Guest blog by Dr Toby Eyre: What I will be presenting at the Lymphoma Management course

From left to right: Toby Eyre, Graham Collins and George Follows pictured at the 2018 Lymphoma Management Course at Keble College, Oxford.

Lymphoma Action’s sixth annual Lymphoma Management Course, run in conjunction with the Oxford Centre for Haematology, returns to Keble College Oxford from Monday 15 to Tuesday 16 July 2019. Aimed at trainees keen to specialise in haematology and medical oncology, the course covers material likely to come up in professional exams such as FRCPath and gives delegates a deeper understanding of lymphoma.

Specialists from across the UK provide a comprehensive overview of the diagnosis, treatment and management of lymphomas for fellow healthcare professionals. Dr Toby Eyre, Consultant Haematologist at the Oxford Cancer and Haematology Centre, will be hosting break-out groups discussing diagnostics and speaking about the specialist area of chronic lymphocytic leukaemia (CLL). 

In this first of a series of guest blogs for Lymphoma Action, Toby (pictured left) shares his knowledge with us and gives a brief insight into what he’ll be presenting on 15 July. Join Toby and fellow lymphoma specialists on 15 and 16 July at Keble College Oxford. 

Why CLL?

This is the first year we’ve included sessions on CLL in this joint initiative co-hosted by the Oxford Centre for Haematology and Lymphoma Action. There are several reasons for this. It’s the commonest type of low-grade lymphoid malignancy and it’s becoming increasingly prevalent as people are living longer with the disease. The good news is that during the last five years there has been an explosion of developments in understanding and treating the condition. CLL has outstripped many other diseases in terms of the progress that’s been made, for example, at least four new treatments have been licensed and approved in the past five years. This is transforming outcomes for patients and opens up really interesting research into individual responses to these drugs alone or in combination. 

Another interesting aspect of the disease are the increasing number of patients presenting with CLL that remains indolent and with no requirement for treatment. On one level this is really positive news for patients: almost one in three will never require treatment. But this poses a huge emotional and logistical challenge. For patients: the psychological challenge of living long-term with a chronic condition that may or may not require treatment at any time. For clinicians: the logistical challenge of managing a growing number of patients on an active monitoring (watch and wait) treatment regime and ensuring their practical, medical and psychological needs are met in a timely, sensitive and effective fashion.

In my session at the Lymphoma Management course I’ll be focusing specifically on patients with CLL who have relapsed. We know that only a small percentage of patients with CLL don’t respond to first-line drugs but the vast majority of patients will relapse at some point. Certain genetic mutations, for example, TP53 mutations or deletions, mean it can be difficult to treat and manage in a small proportion of patients. Each round of treatment has historically been progressively less effective with an increase burden of disease with poor risk genetic features. Clinical trials are helping us understand the best sequencing of treatments for the most effective outcomes. But what makes CLL so interesting (and challenging) is the very individual nature of each patient’s response and their specific resistance mechanism to the drugs. It’s an incredibly rich and fertile area of study and the more we discover, the better we’ll be able to transform the lives of the increasing number of patients diagnosed with refractory CLL.

Diagnosis and treatment

One of the topics myself and my colleagues will cover in depth at the lymphoma management course is the principles underpinning diagnosis and treatment of lymphoma in all its subtypes. One of the crucial elements is ensuring clinicians and specialists feel empowered to be actively involved in multidisciplinary team meetings (MDTs).  Unless we successfully integrate all the different facets – from disease biology; how the condition presents in a particular patient; insights gleaned from radiology, biopsy and other analyses, plus the patient’s specific demographics – then we risk inaccurate diagnosis and incorrect management. 

Sharing insights is an invaluable part of any diagnostic process, but it’s particularly important in lymphoma because treatments for different types often differ considerably.  It’s also helpful to be aware of patterns of presentation and disease behaviour. For example, Hodgkin lymphoma often presents with a mass on the chest, whereas mantle cell lymphoma primarily affects the bowel, lymph nodes and spleen. Using case studies, we’ll host break-out sessions at the course to practise integrated diagnosis and disease pattern recognition. Feedback from previous years tells us that delegates have a much better understanding of lymphoma sub-types after these interactive sessions. As a result, they feel able to advise and diagnose swiftly, accurately and with confidence and sensitivity.

Practicalities of prescribing

We want delegates to come away with a clear understanding of indications, dosing, toxicities and the rationale behind each type of treatment. Underpinning all principles of safe prescribing is an appreciation of the aim of the treatment; the type of lymphoma and the patient’s specific situation. For example, some toxicity might be considered acceptable in curative treatment. However, in long-term management of an incurable lymphoma we need to balance the risk of toxicity against the risk of the disease becoming drug-resistant if we stop and start treatment. 

For example, for some incurable (usually low-grade) lymphomas and high-grade types that can be ‘cured’, R-CHOP is the recommended frontline treatment in both cases.  But the objective of the treatment will differ considerably; for example, having a curative aim in treating diffuse large B-cell lymphoma (DLBCL) but controlling and managing low grade, incurable lymphomas such as mantle cell lymphoma and follicular lymphoma. It’s critical to know this – not just for consenting purposes, but also for the patient’s emotional and psychological wellbeing throughout and beyond treatment.

Individualised treatment

One of the most exciting developments in the treatment of lymphoma is targeted therapies. These mean better outcomes for hard-to-treat lymphomas and fewer side effects for those living long-term with chronic conditions like CLL.

In the Lymphoma Management course, we’ll cover the individualised approach from the perspective of diagnosis through to treatment and ongoing management. For example, genetic testing for mutations that may affect drug resistance; lab tests to apprise prognosis and inform therapeutic decisions; testing at a molecular level to highlight a particular form of lymphoma.

Toby Eyre is a member of the NCRI low-grade lymphoma subgroup and NCRI elderly high-grade lymphoma subgroup. He has a Diploma in Medical Education and a MD doctorate in early phase lymphoid clinical trials.