Thursday, February 2, 2017

When CLL Goes Bad


Our Breathtaking View into Yosemite Valley this Winter
Friends,


I just returned home from a long weekend in Yosemite. It was touch and go whether the roads would be clear enough to get there, but we made it and it was breathtaking!

There was 9 feet of snow where we cross country skied and most of the valley had a thick dusting of white. It was so beautiful.


A week after the 2016 ASH meeting, the CLL Society held our 2nd annual CLL Patient Educational Forum at City of Hope in Duarte, CA. After the forum, I had a chance to chat with Dr. Steve Rosen about the new data that provides hope for patients whose CLL has transformed to Richter Transformation. You can read about it and watch out interview here.


ALL DONE! Thank you to the 233 who participated in our Q4 2016 Reader Poll about your experiences with Testing before Treatment. We're really anxious to dig into the data. Thank you again for your time!




CLL Patient Support Group Meetings Coming Up AND New Ones Forming

Wednesday, February 1st from 4:00 - 5:00 PM in La Jolla, CA:
The UCSD CLL Education and Support Group will be meeting.


Thursday, February 2nd at 7:00 PM in New City, NY:


The CLL Information & Support Group of Rockland County NY, sponsored by LLS will be meeting. More information here.




Monday, February 6th at 6:00 PM in Indianapolis, IN:


The CLL and Indolent Blood Cancers Support Group will be meeting.


Tuesday, February 7th at 7:00 PM in Tucker, GA:
The Tucker - Family Support Group, sponsored by LLS will be meeting.


ALSO - 

We are actively forming CLL-specific support group in a number of cities around the country. To see if your city is one of them, go to our home page  and click on the interest survey for your city. Not listed, but interested in starting one? Email us at support@cllsociety.org. Thanks!


Upcoming Patient Education Meetings
  • Saturday, February 4th from 8 AM to 12:30 PM in San Francisco, CA: The Leukemia and Lymphoma Society is hosting their
    Northern California Blood Cancer Conference 2017 at the Hyatt Regency San Francisco. Dr. John Pagel from the Swedish Cancer Institute and a member of our Medical Advisory Board will be speaking at the CLL Breakout Session. 
  • Saturday, February 18th from 7:30 AM to 2:45 PM in Scottsdale, AZ: The Lymphoma Research Foundation will be hosting Lymphoma Workshop: Understanding Lymphoma Basics and Current Treatment Options which will include disease-specific breakout sessions. There is no cost to attend, but registration is required. Find out more information here.
  • Saturday, March 4th from 9 AM to 3 PM in Anaheim, CA: The Leukemia and Lymphoma Society is hosting their Southern California Blood Cancer Conference 2017 at the Anaheim Marriott. Dr. Herbert Eradat from the UCLA Lymphoma Program will be speaking at the CLL Breakout Session. Find out more information here.
  • Saturday, March 18th from 7:30 AM to 3:15 PM in Washington DC: The Lymphoma Research Foundation will be hosting Lymphoma Workshop: Understanding Lymphoma Basics and Current Treatment Options which will include disease-specific breakout sessions. There is no cost to attend, but registration is required. Find out more information here.
In the meantime....


Stay strong.


We are all in this together.


Brian Koffman, MD

January 31, 2017



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Monday, February 8, 2016

Richter's Transformation and on the Road Again

Friends,

This week in the Beyond the Basics section of the CLL Society website, we have posted an interview from ASH 2015 with Dr. Januario Castro, although discussing an abstract that was presented at the 2015 iwCLL meeting. We talked about Richter’s Transformation, one of the most aggressive turns that chronic lymphocytic leukemia (CLL) can take and specifically, a clinical trial that will be available soon that uses a non-chemo approach to therapy. You can see that interview here. [http://cllsociety.org/2016/02/richters-transformation-of-cll/]

