Republican and Conservative political analysis and commentary

Very slow-growing tumors are difficult to treat with chemotherapy and radiation because both types of therapy work by inducing DNA damage in rapidly-dividing cells. Since most malignancies are rapidly-dividing, they have less time to repair the damage than other cells, and when they try to divide they die.

The bad news is that this makes slow-growing tumors difficult to treat.

The good news is that tumors that grow very slowly don't tend to be overly aggressive, and slow to the point of standstill is pretty OK as far as the patient is concerned. The fact that this can't be seen by CT or PET is also a good thing.

This shouldn't slow him down at all. I actually voted for Paul Tsongas in the 1992 Democratic Primary (more to protest Bill Clinton than anything), but his lymphoma was of the more common, highly-aggressive variety.

And you can add Barack Obama's future lung cancer to the list of political figures with health problems, unless he quits smoking. Either that or he has great faith in tobacco company scientists.

The term "indolent non-Hodgkin lymphoma (NHL)" is not specific enough to be helpful in predicting prognosis. Almost all American pathologists and oncologists use the WHO classification system for lymphomas, and you will not find that term in that reference. What is needed is a specific pathologic diagnosis and staging information.

That said, even the most indolent lymphomas kill the majority of patients within a ten year time frame. The most common of the low grade lymphomas is small lymphocytic lymphoma, and about half of people with that disease die within 7 years. Certainly some people live much longer, but is it sensible for someone to run for president if they have a 50% chance of dying before they finish a first term? Assuming the best form of NHL, he's already 2.5 years out from diagnosis and would take office four years from diagnosis.

Aside from death, living with lymphoma involves disability for many patients, ranging from a moderate loss of vigor to very significant complications associated either with the disease or the therapy for the disease.

Sadly, I really do think this precludes (or should preclude) Senator Thompson from running for President.

DMayes

Look at DMayes' comment above. This is a perfect example of how to say something very misleading while using perfectly factual information.

The problem is that citing older generic information without knowing anything at all about the specifics of the case you are adding confusion rather than enlightenment. There are a few little details required before DMayes can make such assertions, details that I suspect he/she doesn't have. There are myriad factors that are all individual to determine how healthy or sick Sen. Thompson is. The strong likelihood is that he has some other disease or trauma cause problems before the lymphoma ever does, unless his doctors are lying about it.

1) The fact that the disease was discovered in a routine exam rather than because there was a sore lump under the arm suggests Stage 1. The databases include patients who were past Stage 3 when diagnosed (e.g., multiple lymph nodes, spleen and liver involvement, etc.). If you are diagnosed at Stage 1, and are asymptomatic at the time, you are scanned quarterly and the first change leads to more aggressive treatment; the time factor is normally more like a decade of decent health.
2) The data cited include all ages of patients; when you are over 60, the slower metabolism significantly slows the progression.
3) All prior databases of SLL/CLL predate the advent of the current therapies. Before the last 5 years or so, the standard was not to treat indolent lymphomas until they got active, because the available chemotherapies would often induce a remission, but then return and the second time around the disease would not respond to the drugs. This all changed with the approval of immune response modifiers- monoclonal antibodies. You can tell them by the fact that "mab" is part of the drug name.

mABs stimulate the immune system to do what the body does thousands of time every day for our entire lives- catch potential cancers and destroy them. If we didn't have that effective immune function, we would all die of some type of CA within a few months of birth. When we get a cancer, it is because the immune system failed or was overwhelmed by it. mABs make the immune system fight tumors in the same way that we normally do, but because they are biologics, not the same sorts of chemically-based drugs, they do not degrade the future effectiveness of chemotherapies.

To illustrate how the immune system works on cancers, someone who has had an organ transplant generally has to stay on immunosuppressants for life to prevent rejection. I have seen case studies of kidney or heart patients with more than 100 skin cancers around the face because the immune system is depressed and not acting to remove them. In Thompson's case, they gave him mABs and it killed the lymphoma; if it returns, they now have choices- they may even be able to go back to mABs again before doing classical chemo. In a few years, the separate databases of those treated first with mAB-based therapy are going to look far different from the current historic records.

We have no clue how healthy the senator really is- all we can do is trust that Dr. Frist at VolPAC, who obviously knows the details and also knows a little bit about transplants and immune system function (the lymph system is central to our immune system- all the nodes exist for is cleaning garbage out of our bodies) is telling the truth.

