How does risk stratification affect treatment decisions for newly diagnosed DLBCL?

How does risk stratification affect treatment decisions for newly diagnosed DLBCL?

Even though we call this one disease DLBCL, really there are kind of subversions of it. There are higher risk and lower risk versions of it. Some people have such a high risk version that we have to give them more aggressive therapy than just the plain old R-CHOP. Some people have such low risk versions that instead of curing 60% of them, on average, we may be curing 80–90% of them on average.

So this risk stratification thing is not always a detailed discussion between the doctor and the patient, but the doctors are always doing some work towards it. So if patients have more questions about it, they may have to ask, hey, is my DLBCL average risk or high risk or low risk? It’s okay to ask.

And there are a few parts of risk stratification to say who’s high risk, who’s low risk, that are evolving quickly—actually, things that we do, fancy tests that we do now that we were not doing ten years ago. Some of the most important, kind of tried and true parts of risk stratification are that some patients with DLBCL, those lymphoma cells, have an excess amount of certain bad cancer proteins.

Two of them, you might hear your doctor mention—these are called MYC and BCL-2. BCL-2 is a cancer protein, but you can hear in the name it stands for B-cell lymphoma number two. These names aren’t that complicated. MYC and BCL-2, if people’s lymphoma tumors have more of those proteins in them, they are probably somewhat higher risk.

And then sometimes we call those patients double expressor lymphoma, a subtype of DLBCL. And they have a little bit higher risk. They might get the same therapies, but maybe we’re not curing as many of them.

And then there’s even a sort of higher, higher risk version of that where patients have super sky-high amounts of the MYC and the BCL-2 in their lymphoma, and they have it because of a different reason—because of the chromosomes translocated in their lymphoma cells. We call those double hit lymphoma. And these are things we do test for pretty routinely, and probably should always be tested for patients with DLBCL.

And certainly, actually, if someone has that highest risk subtype of double hit lymphoma with high, high levels of MYC and BCL-2, we tend to treat those patients differently. They don’t always just get R-CHOP—sometimes they get a more aggressive version of chemotherapy. And that’s a very individualized thing