CLL Meeting in Tampa, FL: For those of you in the Tampa area, there is a CLL patient meeting hosted by the Florida Society of Clinical Oncology (FLASCO) being held on February 11th at the Embassy Suites Tampa Airport at 5:00 PM. A complimentary buffet dinner will be provided. I’ll be there giving a talk about the importance of support groups. Also, you’ll have the opportunity to ask questions of the expert speakers. Register and find out more information here. [https://www.flasco.org/events/living-with-cll-tampa/]

CLL Meeting in Miami, FL: For those of you in the Miami area, there is a CLL patient meeting hosted by the Florida Society of Clinical Oncology (FLASCO) being held on February 24th at the Miami Marriott Dadeland at 5:00 PM. A complimentary buffet dinner will be provided. I’m not able to attend this meeting, but you’ll have the opportunity to ask questions of the expert speakers. Register and find out more information here. [https://www.flasco.org/events/living-with-cll-miami/]

CLL Meeting in Atlanta, GA: For those of you in the Atlanta area, we just became aware of another patient meeting in February: Saturday, February 27th in Atlanta starting at 9:30 AM at the Sheraton Suites Galleria-Atlanta. CLL patients will be sharing their personal stories, and a local CLL expert will be providing a talk on the basics of CLL. You can call 844-482-6815 to register. A complimentary meal and parking will be provided and you are welcome to bring a guest. I will be at the meeting with an exhibit table and will stay afterwards to meet with attendees to discuss the resources available from the CLL Society. I look forward to meeting you there.

Stay strong.

We are all in this together.

Brian Koffman, MD
Volunteer Medical Director of the CLL Society


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Saturday, March 28, 2015

ASH 2014: Rough Notes from Dr. Clive Zent and Dr. Wiestner on Prognostic Factors and Resistance in CLL (chronic lymphocytic leukemia)

I found these notes that I had originally planned to use to develop blog posts based on a lecture that I attended at ASH 2014.

I still might do that, but first I am sharing this discovery in its raw form.


I took down all this information live on my laptop as it happened in December 2014 in a lecture hall at ASH, so expect it to be very rough and full of typos and mistakes. 


And don't take it for gospel! I have not done my usual fact checking.


Though it is still mostly unedited, I did try to clean it up a bit. Otherwise it would have been completely indecipherable for most. So I explained a few of the acronyms, improved the grammar, added the occasional punctuation, fixed some of the typos and provided some minimal text to help with context.


I wanted to share a sense of what I try to do at ASH and other cancer meetings. 


I wanted to share the velocity and volume of the information that sometimes comes from the podium. 


This is the raw material that I do my best to unpack, decode, make accessible, explain, contextualize, add relevant references, fact check, and publish here and elsewhere.


So this is hardly my usual blog post. I share it for two reasons:

  1. First, it is full of incredibly valuable tidbits of information, albeit in bullet form with almost no explanatory notes.
  2. Second, it shares a bit of a peek behind the curtains about what goes on at some of these huge medical conference.
Here goes.

Dr. Clive Zent

In the 1970s, the only testing for genetic testing and prognostic indicators was by karyotype analysis

Major limits- needs metaphase (not that common in CLL), needs BM (bone marrow). Only looks at whole chromosomes

1990s, we get FISH

Limits: can look at specific site only

Now we have a new era of genetic testing

Old school Sanger Sequencing needed 10% of mutation to find it, slow, expensive
PCR amplification needs only 1%
Next generation now look at whole gene- faster, cheaper
SNP arrays (clinical role unclear)
Copy # variations
Loss of heterozygosity

Usually only find 10-20 genes that are mutated
Usually found in " pathways"  controlling DNA repair such as TP53 + ATM
BRC
IGH

DNA damage responses ATM + TP53 related,  eons 4-9 (5-15%)
TP53 usually mono-alelle  5% at time of dx,
11q 10% (exon 68s)

Loss of function

Most common loss of one 17p with 80% of mutation on other gene
In contrast, 11q loss has only about 30% mutation on other gene
Can also have bi-allele losses

What does in mean?