Actually, it was going to be aggressive lymphoma when it first developed, then decided that being aggressive with Fred! was a BAD IDEA.

Help! I'm starting to channel Frank J!

I am certainly not attempting to be misleading in my discussion of lymphoma. Kurmudge is certainly right to point out that we don't know the specific diagnosis, and that modern forms of therapy may have a significant impact on long term survival in various forms of low grade lymphoma.

However, I stand by my assessment, and in fact, I think the outlook is probably worse than the best case scenario I assumed in my first note, lacking, as Kurmudge pointed out, a specific diagnosis or staging information.

Why? Well, we can infer quite a lot from what is on the record so far both about the Senator's diagnosis and stage.

We know that he has an indolent non-Hodgkin lymphoma, and that he was treated with Rituximab. Rituximab is only useful in B cell lymphomas, and among indolent B cell lymphomas for which Rituximab would be a first line therapy, the vast majority would be either a form of follicular lymphoma (there are three grades), or a form of small lymphocytic lymphoma (there are a few unusual variants). Any other possibilities would be more aggressive than small lymphocytic lymphoma anyway, so, by making this pretty safe assumption, we are still being conservative.

We can also infer that he is at least stage II. Why?

Two reasons. First, it is unusual for indolent forms of non-Hodgkin lymphoma such as follicular lymphoma or small lymphocytic lymphoma to present with localized disease. In the unusual patients in which this is the case, patients are either followed expectantly or treated with radiation, not Rituximab. Rituximab is used in patients with stages II, III, or IV disease.

So, how do patients with indolent non-Hodgkin lymphoma do with Rituximab therapy? Well, one of the most commonly quoted papers comes from Dr. Anthony Greco, an oncologist who spent most of his career at Vanderbilt, and, as one of the most prominent academic oncologists in Senator Thompson's area, it would not surprise me if he turned out to be the Senator's oncologist.

Dr. Greco's study was published in the Journal of Clinical Oncology in 2002, looked at Rituximab in 60 patients with indolent NHL (all stage II, III, or IV, all with either follicular lymphoma or small lymphocytic lymphoma), and found at least some response in 73 percent of patients. The median progression free-survival was 34 months. So, half the patients had progression of their disease within about three years, and this was considered a very good result.

I'm not an oncologist, but I've been a pathologist for 20 years, and have seen many patients with low grade lymphomas (I see them when I go do their bone marrow biopsies, and actually become acquainted with them over time as sometimes they end up having many biopsies over a period of years). This is not a benign group of diseases. It is not a curable group of diseases. True, some patients do very well for a long time. One of my attendings in residency lived for almost 20 years after his diagnosis with SLL/CLL. But most patients die of their disease, usually after an extended period of poor and declining health.

In my opinion, a person running for President now should be able to look out to a ten year horizon with a reasonable expectation of good health. No one with any form or stage of indolent non-Hodgkin lymphoma can do that.

So, I'd be surprised if he did run, and I don't think he should. If it weren't for this problem, I would support him. I'm in sympathy with his politics, and he is the most articulate and forthright of those running or considering running (one might ask why not McCain...I would never vote for someone capable of such a suppression of first amendment rights as is the McCain-Feingold Act...of all of our freedoms, one would have thought that among the safest would have been the freedom to criticize our politicians by name at any time we choose and at whatever expense we wish. If this freedom can be taken away, as it has, then no other freedoms are secure).

dmayes

dmayes:

The problem with your whole argument is that you you immediately jump conclusions based on the treatment - and didn't bother to gather the facts. So here you go.

The ultimate failure is that you diagnosed the wrong cancer - you based your argument on follicular lymphoma. It is not. Thompson was diagnosed in November 2004 with nodal marginal zone lymphoma, an indolent B-cell lymphoma. Nodal marginal zone lymphomas account for only 1% all NHLs. Thats probably why you missed it.

Also, your were wrong about use of rituximab in early therapy. Ruling out CHOP since this is not a diffuse large B cell lymphoma, a standard treatment for a number of NHLs is R-CVP, of which rituximab is a component. I do note that this is more often a stage 3-4 treatment, and since they did not mention chemo and steroids (the "C" is chlorambucil, the P is prednisone), I doubt this is what was used. Rituximab is approved for other uses (Rehumatoid arthritis for instance), and this may have been an "off label" therapy decided upon by the oncologist and the patient's risk tolerance and desires.

