The aim of this is to share some of the challenging lymphoma cases I get asked to comment on, usually via email. I am very aware of the need for patient confidentiality so although the cases will be based on real ones, details will be changed so that it will not be possible to identify patients from the clinical details listed. All the cases discussed are no longer active (at least in my email in box!), so comments in this blog will not be fed back to the treating clinicians so we can speak freely. However we are all, always learning so of course your comments may inform us as we endeavour to treat our patients better and improve their lymphoma journey experience.
It would be GREAT if people could comment on the cases whether:
- you are a physician: what treatments would you suggest? What is your evidence base? What is your personal experience?
- you are a nurse of physician associate: what has been your experience caring for these patients? Can you share advice on coping with a certain treatment strategy?
- you are a patients or carer: have you faced similar treatment? How did you find it? Can you share personal anecdotes of how to cope better with it?
CASE 1
Dear Dr Collins
Could I ask your help please. I have a 65 year old man who presented with stage IIIA diffuse large B-cell lymphoma. He presented with a lump in his neck which was growing quickly and he had quite profound fatigue. Performance status was 1. He was also off his food but had only lost 5% of his body weight over the last few months. His LDH was raised (550 IU/ml) and his International Prognostic Index (IPI) was 3 at diagnosis. He had 1 cycle of R-CHOP but then his cytogenetics came back showing a translocation involving c-myc and Bcl-2 i.e. a double hit. We switched him to DA-EPOCH-R and are planning 6 cycles. He's had 2 cycles so far and is tolerating it very well. His symptoms have improved and his lump has shrunk although he's not been scanned during treatment. I would be interested to hear your views as to whether there is a role for stem cell transplantation as a consolidation in first remission. If so, would you use an autologous or allogeneic transplant?
His only past medical history is hypertension well controlled on ramipril.
Please do comment!
"Dear Doctor Collins," I note that your correspondent in the case of Case 1 asks what you 'would use' for the gentleman in this situation. This suggests that the decision is a unilateral one. The correspondent doesn't mention what the 65 year old gentleman might think about this very fraught decision, or how the patient's perspective, personality, aspirations and preferences might be taken into account. Knowing that you are a fan of shared decision making, I wonder how your response discussed the importance of ensuring that this patient is an active participant in making a decision about his care?
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