A tale of 2 patients
| Initial presentation | Alvin was born in 1955 in a large city that borders the ocean. In 2017 he was diagnosed with DLBCL, not otherwise specified. His diagnostic tumor block underwent IHC analysis, which revealed this to be a non-GCB subtype without evidence of MYC or BCL2 translocation. He had elevated LDH greater than 2 times the upper limit of normal and kidney and bone marrow involvement. | Wilma was born in a rural town in the southern United States in the same year as Alvin. She remembers watching how her small town changed over time after the Fair Housing Act. She was diagnosed with non-GCB DLBCL in the same year as Alvin. She also had elevated LDH and bone marrow but no kidney involvement. |
| First-line therapy | He had excellent performance status (ECOG PS 0), was offered a randomized controlled trial as initial therapy, was randomized to an arm where he received R-CHOP, and started treatment 18 days after diagnosis. | She was self-employed and did not have insurance at the time of diagnosis. She was unable to conduct any work activities (ECOG PS 2) and was admitted to the hospital to start R-CHOP at 13 days after diagnosis. |
| Treatment at relapse | In early 2019 (11 months following R-CHOP), Alvin noticed a lymph node in his left axilla. A biopsy showed relapse of non-GCB DLBCL. He was able to purchase genomic testing using an available solid-tumor panel, but it did not provide information that his treating physician thought relevant to guide therapy. His physician performed HLA testing for Alvin and his siblings, and Alvin underwent salvage therapy with RICE (achieving a partial response) followed by ASCT based on the best available evidence. Last year follow-up imaging revealed evidence of relapsed disease with renal involvement (serum creatinine 2.1), and chemoimmunotherapy was restarted. Alvin was referred for CAR T therapy. He is now in your office awaiting scan results 6 months following completion of treatment. | Wilma had difficulty with fatigue, alopecia, and peripheral neuropathy during her treatment but recovered to feeling as good as she had several years prior to her diagnosis. She returned to work for 34 months and then began to feel progressively more tired and unable to perform her usual activities. She went back to her treating physician and had repeat scans that showed evidence of DLBCL relapse. Her physician referred her to a center more than 250 miles away to consider ASCT. She connected Wilma with a social worker who aided in garnering state-based insurance for cancer patients. A patient navigator at the center coordinated visits and recommended places for Wilma and her caregiver to stay around the center for the period immediately following ASCT. She now returns to see you 2.5 years after ASCT feeling well. |
| Initial presentation | Alvin was born in 1955 in a large city that borders the ocean. In 2017 he was diagnosed with DLBCL, not otherwise specified. His diagnostic tumor block underwent IHC analysis, which revealed this to be a non-GCB subtype without evidence of MYC or BCL2 translocation. He had elevated LDH greater than 2 times the upper limit of normal and kidney and bone marrow involvement. | Wilma was born in a rural town in the southern United States in the same year as Alvin. She remembers watching how her small town changed over time after the Fair Housing Act. She was diagnosed with non-GCB DLBCL in the same year as Alvin. She also had elevated LDH and bone marrow but no kidney involvement. |
| First-line therapy | He had excellent performance status (ECOG PS 0), was offered a randomized controlled trial as initial therapy, was randomized to an arm where he received R-CHOP, and started treatment 18 days after diagnosis. | She was self-employed and did not have insurance at the time of diagnosis. She was unable to conduct any work activities (ECOG PS 2) and was admitted to the hospital to start R-CHOP at 13 days after diagnosis. |
| Treatment at relapse | In early 2019 (11 months following R-CHOP), Alvin noticed a lymph node in his left axilla. A biopsy showed relapse of non-GCB DLBCL. He was able to purchase genomic testing using an available solid-tumor panel, but it did not provide information that his treating physician thought relevant to guide therapy. His physician performed HLA testing for Alvin and his siblings, and Alvin underwent salvage therapy with RICE (achieving a partial response) followed by ASCT based on the best available evidence. Last year follow-up imaging revealed evidence of relapsed disease with renal involvement (serum creatinine 2.1), and chemoimmunotherapy was restarted. Alvin was referred for CAR T therapy. He is now in your office awaiting scan results 6 months following completion of treatment. | Wilma had difficulty with fatigue, alopecia, and peripheral neuropathy during her treatment but recovered to feeling as good as she had several years prior to her diagnosis. She returned to work for 34 months and then began to feel progressively more tired and unable to perform her usual activities. She went back to her treating physician and had repeat scans that showed evidence of DLBCL relapse. Her physician referred her to a center more than 250 miles away to consider ASCT. She connected Wilma with a social worker who aided in garnering state-based insurance for cancer patients. A patient navigator at the center coordinated visits and recommended places for Wilma and her caregiver to stay around the center for the period immediately following ASCT. She now returns to see you 2.5 years after ASCT feeling well. |
HLA, human leukocyte antigen; RICE, rituximab, ifosfamide, carboplatin, etoposide.