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Today is Lymphoma Awareness Day. With the number of cases of Lymphoma increasing, it is important we start talking about it. But, within Lymphoma it is imperative to talk about “Diffuse Large B-Cell Lymphoma” also commonly referred to as DLBCL among the medical fraternity. In a discussion with Harbinder Narula, CEO of BW HealthcareWorld & BW WellbeingWorld, experts shared their insights on lymphoma and its treatment.
Lymphoma is among the 10 most common cancers prevalent in India, in fact, some believe it to be in the top 6, and DLBCL accounts for almost 60 per cent of these Lymphoma cases.
According to Dr. Pawan Singh, Director – of Hematology at Yatharth Super Specialty Hospital, 60 per cent of Lymphoma cases detected are DLBCL as against 25 per cent in the Western countries. Almost 25000 new cases of DLBCL are detected every year in India. And, there are 44000 active cases of DLBCL in India. The good indication from these numbers is that most cases are treatable and well-managed.
The only challenge in DLBCL is that it is found in seniors or is diagnosed late. The usual symptoms of Lymphoma are fever, weight loss and night sweats. Since two of the three symptoms are related to infection, people do not take it seriously and then when it does not get better, they go to a general physician. Now, these symptoms are also similar to the condition of Tuberculosis (TB) and upon empirical evidence some of these patients are given treatment for TB. Now this becomes tricky. If the symptoms do not subside in two weeks, it must be checked for Lymphoma, which in many cases is not done because of ignorance.
Dr Sajjan Rajpurohit, Senior Director of Cancer Care / Oncology at BLK Max Super Specialty Hospital says, “Once the patient begins with medicine for Tuberculosis, when it is misdiagnosed, it could do more harm than good. So, if someone has these symptoms and is advised treatment for Tuberculosis, one must also consult an Oncologist to rule out Lymphoma, preferably before starting medication, unless TB is properly tested for. A biopsy should be done and not be restricted to just FNAC. Timely diagnosis is important for treatment of Cancer, especially when it comes to Lymphoma, which has good treatment available.”
Lymphoma treatment is a non-surgical treatment. DLBCL is treatable, with 50 per cent to 60 per cent of cases responding well. The challenge is that there is a lack of awareness which leads to delayed diagnosis. Also, the symptoms being similar to conditions like TB, it sometimes leads to misdiagnosis and in turn, leads to delayed referrals to a specialist. This results in poor patient outcomes. Also, as a nation, the larger issue is the lack of medical support and access to doctors in the rural parts of the country.
The traditional treatment that has been considered to be the gold standard is R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone). It has been considered to be the standard first-line therapy for DLBCL for over two decades. The challenge to this treatment has been that it is observed that there are 40 per cent patients relapse or cases that do not respond to R-CHOP. In case of a relapse, further treatment becomes even more costly, adding to the challenges for the patient and their caregivers.
Despite efforts to find a better treatment, 11 major clinical trials of new protocols are known to have failed in the last 20 years, resulting in no NEW drug approval for DLBCL for over two decades, until the recent development.
Recently a new treatment option has been given approval in India in December of 2023, after years of it being used in the Western world. This new treatment is a combination of immunotherapy and chemotherapy and is considered to be a breakthrough. It is a targeted immunotherapy antibody-drug conjugate.
Dr RajPurohit says that 77 per cent of the patients responded well with no relapse with the new regime. It has reduced the risk of progression, relapse and death by almost 27 per cent, which is a significant improvement.
The benefits of Pola-R-CHP, the new treatment seems to lower the failure rate as the first treatment compared to the traditional standard of treatment (R-CHOP), and has reduced exposure to heavy drugs, with no increase in toxicity being observed and eventually also lower rate of mortality. This treatment has been tried by doctors for over 2 to 3 years.
Dr. Sushant Mittal, Director, of Medical Oncology, Action Balaji Hospital says that just like most Cancers, Lymphoma is not preventable yet, as the cause is not known. However, he shared a story of a 78-year-old patient, who was a classic case of a delayed referral, and also delayed diagnosis. This patient was diagnosed with stage 3 DLBCL. He was going to be blessed with a grandchild in 3 months and showed keenness to do whatever it takes to be able to see his much-awaited grand child. He was counselled to go in for a newer treatment regime with Pola-R-CHP. He has shown a good response to treatment in the interim PET scan. The treatment has been on for 4 months now, and Dr Mittal is hopeful to see complete remission of the disease soon.
The cost of this new treatment is more expensive than the earlier standard treatment. So, should everyone go in for this new treatment? According to Dr.Mittal, Dr Rajpurohit and Dr. Singh, there is a consensus on this. If a patient can afford the treatment, one must go in for it for the sheer chances of being treated, and a lower rate of failure. But, one must keep in mind that the traditional gold standard has failed mostly in older patients. Keeping this in mind, younger patients can still undergo R-CHOP regimen if affordability is an issue, but for older patients where chances of relapse are relatively higher, the Pola-R-CHP must be the preferred therapy. The benefits are because it lowers the chances of relapse. One must keep in mind that if it relapses, further treatment is even more expensive. This is where counselling and ethical discussion with the treating doctor plays an important role.
The new therapy of Pola-R-CHP lasts around 6 months, and insurance does cover it. Even CGHS recognises this treatment protocol and this treatment is available even in government hospitals.
When asked about the side effects of this new therapy, the doctors confirmed that sometimes the patients have shown signs of lowered TLC and complained of nausea, but these are manageable conditions keeping in mind the overall benefits.
With the increase of Lymphoma disease burden, of which in India, there is an increasing incidence of DLBCL, this new treatment therapy seems to be making treatment even better, giving confidence to the Oncologists, leading to confidence among patients.
We do hope this treatment over time becomes more affordable, even though in India we are blessed for it to be relatively less expensive compared to other parts of the globe.
