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Chai Cancer Care<br />
Together Magazine 2016<br />
Dr Christopher<br />
McNamara is<br />
a consultant<br />
haematologist in the<br />
lymphoma service<br />
at University College<br />
London Hospital.<br />
He completed post-graduate<br />
training in Australia and France<br />
before appointment as consultant<br />
haematologist at the Royal Free,<br />
London in 2004. He moved to UCLH<br />
in 2015. His interests are clinical<br />
trials, radioimmunotherapy and the<br />
interface between the laboratory and<br />
lymphoma patients. He has served on<br />
several guideline development groups<br />
for the European Society of Medical<br />
Oncology, the British Council for<br />
Standardisation in Haematology and<br />
for the national Institute for Clinical<br />
Health and Excellence, where he<br />
served as clinical lead for the national<br />
lymphoma guideline.<br />
Lymphoma<br />
therapy update<br />
We know more than ever about how cancer<br />
of the blood behaves and which treatments<br />
will produce the best outcomes. Consultant<br />
haematologist Christopher McNamara looks<br />
ahead to future developments<br />
Lymphoma is the most common<br />
type of blood cancer affecting<br />
people in the UK. There are many<br />
different types of lymphoma but they<br />
all generally occur when a certain<br />
type of blood cell no longer obeys the<br />
normal control signals that govern the<br />
growth of cells and tissues of the body.<br />
The diseased cells or lymphocytes<br />
aggregate together and typically<br />
spread through vessels connecting<br />
lymph nodes.<br />
A significant amount of research<br />
work has been done to understand the<br />
differences between the different types<br />
of lymphoma. This work, culminating<br />
in a classification system adopted<br />
by the World Health Organisation,<br />
has made important advances in the<br />
way in which lymphoma research is<br />
carried out and in the way in which<br />
people who suffer from lymphoma are<br />
treated. Increasingly, lymphomas are<br />
categorised according to molecular and<br />
genetic changes within the abnormal<br />
lymphoma cells. These genetic changes<br />
influence the way in which the cancer<br />
cells multiply and often how they will<br />
respond to treatment. Understanding<br />
these genetic changes has already led<br />
to significant improvements in the<br />
treatments available for lymphoma<br />
patients and is likely to radically<br />
reform further these approaches<br />
in the future.<br />
“Understanding genetic<br />
changes has already<br />
led to significant<br />
improvements in the<br />
treatments available”<br />
GENES HOLD THE KEY<br />
Many people are surprised when they<br />
hear that the laboratory is the first<br />
and perhaps most important step in<br />
the journey that a lymphoma patient<br />
will begin. The reason for that is<br />
that an accurate diagnosis is critical<br />
for obtaining the best outcome for<br />
a patient; the treatments used, as<br />
mentioned, frequently differ according<br />
to which lymphoma subtype a person<br />
has. It is, therefore, essential that<br />
material from a biopsy be looked at<br />
by an expert pathology doctor. In the<br />
future it is likely that genetic changes<br />
within the first biopsy sample will be<br />
used for all patients to direct which<br />
treatment should be given, even within<br />
the same lymphoma subtype. In<br />
other words, patients with the same<br />
lymphoma subtype will be treated<br />
differently, according to the molecular<br />
changes in their lymphoma.<br />
CHEMO AND<br />
CHEMO-FREE THERAPY<br />
Importantly, the outcome for<br />
lymphoma patients has been improving<br />
in recent times. Twenty years ago<br />
there was concern that, in spite of the<br />
availability of effective treatments, the<br />
overall survival for lymphoma patients<br />
was not improving. That has now<br />
changed. With effective combinations<br />
and information gleaned from properly<br />
conducted clinical trials, effective<br />
therapies that are given to people<br />
with lymphoma today have shown<br />
unequivocally that outcomes have<br />
improved compared with treatments<br />
used as recently 20 years ago.<br />
There is a range of different treatments<br />
available to patients in the UK.<br />
Chemotherapy remains an effective and<br />
generally well-tolerated treatment for<br />
most people. However, it is also fair to<br />
say that there is increasing interest in<br />
‘chemotherapy-free’ based approaches<br />
to managing lymphoma. Frequently,<br />
people affected by lymphoma have<br />
other medical problems, which<br />
preclude intensive treatment or they’re<br />
present at a point in their lymphoma<br />
journey where they are significantly<br />
debilitated and de-conditioned by<br />
the lymphoma itself. This makes<br />
the administration of chemotherapy<br />
sometimes difficult. In addition,<br />
we know from longitudinal studies<br />
that many patients who complete<br />
chemotherapy are affected by long-term<br />
physical, psychological and emotional<br />
problems that are most likely due to<br />
their chemotherapy.<br />
“Treatments by mouth<br />
generally don’t require<br />
admission to hospital<br />
and are very well<br />
tolerated”<br />
Many centres around the world are<br />
interested in this ‘chemotherapy-free’<br />
strategy whereby new drugs other<br />
than chemotherapy are used to induce<br />
a response. A new immunotherapy<br />
involving antibodies directed at<br />
special markers on the surface of<br />
cancer cells called antigens is already<br />
in clinical practice and thousands of<br />
patients have benefited from this<br />
and lives have certainly been saved<br />
as a consequence.<br />
The clinic has also seen the<br />
development of new medicines, which<br />
inhibit signalling inside cancer cells.<br />
These medications have changed the<br />
landscape in some lymphoma subtypes<br />
and are likely to have a significant<br />
impact upon lymphoma therapy in<br />
the future. These treatments can be<br />
taken by mouth, generally don’t require<br />
admission to hospital and are very well<br />
tolerated. They work by penetrating<br />
the lymphoma cell and turning off<br />
the machinery that the cell needs<br />
to survive and prosper.<br />
One of the advantages of these<br />
medications is that they typically<br />
don’t bring with them many of the<br />
chemotherapy-related side effects.<br />
Nausea, vomiting and hair loss are not<br />
common from these drugs and they<br />
often produce very good results, even in<br />
patients who have previously failed to<br />
respond to chemotherapy. It is important<br />
that ongoing research is carried out<br />
to define the longer-term safety and<br />
effectiveness of these agents, but<br />
preliminary studies are very exciting.<br />
There remains a strong desire to<br />
continue to improve the outlook for<br />
people and families not only affected by<br />
lymphoma but also to try and reduce<br />
the short- and long-term side effects of<br />
therapy. Clinical trials that are currently<br />
underway are likely to contribute to the<br />
answer to this question. ■<br />
The next leap forward:<br />
refining treatments<br />
• Molecular differences in<br />
their lymphoma subtype<br />
will mean patients<br />
with the same type<br />
of cancer will receive<br />
different treatments<br />
• Oral treatments<br />
will become more<br />
common<br />
• Advances in<br />
treatments will mean<br />
patients won’t need<br />
to be hospitalised<br />
24<br />
Together 2016<br />
Chai Cancer Care<br />
25