Poor survival

BCR signaling pathways


no known mutations at start (abstract 297 disputes this) but somatic hypermutation, stereotypy

Notch1 10% at dx  in PEST domain
30% of those w RT
up to 20x inc risk of RT
BIRC3 11q22.2  near ATM  6 MB bases from 11q22.3  (asoc w loss of ATM0
significant on its own

RNA editing
SF3B1
splicing factor3 subunit 1
10% at dx
Poor Px dec resp to CIT

Clonal Evolution


No longer believe we develop new clones but start with small one that grow
Freq by FISH  (which is low) 4-5% year, but in next gen 20% after RX
Clinically important for resistance

Does clonal size matter?
Large # of mutations not findable yet, but sub clones of 17p matter even if low #

Comparison of MOLECULAR GENETICS AND PROGNOSIS

13q same as no CLL

TP53 BIRC3  worse

Moving forward

Very high risk-
 P53 and ATM (function testing)
High/intermediate

TP53 - No CIT ( chemo-immunotherapy)

Novel therapies then immune therapies including HSCT or CART1

NOTCH1 targeted theory
SF3B1

Summary Test TP53 and ATM (testing functioning coming soon)

Dr. Adrian Wiestner

Novel therapies in CLL
BCR Pathway
CLL a malignancy of anti-self" B cells
BCR  repertoire is skewed
Stereotyped BCR
often recognizes auto-antigen
Binds self motifs in itself

BCR activation in lymph nodes- CLL dependent on micro-envirnoments

IBRUTINIB NO MTD(maximum tolerated dose)!

RESPONSES WITHIN DAYS

Dramatic shrinkage of nodes but persistent lymphocytosis

With just 1 dose, lymph counts  jumps 50%

Larger patient to patient variability

Different patterns

Unmutated:  high ALC count quick up and down
Mutated: more SLL like, slower rise and fall- more durable results?

Most of the rise in ALC is from cell redistribution at first, but clear that IBRUT does much more
Measured tumor burden falls by CT and BMB

80-90% reduction: can start with trillion of cells

Cells in peril are not a concern: When you look they have inhibited BCR and NF kappa B and low Ki-67 suggesting no proliferation

Idelalisib PI3K delta  NO MTD!

Unaffected by adverse PX  factors inc 17p especially in first yr

IBR AEs
Diarrhea
AF 5% vs 0.5%  but much longer exposure
Bleeding mostly petechiae- not significant
Grade 3 or higher  no difference in either arm
IDEL AEs
Diarrhea 30%,7% colitis
20% Grade 3 Pneumonia

46% PFS  with 17p deletion

Complex karyotype  are the ones who progress- that is the group that progresses


PFS front line 17p del is >80%


Resistance:

Mutation Cysteine 481 is the problem,- IBRUT can no longer bind covalently (still weakly binds and  has some activity) Two cases of resistance, there was activated in PLC gamma 2 downstream (gain of function)

What about progression due to Richter's transformation?

Q: Is it more or less than without ibrutinib?

In 63 cases of 17p  RT was found in 23% at median of 12 months; risk factor was complex karyotype

Maybe it's actually less risk w Ibrut


Steve Treon

Ibrutinib in WM /LPL (Waldenström's macroglobulinemia/lymphoplasmacytic lymphoma) by 


IGM falls by 75% and Hgb climbs

69% major response in WM

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Thursday, January 15, 2015

This was Not Supposed to Happen

Dr. Aaron Caplan's widow, Michelle says it best, but it a story with the saddest of endings.

This is not a post for the faint of heart, nor is it meant to be a downer for us survivors with CLL. '

Maybe its only utility is to remind us to live every day to its fullest, to ask us to accept that we really have much  less control than we imagine, and to urge us to push hard to find smarter and gentler therapies.

Here are Michelle's unedited words, shared with her permission.

This wasn't supposed to happen.  

Aaron had planned to come home to New York today or tomorrow to prepare himself for further treatment.  His doctors had begun applications to three centers for a very promising t-cell therapy that would either precede or take the place of a second bone marrow transplant using his sister, Elana, as the donor.

