4 Advances in Leukemia and Lymphoma Care

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Every year, advances in both medicine and technology lead to new and exciting ways to potentially treat leukemia and lymphoma and to help care for those who already have or currently are undergoing treatment. In some cases, such advances are actually just improvements on current techniques, while others represent the latest in smart tech and other techniques that are downright futuristic.

The following are four advances being explored in leukemia and lymphoma care that sprung from various avenues of research in 2017.

1. Injectable Rituximab

Rituximab, a laboratory-designed monoclonal antibody, has become one of the cornerstones of therapy for certain non-Hodgkin lymphomas. Lymphomas can be grouped basically into two categories, Hodgkin and non-Hodgkin, or NHL.

Rituximab has indicated uses for certain presentations of two of the most common kinds of NHL:

  • Follicular lymphoma
  • Diffuse large B-cell NHL (DLBCL)

Rituximab also has indicated uses in certain presentations of the following diseases:

  • Chronic lymphocytic leukemia
  • Rheumatoid arthritis
  • Wegener granulomatosis
  • Microscopic polyangiitis
  • Immune thrombocytopenic purpura (ITP)
  • Pemphigus vulgaris
     

The Tethered Partner

With all of these different uses, and with rituximab such a prominent therapy in NHL, drug makers have had their eye on rituximab to see if it might be converted from an intravenous (IV) therapy to one that can be given as a shot. If you have ever been a patient requiring an IV medication, then you know the appeal of converting this drug to something that can be given as a shot.

When rituximab is given intravenously, you are attached to a bag on an IV pole, and the poll on wheels with its swinging bag become your “tethered partner” for the next couple of hours or more. Typically this can mean that, if you need to go to the bathroom, you need to wheel your 'partner' along with you.

Sometimes, there can be annoying beeping and alarm sounds coming from the IV machine when you are trying to read, watch TV or just collect your thoughts. For patients dealing with blood cancers, many hours of such tethering may already be in the works, so anything that helps reduce this burden tends to be welcomed.

The New Solution

The new injectable formulation is a mixture of rituximab and a substance called hyaluronidase, which helps deliver medicines under the skin. The U.S. approval is expected summer 2017, and it has already been approved in Europe. When given under the skin, it can be administered in 5 to 7 minutes, compared to an hour and a half or more for intravenous rituximab. Several studies have shown that the new formulation of rituximab delivered under the skin is safe and works as well as intravenous rituximab, leading to similar levels of the drug in the blood. The injected version has been approved in the European Union since 2014. If the FDA approves it, IV rituximab will continue to be available to American patients.

2. Computer Algorithm for Acute Myeloid Leukemia

Wouldn’t it be great if doctors could identify who is likely to relapse after treatment and who is likely to go into remission?

Well, researchers funded by the National Cancer Institute, as well as several other organizations, are working on doing just that, using computers.

Acute Myeloid Leukemia

Acute myeloid leukemia (AML) is a type of blood cancer in which abnormal white blood cells build up rapidly in the bone marrow and interfere with the production of normal blood cells. There are four main types of leukemia—two acute, or rapidly growing leukemias, and 2 chronic, or more slowly growing ones. AML is the most common acute, or rapidly growing leukemia in adults. AML is the second most common leukemia in children, and leukemia, in general, is the most common cancer of childhood.

Data-driven Diagnosis

Making a diagnosis of AML requires knowing the results of certain laboratory tests, in addition to the signs and symptoms of the disease that may be present. This typically involves something called flow cytometry, a method of counting and sorting microscopic particles in a liquid; in this case, the leukemia cells and their markers, proteins and protein-complexes that are detectible as parts of the cells. Analyzing data from flow cytometry can be time-consuming.

Enter: Smarter Computers

Researchers from Purdue University and Roswell Park Cancer Institute have been working on a machine-learning computer algorithm that could help out in this front, and they believe it can extract information from the data better than humans.

Machine learning refers to a branch of computer science that deals with computers being able to expand on certain programmed functions or analyses through “experience,” without being explicitly programmed to do so. The team reported being able to use the flow cytometry data to predict patient outcome with between 90 and 100 percent accuracy.

