The landscape of malignant hematology continues to evolve rapidly, with emerging therapies and improving survival outcomes reshaping the field. Understanding the complexities of blood cancers and knowing when to refer patients to specialized care teams has become increasingly important for health care providers across all specialties.
Disease spectrum and presentation
Non-Hodgkin's lymphomas (NHL) encompass over 60 distinct subtypes, with diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma representing approximately 60% of all NHL cases. Hematologist Matthew Lunning, DO, emphasizes the complexity and diversity of these conditions, noting their unique ability to manifest throughout the body.
"Lymphoma and our blood cancers are very much like the janitor – they have all the keys to the body,” Dr. Lunning says. “A lot of times it likes to sit in the lymph nodes because that's where its home is, but it can present anywhere – on the skin, in the eyes, in the stomach, in the intestines.”
Advances in treatment
The field has witnessed significant advancement in therapeutic options, particularly in cellular therapies. CAR T-cell therapy has emerged as a groundbreaking treatment modality, with multiple commercial products now available for various hematologic malignancies. Dr. Lunning emphasizes the time-sensitive nature of these interventions: "When you think about CAR T-cell, I always preach that every day matters. CAR T-cells don't grow on trees, and so the faster we can see patients and get them into our system, the sooner we can get the T-cells pulled out and start to manufacture."
Bispecific T-cell engagers (BiTEs) represent another promising frontier. These novel therapeutics, initially developed for blood cancers, are now commercially available for solid tumors as well. Key advantages of BiTEs include:
- The ability to redirect and activate T cells directed at a known specific antigen recognition.
- Immediate access with no manufacturing required.
- Design flexibility to target different tumor antigens.
- A smaller size than regular antibodies, potentially improving tissue penetration.
"We're going to see a tsunami of bispecifics as they are many in development broadly in oncology," Dr. Lunning predicts. "We are right now educating not only our own fellows and colleagues on how to manage the toxicities of this class, but also working with community providers on how we can best support them because they can be very resource-intensive therapies. We’re trying to work on a way to bring access to the community when it’s the right time.”
Future directions
Research continues to advance the field, with particular focus on reducing manufacturing time for cellular therapies and developing "off-the-shelf" immunotherapies. Novel approaches include in vivo CAR T-cell generation through direct viral injection, representing a potential paradigm shift in cellular therapy delivery.
Role of specialized care teams
The complexity of modern hematologic treatments underscores the importance of specialized care. The Fred & Pamela Buffett Cancer Center hematology and oncology team offers several advantages:
- Access to novel diagnostic tests for risk stratification.
- Participation in clinical trials, including early-phase studies.
- Expertise in managing treatment-related complications.
- Coordination with multidisciplinary specialists.
"There are a lot of nuances in the management of lymphoma that we help with," Dr. Lunning says. "There may be new tests that may help risk stratify a patient. We can provide access to clinical trials. And if the treatment can be done at home – gas and hotels are expensive – we will work with a patient’s community oncologist to come up with a treatment plan that potentially can be done locally.”
Personalized treatment planning
Treatment decisions are highly individualized, considering multiple factors:
- Disease stage and presentation.
- Patient comorbidities.
- Treatment intent (curative versus control).
- Genetic and molecular testing results.
- Clinical trial availability.
"Sometimes the intent of the therapy is to cure it," Dr. Lunning explains. "Sometimes the goal is to control it, understanding it was found incidentally, and the patient is asymptomatic. And so sometimes we have discussions about not treating it until it until it’s starting to cause a problem.”
Interdisciplinary collaboration
Effective management of hematologic malignancies requires close collaboration among various specialists. This includes:
- Surgeons for optimal biopsies
- Infectious disease specialists for managing immunocompromised patients
- Primary care physicians for managing comorbidities.
Primary care physicians play a crucial role in both early recognition of disease and long-term monitoring. Understanding the intent of therapy – whether curative or controlling – helps guide appropriate follow-up care.
Dr. Lunning emphasizes that a cancer diagnosis often presents an opportunity to address other health conditions: "A lot of times patients get a diagnosis of cancer, and that is kind of a gut check for them. A lot of times it's an opportunity to try to improve upon the health of the whole person."
Optimizing outcomes
The field of malignant hematology continues to advance rapidly, with new therapeutic options offering improved outcomes for patients. Early recognition and referral to specialized care teams is crucial in optimizing patient care.
“The journey starts when we meet the patient, so the sooner that happens, the better,” Dr. Lunning says. “Even if it's not time for their CAR T-cell, at least gets them into the system, and if it becomes time, then we can move as quickly as possible.”
To refer a patient to the hematology and oncology team, call 402.559.5600. If you would like to meet with a member of our team, please email physicianoutreach@nebraskamed.com.