Aaron was not suffering.  He had not given up.  He told our children the night before he passed that they were the reason that he was getting better.  He told me that he would never leave them when they were three and five years old.  He planned to enhance their lives for years to come.  He told me that I looked tired and that he was excited to rest up together as soon as he was home.  On Monday I believed that we would survive and thrive once again.  That our family was safe.  

It is true that we found ourselves in a difficult situation last month with the news about the secondary lymphoma but Aaron always believed that we would make it through this crisis and that, in the end, it might lead us to the elusive cure.  He wondered if he hadn't endured enough before that last transplant and that perhaps he would need to be brought to the brink of death in order to rise again.  No matter what it would take, we planned to do it together and come out the other side into another beautiful stretch of years.  

He began chemotherapy on Tuesday December 16th, the very same day that the Richter's transformation was confirmed with the results of a lymph node biopsy.  That night he drove home from Boston, organized his work, rose at 3:30 am (his usual time--the day was never long enough for him) and worked straight through until Friday.  Saturday he played with our children, cuddled with me, and made dinner for his family.  He was tired but not sick.  The photo that has been shown of the four of us was taken on Saturday December 20th, the day before he went into the hospital.  He was very much alive and focused and excited to see our children perform in their winter solstice concert.  This was not a man who was contemplating death.

The hospitalization was sudden and complicated by this strange and intense hip pain that forced him onto pain killers that made him psychotic.  Aaron was always a lightweight.  He never even took an Advil so to have his system overrun with morphine and Atavan was overwhelming.  Though that day-to-day challenge sparked many concerns for brain bleeds, infections and strokes, he was simply under the influence of the medication.  And what we feared might be metastatic disease to the hip was a musculo-skeletal injury that was worsened by the injection administered to stimulate his bone marrow.  Aaron's cell lines had been blown out by the chemo and his system needed time to recover.  Aaron had patience.  He was willing to endure the many discomforts that accompany low counts.  He never complained.  But we knew that he needed better care.  

Once we relocated him to Boston, the pain was quickly brought under control and while he was exhausted from the ordeal, Aaron was once again oriented and ready to move forward.  His team had begun a new chemotherapeutic regimen that was quickly shrinking his enlarged lymph nodes. We hoped to see a rebound in his counts this week as the cancer levels in his bone marrow were brought under better control.  Aaron was walking around the transplant unit on Monday with a PT, doing squats, and lamenting that what had been a body in the best shape of his life was suddenly so deconditioned.  He intended to turn that around.  Aaron had wanted me to bring the kids home so that they could get back to their routine.  I was not supportive of this decision but he was always the one to put the children ahead of himself.  He was happy to hear their squeals of delight as they raced about and reconnected with their space.  I was counting down the days until we could bring him back into our house that did not quite feel like a home without his presence.

Tuesday morning, I called him on the way to school and learned that he was having trouble breathing.  He said that they thought he had pneumonia.  To be honest, I became a bit hysterical as I did not want to see one more thing stand in our way.  Aaron reassured me that all was well, that it was a slight thing, offered the kids his love, and then the line went dead.

I could not get him back on the phone.  We never spoke again.  I soon learned that Aaron did not have pneumonia but had suffered a bleed in his lungs that was making it hard for him to breathe.  The doctors believed it was from one blood vessel that needed to be repaired.  I agreed to the procedure, packed the car, retrieved the kids and headed to Boston.  Thankfully not alone.  Sasha and Mira's teacher and my friend, Lorna, could see my distress and offered to drive us.  Throughout the drive, we received updates.  Most of them led me to believe that Aaron had a good chance of survival.  

When I arrived, his mother, Louise, was told that Aaron had survived the procedure and that we could see him in a few minutes.  At that time, I imagined his release would be delayed.  Nothing more.  I was completely unprepared for the hastily delivered news that he had spontaneously begun to bleed again, that he had coded twice, and was essentially about to die.  

