I am beginning to have a different view of beta-2 microglobulin as a prognostic factor in CLL. Hitherto, I have been suspicious of its value. It has been championed by the people at MD Anderson Cancer Center and it is practically the only factor they use. I have always contended that it is not so much a prognostic factor as a declaration of how much disease the patient has. I spoke to John Gribben yesterday and he agreed with me.
However, I saw some new data yesterday from the CLL4 trial. They have just done an analysis of the prognostic factors in that trial and for the first time included beta-2M. Sure enough in a multivariate analysis is does help to separate good risk from intermediate risk patients. However, it is interesting to note that when beta-2M is included the prognostic value of stage is eliminated.
Here's what I think is happening. Beta-2M is a measurement of disease bulk. It refines clinical staging. Earlier this year the German group demonstrated that stage A patients included patients with enlarged nodes in their abdomens that were not picked up by routine clinical examination. If these were moved into stage B, then the remaining stage A patients had a better prognosis. We have also known for some time that bone marrow biopsy histology is an important prognostic factor - a diffuse pattern of histology has a worse prognosis than any other. Rai or Binet stages do not show this. To reach stage C or stage III or IV requires a high degree of marrow infiltration. However, as CLL4 demonstrates, patients with 'progressive stage A' have the same prognosis as those with stage B. Progressive stage A comprised patients with s degree of anemia or thrombocytopenia that was insufficient to make them stage C, but was evidence that the marrow was filling up with CLL. If you have more disease you are further along the natural history of the disease.
Look at it this way: Supposing you are stage A (or Rai stage 0,I or II) but your beta-2M is 4.5 then you have either some hidden nodes or relatively large amounts of bone marrow disease. This means that you have had the disease longer than other stage A patients. Supposing the average survival of stage A patients is 12 years, you may well have had the disease for 4 or 5 years already rather than the one or two years of the rest of the cohort. In terms of natural history you have s shorter time left.
Beta-2M, therefore, is a prognostic factor of a different quality to VH genes, ZAP-70 or CD38, which tell you something about the rate of growth of the CLL, or from del 17p and perhaps del 11q, which say something about rate of turnover, something about loss of molecular control and something about drug resistance. Beta-2M is more like stage or marrow histology.
This is not to say it is not valuable. It may well be more useful than CT scanning and bone marrow biopsy, which are both more experimental and invasive.
Having changed my mind I will now interpret beta-2M levels in the light of this new concept.
7 comments:
I was diagnosed in May of '05. The first oncologist I saw my Beta 2 was 2.2; second opinion in 6/05 was 2.1;
In May of '07 at UCSD, Beta 2 was 2.2. Is there any conclusion that can be drawn as to disease progression/bulk given there has been no change in 2 years? Thank you.
One of the disadvantages of beta-2M is that there is variability betwen laboratories. However, yours is well below 4 so there is little change in disease bulk.
Are there any scatter plots linking
Beta 2M to staging or to "years to treatment" that you could present on your blog or give links to please?
If I understand it correctly SLL presents more in the nodes than the blood stream, at least in the early stages. For such people would Beta 2M be a more useful indicator of disease progression than lymphocyte count?
Thank you.
You wrote:
"In terms of natural history you have a shorter time left."
Isn't this a clarion call to develop a cure? Or at least better treatments that lead to longer survival?
Or is the oncologist's only role to predict how long a cancer patient has to live?
"Sorry Mr. Jones. You have nine years left to live. Goodbye!"
Richard
I don't have any data like that.
Anonymous
Absolutely. Although it doesn't quite work like that. All that prognostic markers can do is give an estimate of what is likely to happen. When I produced the VH gene data originally I had in mind to attack the watch and wait approach. I had hoped that we would be able to identify some patients where we would say, "There is no point in waiting, we should treat him as soon as possible." Alas the community has taken a long time to get these trials off the ground. The corollary was that we should be able to pick others for whom we could say, "There is very little chance that these people will ever need treatment."
DX'd in August 04 during a two day stay in the hospital. With daily blood monitoring I found that my beta-2m varied over a factor of 2 in 24 hours creating a confidence issue in using this measure.
tomd
Laboratory error is a possibility with all testing. If in doubt repeat.
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