Insights From: Brad Kahl, MD, Washington University School of Medicine; John P. Leonard, MD, Weill Cornell Medical Center
John P. Leonard, MD: One of the more challenging scenarios in lymphoma treatment is, how do you approach a patient with mantle cell lymphoma who needs induction therapy? There is quite a wide range of induction treatments. For the most part, treatment currently is largely bifurcated—if the patient does need treatment—based on whether or not the patient wants and is appropriate for an aggressive treatment regimen or if the patient either prefers not to have an aggressive regimen or is not a candidate for such. So, in general, many of our trials and much of what we do is focused on is this an elderly patient who’s going to be treated less aggressively, a less fit patient, or is this a patient who is younger and who may want a more aggressive approach. That being said, the lines between those 2 categories are becoming more and more blurred.
So, I would say that in the older patient group, a patient who is not going to get an aggressive treatment regimen, typically those patients are treated with bendamustine- and rituximab-based therapy. And that is a standard induction regimen. That’s better than R-CHOP. Other options would include using CHOP substituting in bortezomib for vincristine. That would be another possibility or R-CHOP substituting in bortezomib for vincristine. But I would say certainly in the United States, bendamustine/rituximab, based on randomized trials, appears to be better than CHOP and better tolerated. So, for the older patient group and for some selected younger patients who are not opting for a more aggressive approach, R-bendamustine is probably the most commonly used regimen outside of a clinical trial.
For the younger patient group who might be candidates for more aggressive treatment, certainly R-bendamustine is also a reasonable treatment option for those patients regardless of what consolidation or maintenance they’re going to get. And I would say in my practice, younger patients frequently opt to get bendamustine/rituximab. That being said, a number of physicians around the country and the world think that patients who are younger with mantle cell should be treated more aggressively, and therefore many of these patients are treated with a combination of CHOP and DHAP, or a version, one way or another, of a more CHOP-like regimen including ara-C. And then those patients may go on to get high-dose chemotherapy and autologous stem cell transplant. Whether or not the transplanted patient is a consolidation is another question that is an important one. But that being said, again, bendamustine/rituximab certainly for the older patients and then the question of younger patients if they’re opting for a more aggressive approach, which would include ara-C, those are really what we’re most commonly doing in the United States and most likely elsewhere around the world as well.
So, in patients with mantle cell who have comorbidities and, for instance, age or renal dysfunction, those are patients who clearly are going to be less appropriate candidates for an intensive treatment option. We may be less likely to give them something like ara-C. That being said, bendamustine/rituximab appears at this point in time to be a reasonable treatment approach for older and more frail patients, patients with renal dysfunction. And in some cases, we need dose reductions but BR is commonly used for those patients as well.