80. When is chemotherapy necessary for mast cell disease?
- For mastocytosis patients, chemotherapy is used for patients with systemic mastocytosis in whom the disease is malignant (aggressive systemic mastocytosis or mast cell leukemia) or seems to be progressing towards a cancerous form of the disease (smoldering systemic mastocytosis). There are very clear cut guidelines for this. Interferon and chemotherapy are used when a patient has smoldering mastocytosis with increasing mast cell counts; aggressive systemic mastocytosis; or mast cell leukemia, in order to kill off mast cells to slow disease progression and extend a patient’s lifespan.
- A patient who already meets the criteria for systemic mastocytosis, who has two or more B findings, is considered to have smoldering systemic mastocytosis. SSM is a transition state between indolent SM, which has a normal lifespan, and malignant forms of mast cell disease, including ASM and MCL.
- Having two or more of the following gets you a diagnosis of SSM: mast cell aggregates that take up 30% or more of cells in a bone marrow biopsy, and/or serum tryptase over 200 ng/mL; bone marrow with too many cells in it overall, without evidence of MDS or a myeloproliferative neoplastic disease; or organ swelling that has not yet affected organ function (swelling of the liver without ascites, spleen swelling enough that it can felt by palpation, lymph nodes swollen to 2 cm or larger).
- Patients with SSM are watched to see if their body is making lots of mast cells quickly, or if their organs are feeling the strain of too many mast cells. One of the way they check this is to see how quickly their tryptase level increases. If their provider feels that their disease is progressing, they receive chemo or interferon to try and knock the disease down enough that they don’t reach the criteria for ASM.
- Patients are diagnosed with ASM if they meet the criteria for SM and any of the following criteria: the body not making enough blood cells, cytopenia (absolute neutrophil count below 1000/ul, hemoglobin below 10g/dl, or platelets below 100000/ul); swelling of the liver along with free fluid in the abdomen (ascites), elevated liver enzymes, or portal hypertension; swelling of the spleen along with decreased blood cells due to damage in the spleen, excessive production of blood cells by the bone marrow to compensate, and likely resolution if the spleen is removed; malabsorption in the GI tract causing low protein in the blood (albumin) and weight loss; and severe bone dysfunction, causing a series of bone breaks and large osteolytic lesions from mastocytosis.
- ASM patients are put on chemotherapy or interferon, usually continuously, unless there is evidence that they have killed off enough mast cells to have a less dangerous disease category.
- Mast cell leukemia patients are on chemotherapy continuously.
- There is no described use for chemo in cutaneous mastocytosis.
- There are situations where patients with other disease categories (ISM, MMAS, MCAS) are put on chemo drugs to try and manage symptoms or shock episodes after all other therapies have failed. While this has been mentioned in literature, there have been no studies on it.
- Chemo drugs should be used as a last resort. They can have significant side effects and complications that cannot always be remedied by stopping the treatment.
- Please note that while newer, targeted chemos have become more common, they are in fact chemotherapy and carry significant risks despite being more tailored, including the potential for organ damage or failure.
For additional reading, please visit the following posts:
The Provider Primer Series: Diagnosis and natural history of systemic mastocytosis (ISM, SSM, ASM)
The Provider Primer Series: Natural history of SM-AHD, MCL, MCS
The Provider Primer Series: Mast cell activation syndrome (MCAS)
Whether or not SM is cancer is, by far, the question I get asked the most. Because I get asked so often, I have done a lot of digging on this topic in the last few months. Here’s what I found.
On the surface, from a biological point of view, SM looks like cancer. It is characterized by excessive, improper cell growth. It can cause organ infiltration and damage. Over 90% of patients have a mutation in the CKIT gene, which is a proto-oncogene. A proto-oncogene is a gene that becomes an oncogene when mutated. An oncogene is a gene that contributes to cancer. CKIT mutations can lead to gastrointestinal stromal tumors (GIST), melanoma, acute myeloid leukemia and, of course, mast cell disease. So if SM has unregulated cell growth and a mutation in a proto-oncogene, that makes it cancer, right?
The World Health Organization (WHO), an organization I generally consider to know what they are doing, says it doesn’t. To find out exactly why, I talked to a pathologist familiar with mast cell disease. This is what she said:
“All cancers are neoplasms, but not all neoplastic cells are cancerous. It is cancerous when the cells grow out of control. In mastocytosis, even if you do nothing (meaning take no medications designed to kill off the mast cells), most of the time, the prognosis is very good because the cells are not growing that much. Not like a cancer. The other thing is when the cells invade other organs and the bloodstream and damage the organs. When it is widespread and damaging, it is malignant.”
The majority of people with systemic mastocytosis have indolent disease, for which the life expectancy is normal, usually without any kind of therapy to kill off mast cells. So if we follow the guidelines laid out above, SM is not cancer. It is a myeloproliferative neoplasm (MPN.)
I know some people with ASM identify as having cancer. ASM has a lot more features we typically associate with cancer, so I think that’s fine. And MCL, obviously, is leukemia.
There is some terminology that gets thrown around incorrectly and I think it scares people who don’t understand that the wrong terms are being used. One of them is chemo. People with more aggressive types of mast cell disease may need chemo drugs. People sometimes use the term incorrectly to reference more common treatments. If you’re a rookie, I can see how you might get scared thinking that lots of people with indolent disease are on chemo.
Another term is compassionate use. Compassionate use is the use of an experimental drug outside of a clinical trial. It is generally allowed only when the person has no other treatment options and is gravely ill. I have seen some people use it when discussing patient assistance programs, in which a pharmaceutical company will distribute a drug to a patient at a significant discount or at no cost. They are not the same thing.
In the last few months, I have noticed that some people with SM will tell people that they have a “rare kind of leukemia.” This is not accurate. With the obvious exception of MCL, mast cell disease is not leukemia. SM is a blood disorder.
I think that part of why some people with mast cell disease say they have leukemia is because they want the sort of empathy given to cancer patients. I understand that. I wrote a whole post about how I hate when people say, “At least it’s not cancer.” But it’s important to remember that cancer has two entities: the medical, biological aspect of the disease, and the social construct. When you have ISM and you tell someone you have leukemia, their first thought is that you could die from it. Mast cell disease is scary enough with scaring everyone around you extra with misinformation.
I know that it’s frustrating that people know what cancer is and they probably don’t know what mast cell disease is. And to be clear, I’m not talking about an offhand comment you make to some stranger asking you why you have a port at the grocery store to get them to go away. I’m talking about the people who are actually in your life. (I’m also obviously not referring to the SM-AHNMD people, who may very well have leukemia in addition to SM.) If our mission is to educate people, stuff like this matters. The words we use matter. A lot.
I’m aware that this post is probably going to make some people angry, and that’s fine. You can feel however you want to feel. But I’m getting enough questions about this from people who are really worried, so I feel it’s important to set the record straight.