About halfway through the enclosed interview with Dr Fredrick Hagemeister, my mind wandered to the CME disclosure forms that I review with our faculty prior to every interview. On these forms, there is a box that the interviewee needs to check if the discussion will include information that is off FDA label. Needless to say, virtually all interviewees check this box.

However, as I listened to Rick (he and his father are both “Fredricks” and for differentiation, Dad is Fred and Rick is Rick) describe a case from his practice where he used a therapy with proven safety and efficacy in mantlecell lymphoma (R-Hyper-CVAD) in a 79-year-old man with diffuse large Bcell lymphoma who had a Burkitt’s-like Ki-67 of 95 percent, I wondered if we should add a box to the form for our guests to check when they are discussing topics that the FDA hasn’t even dreamed about.

This case certainly falls into that category. At diagnosis, the patient presented with a virulent lesion behind his eye that was causing a disfigurement of his face and was invading the dura of his brain. Over the course of just a few days, the lesion visibly progressed, and the patient’s vision began to further deteriorate.

At the time, the MD Anderson Group was about to implement a study comparing R-Hyper-CVAD to R-CHOP in patients with diffuse large B-cell lymphoma, but the trial was still moving through the approval process. After a long discussion with this man and his family, Dr Hagemeister began R-Hyper-CVAD treatment that day (with plans to not alternate ARA C and methotrexate), and remarkably, a documented complete remission occurred in two weeks, at which point the patient’s visage returned to normal and now includes a cautious smile.

The interview with Dr Hagemeister was part of our CME group’s visiting professorship program, and as Rick prepared to head back to Houston from Miami, he fretted that clinicians would get the wrong idea from the case he presented. “I wasn’t trying to recommend that oncologists use this approach outside a protocol setting,” he said. “I normally would have treated this patient as part of a study, but the one that was best suited for him was still awaiting approval, and this patient was progressing too rapidly for us to wait.” I reassured Dr H that the message was clear, and perhaps even more importantly, that oncologists would benefit from hearing about the newest research strategies from one of our country’s most prestigious cancer institutions.

Like many of the other MD Anderson clinical investigators our group has had the honor of working with on oncology programs in the past, Dr Hagemeister is also tuned in to the complex psychosocial needs of cancer patients. The second case he presented was a woman with favorable prognosis Stage IV follicular lymphoma. What made the case a particular challenge was that the patient had an obvious and severe clinical depression, which prompted Dr H to immediately refer her to a psychiatrist who started f luoxetine (Prozac^®).

This psychiatric complication — which occurred without a prior history of mood disorder — seemed to be an acute reaction to the diagnosis, and Dr H considered this a critical factor in his initial treatment recommendation. Like most of MD Anderson’s lymphoma group, Dr H generally prefers to use R-chemo rather than R alone as first-line therapy for indolent lymphoma, but in this case, chemo was delayed to give the patient a chance to become accustomed to the infusion room and to allow the f luoxetine to take effect.

Some months later, with the depression improving and the tumor progressing, FND was added to the rituximab. The patient completed four cycles of that regimen, which resulted in a complete remission. She is now back on R alone as maintenance, and during a recent office visit, she suggested to Dr Hagemeister that perhaps she didn’t require the antidepressant anymore.

These two fascinating cases are reminders that there is no better way to learn medicine than to follow master clinicians on rounds, listen to them talk to patients and then discuss the intricacies of these situations with them. In that regard, this issue of NHL Update includes our second attempt at a patient education audio program, and for this ongoing experiment, we decided to apply the model of “oncology rounds.”

For this supplement, we visited with medical oncologist Dr Lowell Hart who, along with founding father Bill Harwin, leads a 40-oncologist group on the West coast of Florida. Our CME team enjoys working with these docs, who eat up clinical research information as voraciously as they do Joe’s Stone Crabs.

I asked Lowell to select three patients with lymphoma from his practice who would be willing to participate in one-on-one recorded interviews with me and tell their stories to hopefully tens of thousands of other physicians, nurses, patients and loved ones. The final edited program is enclosed and includes chats with a retired septuagenarian and his wife, a 65-year-old receptionist in a dental office and a 39-year-old man who spent most of his adult life touring as a drummer with a rock band. What unites all three of these patients is their recent experience being treated with R and various forms of chemotherapy.

The consistent message from these interviews is that while R-chemotherapy for lymphoma is a challenge, it is also generally quite tolerable. A second clear theme from these three patients was that, in their view, a positive outlook on the future is an important coping mechanism as is continuing to engage in enjoyable lifestyle activities during treatment.

Using the rounds format, we not only hear the perspectives of these patients and their oncologist (Dr Hart), but also Dr Hagemeister, who provides an update on new research concepts in lymphoma in a deliberate, well-thoughtout and very understandable manner.

Our goal with this new patient education initiative is to allow patients to learn “at the bedside” in the same manner that physicians have been doing for centuries. Any feedback in this continuing experiment in oncology education would be most appreciated.

— Neil Love, MD
NLove@ResearchToPractice.net

SELECT PUBLICATIONS

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Czuczman MS et al. Rituximab in combination with f ludarabine chemotherapy in lowgrade or follicular lymphoma. J Clin Oncol 2005;23(4):694-704. Abstract

Forstpointner R et al. The addition of rituximab to a combination of fludarabine, cyclophosphamide, mitoxantrone (FCM) significantly increases the response rate and prolongs survival as compared with FCM alone in patients with relapsed and refractory follicular and mantle cell lymphomas: Results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood 2004;104(10):3064-71. Abstract

Ghielmini M et al. Prolonged treatment with rituximab in patients with follicular lymphoma significantly increases event-free survival and response duration compared with the standard weekly x 4 schedule. Blood 2004;103(12):4416-23. Abstract

Hainsworth JD et al. Maximizing therapeutic benefit of rituximab: Maintenance therapy versus re-treatment at progression in patients with indolent non-Hodgkin’s lymphoma — A randomized phase II trial of the Minnie Pearl Cancer Research Network. J Clin Oncol 2005;23(6):1088-95. Abstract

Hainsworth JD et al. Rituximab as first-line and maintenance therapy for patients with indolent non-Hodgkin’s lymphoma. J Clin Oncol 2002;20(20):4261-7. Abstract

Liu Q et al. Stage IV indolent lymphoma: 25 years of treatment progress. Proc ASH 2002;Abstract 1446.

Marcus R et al. CVP chemotherapy plus rituximab compared with CVP as first-line treatment for advanced follicular lymphoma. Blood 2005;105(4):1417-23. Abstract

McLaughlin P et al. Safety of fludarabine, mitoxantrone, and dexamethasone combined with rituximab in the treatment of stage IV indolent lymphoma. Semin Oncol 2000;27(6 Suppl 12):37-41. Abstract

Romaguera JE et al. Rituximab plus hypercvad (R-HCVAD) alternating with rituximab plus high-dose methotrexate-cytarabine (R-M/A) in untreated mantle cell lymphoma (MCL): Prolonged follow-up confirms high rates of failure-free survival (FFS) and overall survival (OS). Proc ASH 2004;Abstract 128.

Sehn LH et al. Introduction of combined CHOP plus rituximab therapy dramatically improved outcome of diffuse large B-cell lymphoma in British Columbia. J Clin Oncol 2005;23(22):5027-33. Abstract