Wednesday, November 9, 2011

Gentle or Heavy Approach to CLL

Karl is an excellent researcher and a very clear thinker.

Take a look at what he has to say about the choices in an indolent cancer.
What would you choose?

This is the generic question I face.

Do I hit the CLL hard and then dash to a transplant, and be cured or die trying or perhaps worse get a new difficult and sometimes incurable disease, graft versus host?


Do I gently rap the cancer's knuckles with a slightly bigger stick than the rituximab which is no longer doing the job, but hold off on the big clubs to avoid peripheral damage to my already compromised marrow and immunity? Probably that means a clinical trial.

Here is how Karl lays out the options. I will write soon on the specific details of what I need to deal with, what I can't ignore.

"If treatment for cure is necessary; is it possible? If possible, is it necessary?"~ Dr Willet Whitmore (on prostate cancer).

Which seems to apply pretty well to the indolent lymphomas and CLL.However, for most types treatment is eventually, but not always, needed.So there are two basic approaches to clinical care research for the indolent

One being to manage it with treatments that have lower toxicity - and only
as needed.

- With this objective it can be argued that one should treat
earlier (when the need to treat is not evident but expected soon) in order
to have a better chance for the less aggressive therapies to be effective -
but also because milder therapies generally are not as fast-acting and
advanced lymphoma can sometimes require a timely response.

The second goal is to treat the indolent lymphoma with intent to induce a
durable remission (and dare we say it, with a potential for cure) with more
aggressive combination therapy.

- Here treatment is generally deferred to when the need for
treatment is clearly indicated - however, waiting until the condition
becomes too advanced (bulky, causing symptoms) can sometimes limit
therapeutic options and lower the odds of achieving the best results.

Which approach is best? It's sometimes argued that it's better to conserve
one's "bullets" to preserve future options. However, it is also noted that
having a long remission increases your options - enable you to use even the
same therapy again when therapy is needed, and that this might preserve
options and lead to less treatment resistance compared to using milder
therapies more often.

So this is a big reason why --- for the indolent lymphomas --- there is NO
standard of care - no easy, one-size-fits-all formulas for how and when to

So informed choice is a process, which requires an objective understanding
of our clinical context:

1) the natural history - or anticipated clinical course for your type of

2) the potential benefits and risks of the current standards of care,

3) an appreciation of the unique and sometimes changing individual risk
factors - such as one's age and performance, the changing behavior of the
lymphoma, or responsiveness to prior therapies.

The clinical context can influence how much risk is appropriate to take when
treating the lymphoma and also how appropriate it might be to ask about and
consider clinical trials.

All the best,

~ Karl

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