Aaron and I never said goodbye.  Aaron never wrote letters to the children.  Death was not part of our plan.  And in no scenario that I could have ever envisioned was Aaron lying on a table covered in his own blood while I begged him, and God, and every one of the thirty doctors and nurses who surrounded us to save this most amazing man.  My love.  A father who devoted himself to his children.  A doctor with an amazing brain and work ethic.   I couldn't have seen myself nearly on top of him, holding his face, and tasting his blood as his incredible spirit moved out of his body.  I couldn't have believed I would hear from a doctor that the reason for this situation was disastrously bad luck.  But that is what happened.

And it should not have happened.  

Aaron should be on his way home to us.  We should be walking forward arm in arm.  This is what we wanted.  This is what we fought for.  This is what we clung to every day as we loved each other and our children and this incredible life that we had built together.  We fought for life until the end.  He deserved the best kind of luck at every turn.  

Aaron Caplan was kind, generous, loving, brilliant, joyful, energetic, always smiling, embracing life and those around him every minute of every day.  We never fought.  No one ever fought with Aaron.  He operated on an entirely different plane than most people.  He should have had the chance to go on.  I don't know how to do so without him.  He was our whole world.  

Michelle also wrote me:
Aaron so admired you and wanted to donate to your site. I would like to direct people as to how to do this.  Can you please tell me?
If you want to support our nonprofit 501c3 CLL Society Inc. effort to meet the unmet needs of the CLL community, there is Donate button on the very top of this page.

If you prefer to mail a donation, please send the check to:

CLL Society Inc.
PO Box 10546
Newport Beach, CA
92658

Thank you.

May Aaron's memory be a blessing.

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Sunday, November 30, 2014

ASCO 2014: Dr. Susan O'Brien Reviews the 3 years follow-up Data on Ibrutinib in CLL (chronic lymphocytic leukemia)

If you can handle more hisses and pops on an audio recording, you will get to hear some pretty exciting news from Dr. Susan O' Brien who incidentally is leaving MD Anderson after many years of important CLL related research and compassionate patient care to head up a cancer research team  and consult on CLL patients in my backyard at the University of California at Irvine (UCI) starting Jan. 1, 2015

During the interview, Dr. O'Brien shares the three year follow-up data on single agent ibrutinib in relapsed and refractory patients and in the elderly.

In her important ASCO 2014 abstract, published 6 months ago, the data is astonishingly good for those lucky enough to get ibrutinib frontline, the over 65 crowd, a strong argument in favor of moving it and other drugs such as idelalisib or ABT-199 upfront.  In this trial, in the treatment naive arm, there was one early progression with Richter's that was probably there before the trial even began, and the rest of the cohort remains in the happy land of PFS also known as progression free survival.

The data is still very good for the difficult to treat relapsed and refractory group, but the curve is not flat. Relapses happen. This is especial true for those of us like me with the dreaded 17p deletion, where half the patients have started to progress after a little more than two years. While this is clearly much better than anything else out there in this most challenging population, ibrutinib has not hit a home run for this group as it might have for the treatment naive patients.

Despite significant recent progress, effective long term therapies for relapsed 17p deletion still remains one of the more pressing unmet needs in the world of CLL.

Dr. O'Brien discusses what these relapses look like, and mentions a strategy that I would strongly consider, namely that even at the time of relapse, one stay on ibrutinib until a new therapy is begun, as the BTK inhibitor, even it is no longer irreversibly binding, it is still partially braking the disease progression.

Let's listen to Dr. O'Brien.


Again sorry for the audio noise. Once these final ASCO interviews are posted, I promise I will not only be notching up the quality of what you see and hear about CLL here and elsewhere, but with the help of many others, will be expanding into whole new realms of education and support to meet the unmet needs of our community. Stay tuned.


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Monday, December 2, 2013

iwCLL 2013: Dr. Jeff Sharman Discusses Richter's Transformation in CLL

In the final segment of my interview with Dr. Jeff Sharman discusses the dreaded complication of Richter's Transformation.

