So, what is the conclusion? Who should have a transplant and when. As usual, the best results are achieved in people who don't need one, and transplanters delight in doing these because it makes their results look good. However, all transplants have a risk of killing the patients, and the procedure is not so safe that it should be performed if it is not necessary.
Perhaps the most obvious group to benefit are patients without co-morbidities who need treatment but have del 17p. Even in this group there is probably a need to debulk the disease before the transplant and how to do this is controversial.
The second group is for patients who have failed to respond to a fludarabine containing regimen or relapsed following treatment with one within 12 months.
The only other sensible advice is not to muck around with other regimes like PCR, cladribine or various experimental treatments. If a transplant is necessary it should be performed as soon as the criteria are met.
There is no information about which reduced conditioning regime should be used, but almost certainly a non-ablative treatment is preferable to an ablative one. T depletion is still in the melting pot. Almost certainly it is better to go to an experienced unit that has performed many previous transplants in CLL (not one that has specialised in other diseases).
With a fatality rate of about 50% or more, I think a lot of patients would be interested in other treatments.
ReplyDeleteAnd if advances are to be made, they will first surface in the hard-to-treat patient who has failed multiple treatments.
I remember reading a study that showed that only 7% of patients were alive after a transplant after 15 or 20 years. This means that 93% of the people die either from the treatment itself or disease progression, or for some other reason.
Dismal statistics.
The lesson I'm getting is that the dangers of a transplant are such that anyone who has had a successful front-line FCR regimen that gave him a long-lasting progression-free period should try FCR again unless he has become 17p deleted.
ReplyDeleteHe's in much the same position as a patient who has had no treatment, with regard to the wisdom of having a transplant.
What I wonder about is how important the number of cycles the patient had in his first cycle of FCR is in the decision making process. Many have only 4 cycles instead of the full 6.
Should those who had only 4 cycles reasonably expect a better result in a second round of FCR if they responded well in the first with only 4? Would they be less likely to be fludarabine refractory because they had less fludarabine in the front-line round than those who had the full 6 cycles?
And, therefore, be better off avoiding a transplant?
Probably means that there is less marrow damage and therefore more reserve for a second go around.
ReplyDeleteI am a 37 year old male. I have a lymphocyte count of 29.4 (this has remained constant since July 2009). My red blood cells and platelets are within normal limits. I have not had any genetic tests yet to check for FISH, VH mutation etc . . . However, I did have a bone marrow biopsy and this showed a cellular lymphocyte count of 71%. My consultant said that this was not a reliable marker because the lymphocytes can concentrate in a particular area (not spread evenly across marrow). He said my general health, constant lymphocyte count and normal red blood count and platelets were more accurate. He said that I should not be worried! Should I be worried? 71% seems high and would appear to be pushing towards saturation. Is this something that is likely to make a stem cell transplant more likely – if the marrow cannot work properly because of lymphocyte saturation?
ReplyDeleteAnon
ReplyDeleteMost people with CLL have a heavy marrow infiltration. It is a pointless examination in most people. Only VH genes and FISH tell you anything about the future.