By Beth Gilbert
Dr. Heald presented "Successful Treatment of Cutaneous T-Cell Lymphoma" at the American Academy of Dermatology's Academy '05 here.
"As the number of therapeutic options continues to increase, dermatologists are faced with a number of different treatment options and the decision to pick one over another becomes difficult. Do I take A or B or C or D?"
Dr. Heald recommends that dermatologists should not focus so much on an individual therapy at the initiation of treatment, but on a goal; success is defined by achieving that goal. Doctors need to try to focus with the patient on whether the goal of therapy is to achieve a remission or whether the goal is going to be palliation. Under each of these goals, Dr. Heald says dermatologists have a menu of treatment options.
Remittive vs. palliative options
Instead of looking at all the therapies on each "menu", dermatologists need to realize that they have one group of therapies that is for achieving a remission and one group of therapies that is for palliation.
It is important that dermatologists prioritize these therapies according to the goals of treatment, and "assign" each of these therapies into palliative and remittive type regimens.
Specifically, Dr. Heald says that the success of a remittive therapy regimen is almost completely defined by tumor burden. Remission means that tumor burden has gone to zero.
The success of a palliative therapy regimen is more defined by how much time those involved in the care of the patient (including the patient and other caregivers) spend on the therapy. Quality of life issues and matters of daily care are also considerations in palliative therapy.
"Those are measures of palliation whereas skin scores are measures of tumor burden that would be used for accessing whether a remittive regimen was successful," Dr. Heald tells Dermatology Times.
Dr. Heald discusses two specific examples of remittive and palliative approaches to the treatment of cutaneous T-cell lymphoma.
In general, the remittive therapies tend to be the therapies that are more involved, interrupt the patient's life and have more side effects. The ideal palliative therapies have very few side effects, don't interfere with life and can still give improvement.
"For example, if the goal is remission for a patient with erythrodermic form of the disease, total body red skin, the best chance of getting a remission is going to be to incorporate total skin electron beam into the patient's therapy regimen. If you look at percentages of complete responses with total electron beam, they are higher than with any other therapy we use.
"On the other hand, it makes your hair fall out, there are very few centers in the country that do this and it takes nine weeks to 10 weeks to complete, so this is a persistent interruption in the patient's life," Dr. Heald says.
If the goal is palliation, there are two very good options that can be used. One is oral Targretin (Ligand Pharmaceuticals) therapy that the patient can take at home. Dr. Heald says that this therapy can reliably make the patient feel better by reducing redness and scaliness. The second option is for the patient to go to a center that has photopheresis available. This regimen demands only two half days per month from the patient, and produces only minimal side effects.