I had tears in my eyes searching through my emails from three years ago. One of my close friends (and brother of my cartoonist bff) had emailed my sister asking for medical advice. What my friend Junior was after, was a second opinion for his father. He said “our family is in panic since we heard the diagnosis… At home, we are all terribly anguished”, to which my sister replied, “call anytime and we’ll try to help – after all, you are part of the family.”
Junior’s father had been diagnosed with follicular lymphoma, the most common form of non-Hodgkin lymphomas, and they were after a treatment. This was Brazil, where not all drugs are readily available. That’s where my sister comes in: she is a doctor and searched around for hematologist colleagues and experimental treatments. My friend however, is the one who did all the legwork. After several doctors and opinions, he got his father Beco the treatment he needed.
Fast-forward to three years later, where Beco and I reminisce and he tells me more about the ordeal. He describes the initial warning signs of the disease: “fever, night sweats, and rashes… I discovered my diagnostics by chance, during a tomography exam to find kidney stones.”
The recommended chemotherapy treatment for non-Hogdkin lymphoma (a form of cancer where B-cells are overactive) is a drug cocktail called CHOP. Each letter in the acronym represents a different drug, which are combined with the goal to attack cancer from multiple fronts (e.g., one drugs blocks DNA while another prevents B-cells from multiplying).
Rituximab is a new drug (an antibody that binds B-cell membrane proteins), which can be coupled with the CHOP regimen. Beco tells me on an email that “the difference of coupling rituximab with CHOP is that it gives the patient three extra years in remission.”
The drug targets CD20 proteins on the membrane of B-cells. We don’t know for sure what function those CD20 protein is performing, but it is believed that it acts as a gate for the passage of calcium ions into B-cells. Researchers have looked into that binding mechanism, in which rituximab binds to its target specifically on amino acids 170-173 and 182-185. To get a snapshot of the drug in action, Du et al. obtained an X-ray image of the crystallized rituximab bound with a piece of CD20. The researchers grabbed a small chunk of the CD20 protein corresponding to amino acids 163 to 187 (represented as the tiny string on the image below).
A panel: Rituximab is represented in yellow and green ribbons. The blue string represents the peptide extracted from CD20. /15073.long B panel shows electron representations, and C panel, a close-up. Image credit: Du et al,
Beco got access to rituximab combined with CHOP, or R-CHOP. He was even able to get a newer generation of drugs, bendamustine. But that’s because my Junior and his family found and signed him in to a clinical trial managed by an American laboratory. “I got into the clinical trial to use rituximab combined with bendamustine, which is a more efficient chemotherapy drug with lighter side effects. The latter is not even available in Brazil – I was lucky!”
Because of his treatment, Beco tells “Since my son found the clinical trial I participated in, the lymphoma is under control. I’m still being treated with rituximab every two months for another year.” And a similar outcome is what we would like to see for other Brazilian patients.
Rituximab is available in Brazil, but not listed under the universal healthcare system. That means that lymphoma patients are treated with CHOP, but not R-CHOP, which increases their lifespan. “It is not a matter of cost, because those patients and the system will spend more money in extra chemotherapy drugs, and will die earlier.”
A Brazilian non-profit organization, Abrale, used a petition to collect signatures of rituximab supporters. The Brazilian ministry of health asked for at least 50.000 signatures to consider adding the drug to the universal health care system. As of the past few weeks, the petition gathered 61.000 signatures.
Beco is now in remission for the past three years. “We hope it stays quiet for a little longer”. And now, it may as well stay quiet for many more Brazilian patients.