we call an autologous stem cell transplant, so, high doses of chemotherapy with stem cell rescue was the standard of care for many years. But many patients would not be eligible for that kind of therapy, first, because they were too old or they had too many medical problems, what we call comorbidities.  

But also, because in order to have a good outcome with this kind of treatment, we need to first get the disease into remission, and that can prove challenging. So, for many years, though, what we call autologous stem cell transplant was the standard of care. But a disease that is most common in people in their mid-60s and above, this was not an option for many patients, but also, many patients just never became eligible because their disease was too difficult to control. And so, in recent times, over the past six years or more, a new therapy called CAR T-cell therapy has emerged.  

This harnesses the patient’s own T cells. The T cells are collected from the blood stream, and then they are genetically engineered so that they target the marker on the lymphoma cells. It takes about three weeks or so to go through the process of altering these cells and creating these CARs, and then re-infusing them back into the patient now targeting the patient’s lymphoma. And, this is a therapy that’s incredibly promising.  

It was approved a while ago for patients in the third line, meaning if your disease came back after your first treatment, let’s say, R-CHOP, and then you receive second line treatment, but that treatment didn’t really work, you were a candidate for CAR T-cell therapy. And about 35 to 40 percent of patients would do very well with that therapy. It’s not a hundred percent, but still, it was a very good option for individuals. Now, we have clinical trials comparing patients who relapse. So, at the time the first relapse, if that relapse occurs within a year or the patient progresses while on initial treatment, CAR T-cell therapy has been shown to be better than the old standard of care, which was the second line of treatment in the stem cell transplant.  

So, we now have this very promising new strategy for patients as well as for a subset of patients who are not eligible to go on to conventional autologous stem cell transplant because they’re too old or they’ve got a heart disease or some other comorbidity that makes them not a candidate for a standard stem cell transplant. So, this is very exciting and is approved for patients with relapsed disease, or refractory disease, or disease that progresses during initial treatment, or recurs within a year as well as this group of patients who are either too old or too sick to have an autologous stem cell transplant.  

But, there are many new iterations, new variations on this theme that are under investigation right now. So, there are lots of clinical trials to consider for a patient with relapsed disease or refractory disease because we have new versions of CAR T-cell therapy that are under investigation as well as a whole list of new agents, targeted agents and what we call bite antibodies and so on.  

So, things are very promising and there’s a tremendous amount of research going on right now, much of it translating into improved responses and survival for patients with diffuse large B-cell lymphoma. 

Which Emerging DLBCL Therapies Are Showing Promise?

Which Emerging DLBCL Therapies Are Showing Promise? from Patient Empowerment Network on Vimeo.

What’s next in diffuse large B-cell lymphoma (DLBCL) treatment? Dr. Justin Kline reviews developing research that could transform the future of DLBCL treatment.

Dr. Justin Kline is the Director of the Lymphoma Program at the University of Chicago Medicine. Learn more about Dr. Kline, here.

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What about emerging therapies, Dr. Kline? What approaches are showing promise?

Dr. Kline:       

Well, I think probably in DLBCL, the biggest breakthrough, I don’t even know that I can call it emerging at this point, because it’s on the market, so to speak.

But I think it’s important to talk about, again, is CAR T-cell therapy, and this is a type of immune therapy where a person’s own immune cells called T-cells are taken from his or her bloodstream. And then using a special type of a virus, those T-cells are manipulated or engineered, that sounds better, to express on their surface something called a chimeric antigen receptor, which is somewhere between an antibody and a normal T-cell receptor. But anyhow, this chimeric antigen receptor confers or allows the T-cell to recognize a protein that’s expressed on the surface of B-cells, cancerous or otherwise, called CD19. And when that chimeric antigen or CAR antigen, excuse me, that CAR receptor expressing T-cell sees a lymphoma cell, it engages it and kills it, a pretty clever idea which has been in the works for decades now.

