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Advice for Future Management of Mantle Cell Lymphoma

Insights From: Bijal D. Shah, MD, H. Lee Moffitt Cancer Center & Research Institute; Lauren C. Pinter-Brown, MD, UCI Health; Eduardo Sotomayor, MD, GW Cancer Center
Published: Tuesday, Feb 26, 2019



Transcript:

Lauren C. Pinter-Brown, MD:
We’re already in an exciting period. Ten years ago, we would tell patients that if they didn’t have very aggressive chemotherapy and an autotransplant, that they could look forward to a longevity of 3 to 4 years. And that is not the case any longer. So I’m hoping that with more and more agents, much like we’ve seen with follicular lymphoma, that we can extend our overall survival of patients so that now we’re talking about this being a chronic disease for many patients. Of course, there will need to be work done to understand why and how people go through blastoid transformation and how we will deal with them more effectively.

Bijal D. Shah, MD: If I had 1 piece of advice, it would be don’t be afraid to refer patients. I don’t think that’s a fear per se. I think that when you’re taking care of an elderly patient, and you’re worried about the commute, and you’re worried about these kinds of things, the psychosocial factors, in particular, I would say in this situation with the disease being as rare as it is and as heterogeneous as it is, getting some input from a subspecialist at a major cancer center can be hugely informative. And it can be in ways that are unexpected: sequencing, access to clinical trials, and so on. That may radically improve the longevity and also the quality of life of the patient that’s in front of you. So I think that’s something that would be my primary form of advice.

Eduardo Sotomayor, MD: What I would tell the community oncologists, first of all, is that there is a lot of excitement in mantle cell lymphoma. For those community oncologists who are my age, we grew in the era that we thought the mantle cell lymphoma was an aggressive, incurable, bad disease. Well, that’s changed. First of all, when you see a patient with mantle cell lymphoma you don’t want to affect their quality of life. Mantle cell lymphoma is an incidental finding, and you are doing fine. There is a group of patients in which you can do watchful waiting. It’s safe. What I do is when I make a decision that this patient is going to be followed using watchful waiting, I see that patient once a month for 3 months just to have what I call “a flavor of the disease,” how the disease is behaving in that particular patient. So that’s number 1.

So number 2 is if your hematopathologists see large volume of mantle cell lymphoma patients, be fine with that. But if not, I would refer mantle cell lymphoma patients to your near academic center to see what type of clinical trials may be available for the patients or maybe a clinical trial assessing minimal residual disease or maybe there is a study looking at molecular abnormalities in mantle cell lymphoma tissues—information that at some point might help your patient. So get a second opinion in a near academic center. But I always say if the patient is going to receive a standard treatment, that standard treatment can be delivered close to home. It’s better for the patient because the patient doesn’t have to ride 20, 30 miles or go to downtown though the city with all the traffic. It’s better for the patient to receive treatment close to home.

In summary, my message is be aware of the watchful waiting. Refer your patients to a community academic center. If the patient is enrolled in a clinical trial, probably the patient will be treated in the academic center. When the patient needs to receive approved therapies, it is better to do that treatment at home. My third mention, and final mention, is do not think that because this is an oral agent, it’s going to be, “Take your pills and see you in 6 months.” There is a spectrum of side effects that you need to be aware for each specific. And try to be ahead of the problem. Don’t chase the problem. Always start thinking what might happen in this patient and review the medications that your patient is taking, because it’s oral agent with a lot of interactions.

Transcript edited for clarity.
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Transcript:

Lauren C. Pinter-Brown, MD:
We’re already in an exciting period. Ten years ago, we would tell patients that if they didn’t have very aggressive chemotherapy and an autotransplant, that they could look forward to a longevity of 3 to 4 years. And that is not the case any longer. So I’m hoping that with more and more agents, much like we’ve seen with follicular lymphoma, that we can extend our overall survival of patients so that now we’re talking about this being a chronic disease for many patients. Of course, there will need to be work done to understand why and how people go through blastoid transformation and how we will deal with them more effectively.

Bijal D. Shah, MD: If I had 1 piece of advice, it would be don’t be afraid to refer patients. I don’t think that’s a fear per se. I think that when you’re taking care of an elderly patient, and you’re worried about the commute, and you’re worried about these kinds of things, the psychosocial factors, in particular, I would say in this situation with the disease being as rare as it is and as heterogeneous as it is, getting some input from a subspecialist at a major cancer center can be hugely informative. And it can be in ways that are unexpected: sequencing, access to clinical trials, and so on. That may radically improve the longevity and also the quality of life of the patient that’s in front of you. So I think that’s something that would be my primary form of advice.

Eduardo Sotomayor, MD: What I would tell the community oncologists, first of all, is that there is a lot of excitement in mantle cell lymphoma. For those community oncologists who are my age, we grew in the era that we thought the mantle cell lymphoma was an aggressive, incurable, bad disease. Well, that’s changed. First of all, when you see a patient with mantle cell lymphoma you don’t want to affect their quality of life. Mantle cell lymphoma is an incidental finding, and you are doing fine. There is a group of patients in which you can do watchful waiting. It’s safe. What I do is when I make a decision that this patient is going to be followed using watchful waiting, I see that patient once a month for 3 months just to have what I call “a flavor of the disease,” how the disease is behaving in that particular patient. So that’s number 1.

So number 2 is if your hematopathologists see large volume of mantle cell lymphoma patients, be fine with that. But if not, I would refer mantle cell lymphoma patients to your near academic center to see what type of clinical trials may be available for the patients or maybe a clinical trial assessing minimal residual disease or maybe there is a study looking at molecular abnormalities in mantle cell lymphoma tissues—information that at some point might help your patient. So get a second opinion in a near academic center. But I always say if the patient is going to receive a standard treatment, that standard treatment can be delivered close to home. It’s better for the patient because the patient doesn’t have to ride 20, 30 miles or go to downtown though the city with all the traffic. It’s better for the patient to receive treatment close to home.

In summary, my message is be aware of the watchful waiting. Refer your patients to a community academic center. If the patient is enrolled in a clinical trial, probably the patient will be treated in the academic center. When the patient needs to receive approved therapies, it is better to do that treatment at home. My third mention, and final mention, is do not think that because this is an oral agent, it’s going to be, “Take your pills and see you in 6 months.” There is a spectrum of side effects that you need to be aware for each specific. And try to be ahead of the problem. Don’t chase the problem. Always start thinking what might happen in this patient and review the medications that your patient is taking, because it’s oral agent with a lot of interactions.

Transcript edited for clarity.
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