Editor's Note
	Eat your heart out, Larry King

OK, I feel better now, and we can get on to introducing this new audio series...

Figuring out and simplifying the management of non-Hodgkin’s lymphoma (NHL) has been on my list of “things to do” for a long time, so when our group received support to launch this audio series, I approached it with great enthusiasm. The first person I wanted to chat with was the NHL maven of mavens, Sandra Horning, and on my long flight from Miami to San Francisco to visit her, I voraciously read a sampling of her recent publications.

When we sat down to chat, I was a bit nervous about my relative NHL illiteracy. However, Dr Horning — in a mind-saturating multi-hour tutorial — quickly got me up to speed on many of the critical research issues that impact daily practice, and key questions being addressed in ongoing and maturing clinical trials.

By the time John Hainsworth visited our education center some weeks later, I felt much more comfortable asking the challenging questions that have become the centerpiece of our group’s education activities.

On the surface, NHL seems to be a complex disease with unique management strategies. However, as I learn more, similar principles emerge between this disease and other tumor types. At times during my fascinating chats with Dr H and Dr H, my mind flashed to research issues that pose the same challenges we face in breast, prostate, colorectal and lung cancer. For example:

1. Expectant management of low-grade follicular lymphoma

A recent publication from Dr Horning and colleagues demonstrated a mean survival of about 19 years in carefully selected patients. However, with the availability of a treatment that is considerably less toxic than chemotherapy (rituximab), fewer patients are currently electing to forego antitumor therapy.

This issue is analogous in some respects to “watchful waiting” in prostate cancer, but in contrast to NHL, many more prostate cancer patients are being followed off therapy for low-grade, very localized lesions. The challenge of this approach in any tumor type is that patients often understandably feel a bit nervous about leaving their cancer untreated.

2. Dose intensity and dose density

The ultimate question in this arena is the role of transplant, but Dr Hainsworth also comments on every two-week CHOP, utilizing growth factor support. Since most patients over age 60 will receive preemptive growth factors, one wonders about the impact of every two-week therapy on tumor control and quality of life. While breast cancer already has one major trial (CALGB-9741) addressing this question in more than 3,000 patients, similar studies in NHL are much smaller, and more data on this question is urgently needed to provide a definitive research-based recommendation.

3. Predictors of response to therapy and prognosis

Assessments of HER2, ER and PR are mainstays in breast cancer management, and the new Oncotype DX™ assay may help identify women who can forgo chemotherapy. Similar strategies are also being successfully applied in non-small cell lung cancer and colorectal cancer as discussed in recent interviews for our Lung Cancer Update and Colorectal Cancer Update series with Drs Tom Lynch and Heinz-Josef Lenz, respectively. Cellular antigens have been used to classify NHL for some time, and genomic predictors of prognosis are the subject of several recent publications. There is hope that at some point, treatment decisions for all of these tumors will be based in large part on genetic information rather than a “one-size-fits-all” approach.

4. Combination of biologic agents with chemotherapy

Clearly, rituximab-chemotherapy regimens have become standard first-line therapy in many NHL situations, but other targeted therapies are also being investigated, including tyrosine kinase inhibitors and the anti-VEGF agent bevacizumab. A recent research leader “Think Tank” our group conducted in colorectal cancer included some fascinating banter about “bev” and its potential mechanisms of action. If speculations by Lee Ellis and others are correct — that this agent facilitates the delivery of cytotoxic agents to tumor cells — patients with NHL and many other tumors may benefit from this potentially exciting treatment strategy.

Our CME audio programs generally include interviews with three or four research leaders, but the complex nature of NHL and the plethora of relevant information provided by Drs Horning and Hainsworth have led us to make an exception, and this inaugural issue focuses on the thoughts and perspectives of these two insightful and experienced investigators. I know that you will enjoy hearing and learning from these great minds in the field.

— Neil Love, MD
NLove@ResearchToPractice.net