From my consultations, this is a bit aggressive in terms of standard treatments, - but were I in Fred Thompson's position I would think the risks would be worth it - consider the 4 year old and 18 month old children he has; taking bit of a risk with a harder treatment line is worth it in terms of better life expectancy. And it beats chlorambucil's potential (chemo) side effects - rituximab is simpler for the patient (IV infusion 1 time a week for 4 weeks).

Furthermore, your statement of stage 2 is squarely at odds with the reality. For those of you unfamiliar, here are the general definition of NHL stages:

Stage 1 The lymphoma is only in one group of lymph nodes, in one particular area of the body.

Stage 2 More than one group of lymph nodes is affected, but all the affected nodes are contained within either the upper half or the lower half of the body.

Given the descriptions of a single lump under the jaw and no other areas involved (the armpits and/or neck would have been stated had it been stage 2), Sen Thompson's lymphoma was very likely stage 1.

Secondarily, the literature available very much disputes you presumption that people die from the disease more often that other causes. I beleive you are mischaracterizing it based on talking to an oncologist that I know, and from others experienced in the field. There may be other info more current that his oncologist in Georgetown has than what you cited (not to mention you cited outcomes for the wrong disease). Here are some sources for you to consult - they proved valuable for me, and might educate you.

Oxford Textbook of Oncology (2nd edition). Eds Souhami et al. Oxford University Press, 2002.
Wintrobe’s Clinical Haematology (11th edition). Eds Lee et al. Williams and Wilkins, 2004.
Malignant Lymphoma. Eds Hancock et al. Arnold, 2000.
Improving Outcomes in Haemato-oncology. National Institute of Clinical Excellence, November 2003.
British Committee for Standards in Haematology guidelines on nodal non-Hodgkin lymphoma, draft 2. August 2002

On top of all that, a direct quote from Thompson's doctor basically demolishes your position that Sen Thompson is physically at risk for serving out his term:

"Some lymphomas are very aggressive, but people with slow-growing types, like Senator Thompson's, often dying from natural causes associated with old age, rather than from the disease. In 2004, Senator Thompson was diagnosed with a form of lymphoma. Today, he is in remission from this, slow-growing disease. Senator Thompson chose to receive such therapy (Rituxan), but he is no longer in treatment as he is in remission. Doctors cannot currently detect the lymphoma by physical examinations or scans. Senator Thompson has never been physically ill or had any symptoms from his lymphoma or had any side effects from the therapy." Bruce D. Cheson, M.D. Professor of Medicine Head of Hematology Division of Hematology/Oncology.

The one thing you get right is that there would probably be a recurrence eventually, followed by likely retreatment with rituximab. That much was stated by Sen Thompson's oncologist in an interview later.

But most damning to you are the words from Fred Thompson himself: "I have had no illness from it, or even any symptoms. My life expectancy should not be affected."

How do you square that with your statements -- Are you accusing Fred Thompson of lying to the public about his fitness for the Presidency? Or, more likely, is it you that is overstating the case? In effect, I believe you are trying to discredit by use of half truths - and to me, thats disingenuous and deceitful, unless its out of pure ignorance. And I solved that problem with a bit of research and people I know in the medical field, why couldn't you?

I'd likely get a more honest and informed opinion from a survivor, or from an RN who works oncology and has done so for 25 years, than I would apparently get from you. And I have gotten just such an opinion. My mom is that nurse, and my father was 8 years out from mild chemo with with nary a sign at age 74 (MI took him). As a matter of fact, his type II diabetes was a far larger issue for his health.

So, yes Sen Thopson has a form of cancer, but not its not as debilitating and disqualifying as you attempt to make it out to be, and your diagnosis and prognosis is flat out wrong and appears to be a scare tactic.

I suggest you stick to your tissue samples and your area of practice; leave diagnosis and prognosis of lymphomas up to *real* doctors involved in this - professional oncologists.

The bottom line is: Were Thompson truly at such a risk as you describe, he would not run, its not in his character.

To say otherwise reveals even more about you than it does him.