First he explains exactly what we are talking about and the importance of understanding the difference flavors of this sinister secondary blood cancer.

Why are we seeing more Richter's?

What is the future for those of with CLL?

Dr. Sharman was very generous with his time exploring these tough questions.

And I plan to prevail upon him again to update us from ASH next week.

But first I willing be posting many more interviews from iwCLL. So much news to share.

Here is Dr. Sharman. I so appreciate his making himself so available to the CLL community.



Personally, I saw my PCP today and he said my chest was clear. Great news. Still have a persistent cough, now dry and painful, but I am getting better. Voice is raspy, but I can talk, between coughs that is.

I am winning this battle will my allies of levaquin, cough meds, and pot after pot of a  hot tea made from mullein leaves, marshmallow roots, and slippery elm to sooth my weary throat.

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Tuesday, July 16, 2013

ASCO 2013: Dr. Wierda on Prognostic Factors in CLL (Chronic Lymphocytic Leukemia)

The whole arena of prognostic factors in CLL is constantly evolving, but a few principles have remained constant over the years.

1: Most, if not nearly all the data is retrospective.

2: Dr. Wierda and many others are refining algorithms that will weight the many variables to better predict our future including such helpful information as the expected time to first treatment or our chances of a durable remission or ultimately our chances to live long and prosper.

3: The markers predict for groups, not individuals, but that doesn't mean we should be therapeutic nihilist and ignore what our FISH tests tell us about what options improve our odds.

4: Bad prognostics are not in themselves an indication for treatment (outside a clinical trial).

5: Good prognostics doesn't always mean that our CLL will be a non-event.

6: New prognostic factors are being discovered all the time, but few will be of much clinical import.

Here is the second part of my interview with Dr. Wierda from ASCO 2013.

I will let him fill in the details on all these topics and other aspects of this moving target.

Again my thanks to  my friends at Patient Power for sharing the work and supporting the effort to get the important news about CLL from ASCO out and available to all those of us who need it to inform our choices about how we handle our disease. Check in on their website on a regular basis as Andrew Schorr is frequently update his informative site.



In fairness, I must add that other researchers have published data supporting a possible relationship between Notch1 and Richter's Transformation (or Syndrome),

I quote from a letter in the British Journal of Haematology, 2012, 158, 415–429


"NOTCH1 mutations were associated with a ~5·8-fold increase in the crude hazard of transformation into a clonally related RS (Richter's Syndrome) "

This is from an editorial from haematologica | 2012; 97(3)

"In fact, the first studies reported a high frequency of NOTCH1 mutations in .... disease progression towards transformation into Richter’s syndrome."

Now this is not the same level of evidence as in a full article, and as such might not pass mustard for Dr. Wierda and others as proof positive of the correlation, but it convinced me that it is worthy of further study.

There is just too much data out there for anyone of us to be aware of it all.

And that's OK.

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Monday, April 1, 2013

ASH 2012: Dr. Richard Furman Discusses What is Known and What Isn't About the New Treatments in Trials

In the final part of Dr. Furman's interview from ASH 2012, the doctor who had the most early experience with GS-1101 (idelasilib) and ibrutinib discusses the still limited experience of disease progression with these new small molecules. He reminds of the real risks of bone marrow damage (MDS) and transformation to a more aggressive cancer (Richter's) and offers an interesting hypothesis on why Richter's might be found more often with these treatments.

He reviews the open pivotal for idelasilb (GS1101) and the associated crossovers, plus the trial for ibrutinib versus ofatumumab.

But there are other trials out there too that he didn't mention, especially for patients in special categories, such as 17p deletion or age  > 65.

So always remember to check what clinical trials might be a fit for you at http://clinicaltrials.gov when you are considering treatment. Don't count on your doctor to know all the latest. See my prior post on clinical trials.

Dr. Furman candidly outlines what is known and not known about how these drugs work.

What I really like is the strategy he outlines of using these drugs one after another as stepping stones to a normal life expectancy.



More to come from ASH 2012.

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