3. Smarter Scanning to Look for Relapse

Half of all patients with Hodgkin lymphoma and diffuse large B-cell lymphoma (the most common form of non-Hodgkin lymphoma) will relapse and require additional therapy. Given that statistic, how often should such patients be scanned to make sure the cancer has not returned?

Why Not Scan? Better Safe Than Sorry, Right?

If routine surveillance imaging can detect relapses early, when there are no symptoms, and if this improves survival for such patients, that would be a good thing, but there are many unanswered questions in this area.

On the surface, it seems like it would be a good idea for people who have been treated for these diseases to get regular scans, to make sure the cancer has not come back. This is true to a point, but on the other side of the equation, the accompanying radiation from such scans carries the risk of promoting a second malignancy. You wouldn't want people who are at very low risk for recurrence, whose disease has essentially been snuffed out with effective therapy, to be subjected to unnecessary repeated scans, exposing them to radiation, looking for a relapse that may never occur. Another consideration is that false positives happen. According to recent studies, a meaningful fraction of patients have to deal with false-positive scan results, which produces additional anxiety and medical interventions.

Researchers from Emory University and from Mayo Clinic recently published results from a study they conducted to examine some of these questions. They evaluated the surveillance-imaging role in relapse detection and reviewed its impact on survival for relapsed patients with Hodgkin lymphoma or DLBCL non-Hodgkin lymphoma. Generally, they found that current imaging approaches do not detect most relapses prior to clinical signs and symptoms or improve survival.

Identifying Higher Risk Disease

That said, not all people in the groups examined in this study were are at the same risk for relapse. So, that raises the question, which groups of patients are high enough risk for relapse that benefits of routine surveillance scanning would outweigh risks? Investigators noted that future forward-looking studies are needed to determine whether routine scanning for relapse might provide benefits when you select the right patients to scan, the so-called “highly selected populations.”

For now, this group of researchers felt that it is reasonable for patients with DLBCL and known high-risk features—including International Prognostic Index (IPI) of 3 to 5—to consider scans on an individual basis after discussing risks and benefits and also knowing that early detection of relapse has not been definitively proven to improve survival.

4. Nano-CAR-T Therapy

For patients with blood cancers and their loved ones, there is quite a bit of excitement about CAR-T cell therapy. New breakthroughs involving CAR-T cell therapy are reported often, seemingly every day.

About CAR-T Cells

T-cells are a type of immune cell that we all have in our bodies. They are specifically known as T-lymphocytes, a type of white blood cell. T-cells have receptors on their surfaces, called T-cell receptors, or TCRs. These TCRs bind to antigens on foreign invaders or otherwise-threatening cells, like cancer cells, helping the body to mount an immune response, to fight the threat.

When T-cells are used for CAR-T cell cancer therapy, they are first are collected from a patient’s own blood. Then, in the laboratory, the T-cells are modified to produce special receptors on their surface called chimeric antigen receptors, or CARs, which are able to bind to certain surface proteins of particular cancer cells. These T-cells with their CARs can then lead to cancer cell destruction, once they are reintroduced into the patient.

Nanotechnology Meets CAR-T Cells

One of the somewhat cumbersome moving parts to this therapy has been that the patient's cells need to be harvested, engineered outside the body, and then re-introduced once there are sufficient numbers of them to do the job. Wouldn’t it be neat if that engineering step could be done on your own cells more quickly, perhaps with microscopic engineering tools? That is the idea behind the use of nanotechnology in this application. Nanotechnology here refers to the use of microscopic machines to deliver benefits inside the body.

Researchers at the Fred Hutchinson Cancer Center recently demonstrated that nanoparticle-programmed immune cells could clear or slow the development of leukemia in their laboratory model of the disease. The “proof-of-principle” research is an important first step, and the findings were published in "Nature Nanotechnology." Dr Matthias Stephan, an investigator in this group, was quoted as saying “Our technology is the first that we know of to quickly program tumor-recognizing capabilities into T cells without extracting them for laboratory manipulation.”

Sources:

Genentech. FDA advisory committee unanimously recommends approval of Genentech’s subcutaneous rituximab for certain blood cancers.

Stanford Medicine. Computer algorithm predicts outcome for leukemia patients.

Cohen JB, Behera M, Thompson A, et al. Evaluating surveillance imaging for diffuse large B-cell lymphoma and Hodgkin lymphoma. Blood. 2017;129:561-564.

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