Tuesday, March 13, 2007

update on medical consultations

Until now, I haven't had the time to explain the results of my recent medical consultations with Dr. Patrick Stiff at Loyola University's Cardinal Bernadin Cancer Center and Dr. Hugo Castro-Malaspina at Sloan-Kettering.

On 2/27, Su and I traveled to Loyola University Medical Center where we met Dr. Stiff. He said an allogeneic transplant is my best chance. There are, however, three different types of allogeneic transplantation. The "mini-transplant" in his opinion is ineffective. The "maxi transplant" is too toxic. At Loyola, he does what he described as the Goldilock choice: the "reduced intensity prep." It's the middle course of action. The conditioning regimen at Loyola is BEAM, which is composed of BCNU, Etoposide, Ara-C (Cytarabine?), and Melphalan.

He told us that Loyola's numbers are as follows: 50% chance of cure, 40% chance of relapse (within first 3 months), 10% chance of fatal complications. Based on my phenotype or constitution, he believes that there is a greater risk from fatal complications than relapse and he is in agreement with the other specialists, whom we've met, who believe that my risk of fatal complications following the transplant is 7-10%.

The consensus is that one of the most important steps in the overall treatment process is the salvage chemotherapy, which I will have at the University of Chicago Hospitals prior to the transplant. Patients in remission at the time of transplantation have a better chance of achieving remission and cure. Dr. Stiff likened it to a washing machine analogy. He said the salvage chemo is like the pre-treatment of a stain (i.e. Shout!) and the transplant is akin to putting the soiled piece of clothing in the washing machine. If the Shout! can soften up the stain, then its removal by the washing machine will be easier and better assured. Consequently, he argued that I not proceed with transplantation until I'm in remission.

There are a variety of drug protocols, which could be used to get me into remission. Gemcitabine (Gemzar), one component of the GND regimen proposed by Dr. Schuster and approved by Dr. Moskowitz, is a great agent he told us. It has worked in about 70% of patients. He said Gemcitabine is the single most important component of the GND regimen. He seemed to suggest that the jury was out on whether Navelbine and Doxil combined were very effective, but that Gemcitabine without a doubt was the star of this particular chemo regimen. Dr. Stiff was fine with GND. If, however, GND doesn't shrink the cancer after 2 cycles of treatment, he suggested I find and move on to a different regimen, such as EPOCH. There's no benefit, he told us, for continued treatment resulting in no promising results.

With regard to the antibody SGN-30 study offered by Dr. van Besien at the University of Chicago Hospitals, he felt that alone it was a "bust" and wouldn't recommend it. However, when used in combination with GND it may offer some beneficial effect. The key again is Gemcitabine. At best, the antibody will provide some benefit. At worst, it will not offer no benefit.

An unrelated donor is ideal, he told us. When investigating cancer centers, I should find out how many allogeneic unrelated adult transplants each center has done and what their numbers are (cure, relapse, and fatal complications). In his opinion, nothing less than 7/8 or 9/10 unrelated donor match on the allele level is adequate. Anything less and chances of relapse and/or complications are increased greatly. If 7/8 or 9/10 match can not be found, then, cord blood would be the next area of exploration. For cord blood, Dr. Stiff said a 4/6 match is necessary and it must be done according to the allele level not the antogen level.

The first three months post-transplant are critical, he stated. It is during this critical period that the donor cells will engraft into my bone marrow and I will be susceptible to acute GVHD and thereafter, to chronic GVHD.

According to Dr. Stiff, about 1,500 people receive stem cell transplants per year in the US. Of those, 100-150 go on to need a second transplant. I'm a "rare bird," he told us. Hodgkin's Disease is a relatively rare cancer, but of those who are treated initially (about 80% cure rate at first diagnosis) very few find themselves in need of first transplant, let alone a second one. He went on to say, however, that I am indeed typical - male in 20s-30s - of those who do need a second transplant.

I left the appointment most impressed by Dr. Stiff. He appeared to have an excellent understanding of the uniqueness of my situation and the various issues that I needed to be aware of. He was very easy to talk to and he explained the different phases and related issues of my treatment very well.

On 3/5, I met Dr. Castro-Malaspina. I was accompanied by my dad, Eileen, and Su.

Dr. Castro-Malaspina agreed that GND is a good salvage chemotherapy regimen. If GND doesn't produce results, he proposed MOPP. Like Dr. Stiff, he thought that the SGN-30 antibody study might be beneficial but it was no promise. He was not against the idea as long as it was combined with GND. He too was in agreement with Dr. Stiff that the transplant is most promising when the patient is in remission.

For an unrelated donor match, 9/10 or 10/10 match on the allele level would suffice. For a cord blood, there must be a match of at least 4/6.

He told us that a mini-transplant would be the treatment of choice at Sloan. If I'm in full remission at time of transplantation, the conditioning cocktail is milder containing the drugs Fludarabine and Cytoxin as well as low-dose total body irradiation (TBI). But if there's still some disease present, the conditioning regimen is more aggressive: Melphalan and Fludarabine. He informed us that Sloan-Kettering has been performing mini-transplants since 1998 and more since 2001. In total, it has done 100-150 of which 30-40 have been for Hodgkin's Disease. Cord blood transplantation is newer at Sloan-Kettering. It has done about 30 of them. The person who leads the cord blood transplantation is from the University of Minnesota, where cord blood transplants were developed.

Cord blood cells take longer to engraft than adult stem cells: 10-12 days for adult stem cells and 17-20 days cord blood cells. Consequently, a transplantation with cord blood may result in a longer hospital stay. There is, however, less occurrence of GVHD with cord blood transplants than unrelated donors. He believes this is because cord blood cells are "more naive" and less determined than their adult counterparts.

Dr. Castro-Malaspina raised the issue of acute and chronic GVHD. There's a 20-30% chance of developing acute GVHD during the first 100 days following transplantation, however, it is treatable in most cases. Chronic GVHD occurs after the first 100 days and there's a 40-50% chance of this happening. Again, this too is treatable generally. Death from severe GVHD in the first 100 days is less than 10%. After GVHD, the biggest risk is infection (mostly viral).

He calculated that there's a 50-60% long-term survival rate if I am put into remission prior to the transplant. A relapse tends to occur in the first three years following the transplant, however.

On a side note, at these appointments I learned too that the tough skin on my left abdomen at the site of the incisions are scar tissue resulting from the laparoscopic splenectomy.

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