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Just give her the beans!
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Beans? What beans?
I had a sick patient with Hodgkin’s lymphoma and my close friend, frequent travel companion and recognized lymphoma maven Dr. Morton Coleman was suggesting giving her beans! It reminded me of what General Tony McAuliffe said when surrounded by German forces during WWII’s Battle of the Bulge. When McAuliffe heard the Germans’ demand for surrender, he said, “Us surrender? Aw, nuts!” He then wrote down, “To the German Commander: ‘Nuts!’ The American Commander.” The Germans couldn’t figure out what “Nuts” meant. I didn’t know what “beans” Mort was talking about.
It turned out that the beans meant the combination of vinorelbine (Navelbine, Pierre Fabre), gemcitabine, and Doxil (Orthobiotech) — “bines” pronounced beans. Mort had seen my patient in consultation and made the recommendation of this three-drug combination. My patient, a 69-year-old woman, developed Hodgkin’s lymphoma at age 61. At presentation, she had retroperitoneal, neck, axillary and bone marrow involvement. Radiation, given to her tonsils when she was a 7-year-old, might have been a contributing factor. Her daughter, now 38, developed Hodgkin’s lymphoma in the neck at age 25 and was successfully treated with ABVD. (She is presently a cabaret singer, possibly because she was able to avoid radiation therapy.)
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My patient initially had a complete response to six cycles of ABVD combination therapy. She was disease-free for six years until age 67, when she developed an FUO with temperature elevations to 103.5º F. An abdominal CT scan showed retroperitoneal disease and she was given five cycles of COPP therapy, which were ineffective. Because of the patient’s age, obesity, diabetes, her preference, and the fact that this was a late, somewhat localized first relapse, I wanted to avoid autotransplant. I also wanted to try to avoid the more aggressive etoposide-based alphabet soup of relapse regimens, such as ESHAP, MIME, EIP, EVA, ICE, CEVD, VIM-D, MINE, CAV or Mini-BEAM. Other possible non-etoposide regimens included DHAP, ABDIC, ASHAP, ChlVPP, C-MOPP, ifosfamide with vinorelbine, and vinblastine as a single agent. There were also some newer gemcitabine regimens (IGEV, GVD) available, which I found on my review of salvage regimens, but which one to choose? Mort suggested GVD.
I learned that a CALGB study employed 21-day cycles of gemcitabine, vinorelbine, and Doxil (GVD) in 76 patients with recurrent or refractory Hodgkin’s lymphoma using different doses for those with or without a prior hematopoietic cell transplant. It was essentially a pretransplant salvage regimen with apparently less toxicity than the more standard, older approaches. The response rate for all patients was 70% with 19% complete remissions. Four-year, event-free survival was 52% in transplant-naive patients when it was followed by autologous transplant. Four-year overall survival was 70%. The regimen was even active in transplant failure patients. The patient and I decided it was worth a try.
I gave my patient the GVD and she had a complete response. Her last treatment was September 2007. She was subsequently able to visit her grandchildren in Israel and is enjoying her complete response, which continues to the time of this writing.
So what’s the point? In fact, many patients with lymphomas (and now even solid tumors) who were previously thought to be incapable of sustaining a meaningful salvage or second-line response are being helped significantly with new drugs and new regimens. However, as this patient’s management demonstrates, following newer guidelines may be confusing because of the sheer number of possible treatments and the difficulty in picking the best treatment with the fewest side effects for a particular patient. Even in this day and age of evidence-based medical care, there is still something to be said for fine-tuning or tailoring individual patient care, and for the experience and judgment of senior physicians who have watched oncology treatments evolve.
McAuliffe had the right idea. Every day, oncologists do their best not to surrender. To cancer, we say, “Nuts!”
Arthur Topilow, MD, is in private practice at Atlantic Hematology & Oncology in Manasquan, N.J.
For more information:
- www.thedropzone.org/europe/Bulge/kinnard.html
- Bartlett, N, Niedzwiecki, D, Johnson, J, et al. Gemcitabine, vinorelbine, and pegylated liposomal doxorubicin (GVD), a salvage regimen in relapsed Hodgkin’s lymphoma: CALGB 59804. Ann Oncol. 2007; 18:1071.