The outcome for patients with MCL has probably improved over the last decade. This is certainly something we have seen in clinical trials but it has not necessarily translated into an improvement on a population basis. We are entering a very exciting phase in the clinical trial arena with the rapid emergence of some promising new molecules that appear highly active in MCL. Drugs like Ibrutinib have the potential to fundamentally change the way we treat patients. The challenge that lies ahead for us is to work out the best way to use this and similar drugs. My view is that we are approaching an era when we can seriously challenge the use of chemotherapy as the cornerstone of treatment in this disease. Rather than using these new agents to try and improve on chemotherapy based approaches we should be using them as an alternative.
This way of treating patients may improve on the responses seen with chemotherapy. Even if they don’t but if they can deliver similar outcomes these molecules seem to have far fewer side effects. We believe that this is a more patient centred approach, focusing on quality of life. A trial randomising between these two ways of treating patients is at an advanced stage of planning within the unit. As well as exploring Ibrutinib as part of front line therapy there are a number of other non-chemotherapeutic agents (other BTK inhibitors, Pi3K inhibitors, bcl-2 inhibitors and newer monoclonal antibodies) which are going to be explored in combinations in patients with relapsed disease. We will be involved with the development of a number of these novel treatments.
We have recognised 2 distinct groups of patients with MCL for over a decade in our unit. Most patients have an aggressive type of disease which requires early treatment but there are a minority who have ‘indolent’ behaving disease. This means that for these patients, the disease behaves in a different way; in some cases it requires no treatment, sometimes for many years. We still can’t know which patients fall into the later category when they are diagnosed. There are some features that are more common in patients with the indolent disease but no reliable test that can be done at diagnosis which could be used to guide treatment decisions. We are opening a new study that will look at the genetic features of these two groups because we think that this information will hold the key to making this distinction. We will collect a few samples from 300 newly diagnosed patients from across the country and then follow up what happens to them over a period of some years. We hope this will ultimately lead to a laboratory test that can distinguish these two distinct groups of patients.
Professor Simon Rule