But CAR T-cell therapy has now been approved for not only DLBCL but many other types of non-Hodgkin lymphoma. And I think in the past decade, far and away, that’s the biggest breakthrough. There are other types of immunotherapy, probably most notably a type called bispecific immunotherapy, which is a pretty clever type of immune therapy where these specially engineered antibodies that are capable of binding or sticking to not only a person’s T-cell, a T-cell that’s already in his or her body, and a B-cell, a lymphoma cell that’s right next to that T-cell, sort of holds them together, and the part that binds the T-cell actually activates it, triggers it to kill the B-cell. And so there are a number of companies that have those bispecific therapies that are in development. I suspect a couple will be approved by the FDA, I would guess, in 2022.

These bispecific immunotherapies have been very effective, again, in DLBCL that’s come back, relapsed or refractory, as well as in other lymphomas. They do have some side effects that are similar to what we see in folks with CAR T-cell therapy. I won’t belabor what those are, but they are also very effective. There’ve been a number of drugs that, either immunotherapies or other types of therapies, that target that same CD19 protein on diffuse large B-cell lymphoma cells that have recently been approved by the FDA, either alone or in combination. Targeted therapies are always exciting. Although as compared with other lymphomas, these targeted therapies, many of which are oral, which are pills, have not been particularly effective in relapsed DLBCL.

So, I think that among the most exciting therapies are those that take advantage of our own immune systems to recognize and kill the lymphoma cells.

An Expert Review of DLBCL Research and Treatment Advances

An Expert Review of DLBCL Research and Treatment Advances from Patient Empowerment Network on Vimeo.

What’s the latest in diffuse large B-cell lymphoma (DLBCL) treatment advances? Expert Dr. Robert Dean provides an update about emerging DLBCL research and explains recent treatment approvals for relapsed DLBCL patients.

Dr. Robert Dean is a hematologist/medical oncologist at Taussig Cancer Institute at the Cleveland Clinic. Learn more about Dr. Dean, here.

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Is there emerging DLBCL research that you feel patients should know about?

Dr. Dean:

I would say, “yes.” One of the things that has really been striking for me in the last few years alone in caring for patients with large B-cell lymphoma is how we’ve gone from a more surface-level understanding as we’ve been talking about what some of the differences are between different cases of large B-cell lymphoma to being able to get a better readout of why the lymphomas sometimes behave the way they do.

I want to be careful to make sure that patients who might be listening to this understand that we still don’t have a crystal ball. We can’t review their biopsy, look at their scans, and tell you, “I know that if you get R-CHOP you’re going to be cured.” Or if they’re a high-risk situation we can’t look into a crystal ball and tell them, “I know that R-CHOP won’t work for you, and you should do this tougher, more intensive treatment.”

We still see a lot of outcomes that we can’t necessarily predict from those other kinds of tools. They just give us a better sense of what the odds are for people as we’re at the start trying to make decisions about what to do. Another element that has really been striking has been the introduction of engineered T-cell immune therapy, which has provided an option for cure for some patients that otherwise we wouldn’t have had an option, and worked for about half the patients that go through it overall.

What’s coming down the road in clinical trials that are still ongoing is information that’ll help us decide if that approach to treatment should move to being second in line instead of a stem cell transplant for some patients, and they’re even doing studies looking at whether, for very high-risk patients, adding a CAR T-cell treatment onto the end of initial chemotherapy leaves them better off in the long run.

So, those are questions that will take some time to answer with ongoing studies, but I think are really exciting because they’re taking advantage of some of these newer treatment approaches that we know are helping some patients when their first attempts at treatment didn’t work and seeing if they might leave them better off if we use them earlier in the process.

There are other studies ongoing looking at seeing if we can improve upon the results that we get with treatments like R-CHOP as the first pass at treatment. Many such studies have been done and have not shown any benefit by adding this drug or that to the standard R-CHOP treatment, but there have been a few new drugs approved for treating people with large B-cell lymphoma after it’s relapsed in the last few years. For example, one called polatuzumab vedotin. Another combination of the drug lenalidomide and a new antibody-based drug called tafasitamab.

And then there’s another drug called loncastuximab. So, there’re studies going on with all of those looking at whether they offer more benefits to patients if we use them earlier in the game.