Those suffering from follicular lymphoma have become accustomed to bone marrow biopsies throughout their treatment so that doctors can monitor their responses. However, a new study has shown these processes may not be as integral as former mandates have implied. The study has recently been published in the British Journal of Haematology.
How are bone marrow biopsies used for follicular lymphoma patients?
When follicular lymphoma is first found in someone, bone marrow biopsies are used to analyze the intensity of their disease. At certain intervals during and after treatment additional imaging is performed. If the results show to be negative, these bone marrow biopsies, or BMBs, will be used again to corroborate the findings, according to mandate.
BMB patient experiences
Unfortunately, bone marrow biopsies can be harrowing experiences for patients. The BMBs involve drilling through bone, but some patients claim that it feels more like sawing through them. Although patients often opt for anesthesia resulting in a lack of topical pain, there is a very intense interior pain associated with the procedure. The drilling also results in shaking throughout the body, which can be a very frightening experience for patients.
These accounts are not unusual, with 70% of patients reporting feeling pain and 32% of patients attesting to the pain being intense or severe. Alongside the physical pain, many patients experience anxiety before and during the procedure.
Why wouldn't patients need bone marrow biopsies?
Researchers recently conducted a study on 99 follicular lymphoma patients, spanned across 32 clinical trials done at Weill Cornell Medical College. Their study found that the compulsory bone marrow biopsies only had assessment changes in less than 1% of patients, implying that the biopsies are unnecessary. Their research is now sparking a dialogue of whether bone marrow biopsies being mandatory should be changed.
The study found that bone marrow biopsies did affect response assessments for follicular lymphoma patients with initially positive bone marrow biopsy results who showed complete responses to imaging taken after their treatments, but still had residual lymphoma within the bone marrow. However, not many people were affected in this specific way.
The results and efficacy of the BMBs clearly vary, but it was found that when the disease can be considered to be in complete remission (an assessment that can be done by imaging), then bone marrow disease is likely to respond positively. Also, this analysis would often be under the threshold of detection of a BMB. Therefore, it does not imply that lacking BMBs lessens the strength of the assessment.
Explanation from the author
Author of the study Sarah Rutherford, MD, who is a medical oncologist at New York Presbyterian and Weill Cornell Medicine in New York City, stated that, "In our patient-centered approach to care, we find that these biopsies are painful and anxiety-provoking. The procedures take time, add to healthcare costs, and are a hindrance for patients to participate in clinical trials. In routine clinical practice, we do not often do bone marrow biopsies in follicular lymphoma patients. Removal of this barrier can contribute significantly to increasing patient interest in clinical trials, which can provide them access to novel and promising therapies."
This outlook from the researchers is evolving medical care to no longer force patients to endure intrusive procedures that prove to be minimally effective, leaving room for more significant treatments without fatiguing or demoralizing the patient.
Not only can the procedures be painful, but the cost is also often difficult for patients to afford. According to John Hopkins Hospital, the average cost of a bone marrow biopsy is around $5,400. Not only is spending so much on a procedure expensive to patients in general, but especially so when they are spending so much on what is deemed by many medical professionals as unneeded. As such, it is not surprising that many patients view it as a "waste."
Reinforcing opinions from Dr. Khan
Doctor Rutherford is far from alone in her claims. Nadia Khan, MD, is a lymphoma expert and assistant professor in the Department of Hematology-Oncology at the Fox Chase Cancer Center in Philadelphia and she states, "this study basically confirms what we know about BMB in follicular lymphoma in most scenarios. In the era of PET/CT [positron emission tomography/computed tomography] scans and also in the setting of advanced-stage vs early-stage disease, BMBs may not provide information that is likely to change clinical management."
However, Dr. Khan does concede the importance of having to be aware of whether or not patients who have the stage one or two forms of the disease already have bone marrow involvement, which is not information that can be properly assessed by PET or CT scans. She also stated that those who suffer from follicular lymphoma who have stage one Ann Arbor disease are extremely unlikely to have bone marrow involvement, meaning that a BMB is almost certain to be negative.
Are BMBs useful at all?
While they are being proven to be unnecessary for the majority of patients, BMBs may still hold some value. They can still provide vital data about patients who have advanced diseases who want to track transformation, that would not be visible in other scans.
Follicular lymphoma can be found in the bone marrow, furthering the occasional need for BMBs, because PET/CT scans are not sensitive enough to properly assess this involvement. Therefore, even though they might not be needed, Dr. Rutherford believes that in certain scenarios the practice should not be abandoned. One such scenario would be when a patient has a low blood count.
Dr. Khan also explains when bone marrow biopsies can be important, "a BMB is recommended when there is a clinical suggestion of marrow infiltration. If patients have cytopenias, it is important to determine if there is marrow involvement, and in a patient with prolonged cytopenias who shows partial remission in response to treatment, one needs to understand if the marrow has cleared."
Both Dr. Rutherford and Dr. Khan acknowledge that BMBs can be vital in specific situations, but simply seek to see BMBs diminished when they are short of necessary.
Alleviating BMB side effects
Although BMBs are often unpleasant for patients, there are means to make them better. By reducing the time of the procedure and ensuring that the physician has sufficient experience in administering the biopsy, anxiety and pain can be significantly reduced. Foregoing BMBs when they are not necessary is the best option, but making patients as comfortable as possible when they are is also a step in the right direction.
This study has started a dialogue within the medical community about whether BMBs are truly needed, but it does not stop there. Dr. Rutherford, along with her colleagues, are beginning to look to the next stage of their study, which looks at patients in other centers. If these studies experience further success, it is possible that the BMB requirement may be removed, which would assist many patients. If these requirements are dropped, it is likely that enrollment in lymphoma clinical trials will increase, which can lead to further progress down the road. Dr. Rutherford and Dr. Khan agree that noninvasive testing, when sufficient, is a much better alternative for patients.