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Follicular Lymphoma: Overview of Treatment Options

Panelists:Bruce Cheson, MD, Georgetown Lombardi Comprehensive Cancer Center; Nathan Fowler, MD, The University of Texas MD Anderson Cancer Center; Anas Younes, MD, Memorial Sloan Kettering Cancer Center
Published: Sunday, Oct 22, 2017



Transcript:

Bruce Cheson, MD: We are fortunate in having an increasing number of new treatment options for our patients. One of them is a spin off an old option, and that is the new subcutaneous rituximab. We’ve been using vitamin R [rituximab] for almost 2 decades now, and now we have the opportunity, instead of the 6 hours down to 90-minute regimen, to do 6 hours down to 10 minutes. Are you ready to adopt that for your patients?

Anas Younes, MD: We have already adopted this for our patients at Memorial Sloan Kettering. We started treating patients with it this week or last week. So, I think it’s a great advancement from a practical point of view. The science is still the same. The outcome is still the same. But for the patient, and I think for hospitals and clinics, it cuts down on the time required for giving treatment significantly. I think it’s a major improvement.

Bruce Cheson, MD: But what I’ve heard is that for us and the patients, that’s great, but in the community, perhaps keeping patients in the chair longer is financially more beneficial. Is that something you’ve heard?

Nathan Fowler: I do know that, or I’ve heard that, reimbursement can be related to infusion times. I think it’s hard to know how this is going to play out. There has been a shift in private practice to move infusion centers to community hospitals. So, I think local doctors are no longer operating their own infusion centers. I’m not sure how that’s going to affect the uptake of subcutaneous rituximab, but I’m sure we’ll see things play out.

Bruce Cheson, MD: I think it’s a colossal advance for patients. The studies have shown from doing quality of life measures that patients just love it.

Nathan Fowler: Yes, I agree.

Bruce Cheson, MD: How is this going to be impacted by the biosimilar rituximabs that are coming out?

Nathan Fowler: As you mentioned, there are several generic rituximab biosimilars that will be entering into the market in the United States, probably within the next 1 to 2 years. Again, this is pure speculation, but I think that subcutaneous Rituxan [rituximab] or other nongeneric rituximabs will have to adjust their price point. Because, if it’s easier for patients and it is significantly less expensive, I can’t see why you’re not going to see a shift in usage towards generic products.

Bruce Cheson, MD: Yes, there’s a lot of jockeying for costs going on right now. They’re moving into this arena.

Nathan Fowler: With the subcutaneous rituximab, there are so many of the new, or novel, combinations that use rituximab as a partner. I’m wondering, as folks who do clinical research, how do you see subcutaneous rituximab compared to infusion rituximab as a combination with novel agents? What I’m thinking about, obviously, is a drug called lenalidomide. There are not a lot of data on subcutaneous rituximab with lenalidomide. If lenalidomide becomes a standard, is this something that people will potentially use in combination with lenalidomide?

Bruce Cheson, MD: It would make life easier for a lot of people, yes, but there are other new drugs out there. The FDA granted accelerate approval for copanlisib, Aliqopa, for patients with relapsed follicular lymphoma. What do we have in that arena now, for third-line therapy for follicular lymphoma?

Anas Younes, MD: If you look at drugs that are approved, there is really not much for that space with the exception of the oral PI3 kinase inhibitor idelalisib, which was approved almost with a similar indication. So, patients get R-bendamustine then R-CHOP [cyclophosphamide, doxorubicin, vincristine, prednisolone], or the other way around, and after that there was only 1 agent before this was approved—which was, as you mentioned, idelalisib—and now copanlisib is approved. People tend to use lenalidomide plus/minus rituximab off-label, but by the NCCN guidelines. But once you use these agents, there’s really not much outside of clinical research that we use. So, I think the addition of copanlisib is a major option that will be offered to patients who are unwilling to participate in clinical trials or who don’t have the option to participate in clinical trials.

Bruce Cheson, MD: I’m going to make you smile. You forgot Y-90 ibritumomab tiuxetan.

Anas Younes, MD: I know, I did not forget them. That is true. There are 2 single agents—for those who are not old enough to remember them—Bexxar [tositumomab] and Zevalin [ibritumomab tiuxetan], the radioimmunotherapy conjugate. Unfortunately, despite their high response rates, they’re not used widely anymore because of issues related to administration, toxicity, etc. They’re good drugs, and they’re not used chronically. They’re just a one-shot deal.

Bruce Cheson, MD: They’re 1-day day agents, and you’re done.

Anas Younes, MD: Yes, you’re done, but they just vanished.

Transcript Edited for Clarity 
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Transcript:

Bruce Cheson, MD: We are fortunate in having an increasing number of new treatment options for our patients. One of them is a spin off an old option, and that is the new subcutaneous rituximab. We’ve been using vitamin R [rituximab] for almost 2 decades now, and now we have the opportunity, instead of the 6 hours down to 90-minute regimen, to do 6 hours down to 10 minutes. Are you ready to adopt that for your patients?

Anas Younes, MD: We have already adopted this for our patients at Memorial Sloan Kettering. We started treating patients with it this week or last week. So, I think it’s a great advancement from a practical point of view. The science is still the same. The outcome is still the same. But for the patient, and I think for hospitals and clinics, it cuts down on the time required for giving treatment significantly. I think it’s a major improvement.

Bruce Cheson, MD: But what I’ve heard is that for us and the patients, that’s great, but in the community, perhaps keeping patients in the chair longer is financially more beneficial. Is that something you’ve heard?

Nathan Fowler: I do know that, or I’ve heard that, reimbursement can be related to infusion times. I think it’s hard to know how this is going to play out. There has been a shift in private practice to move infusion centers to community hospitals. So, I think local doctors are no longer operating their own infusion centers. I’m not sure how that’s going to affect the uptake of subcutaneous rituximab, but I’m sure we’ll see things play out.

Bruce Cheson, MD: I think it’s a colossal advance for patients. The studies have shown from doing quality of life measures that patients just love it.

Nathan Fowler: Yes, I agree.

Bruce Cheson, MD: How is this going to be impacted by the biosimilar rituximabs that are coming out?

Nathan Fowler: As you mentioned, there are several generic rituximab biosimilars that will be entering into the market in the United States, probably within the next 1 to 2 years. Again, this is pure speculation, but I think that subcutaneous Rituxan [rituximab] or other nongeneric rituximabs will have to adjust their price point. Because, if it’s easier for patients and it is significantly less expensive, I can’t see why you’re not going to see a shift in usage towards generic products.

Bruce Cheson, MD: Yes, there’s a lot of jockeying for costs going on right now. They’re moving into this arena.

Nathan Fowler: With the subcutaneous rituximab, there are so many of the new, or novel, combinations that use rituximab as a partner. I’m wondering, as folks who do clinical research, how do you see subcutaneous rituximab compared to infusion rituximab as a combination with novel agents? What I’m thinking about, obviously, is a drug called lenalidomide. There are not a lot of data on subcutaneous rituximab with lenalidomide. If lenalidomide becomes a standard, is this something that people will potentially use in combination with lenalidomide?

Bruce Cheson, MD: It would make life easier for a lot of people, yes, but there are other new drugs out there. The FDA granted accelerate approval for copanlisib, Aliqopa, for patients with relapsed follicular lymphoma. What do we have in that arena now, for third-line therapy for follicular lymphoma?

Anas Younes, MD: If you look at drugs that are approved, there is really not much for that space with the exception of the oral PI3 kinase inhibitor idelalisib, which was approved almost with a similar indication. So, patients get R-bendamustine then R-CHOP [cyclophosphamide, doxorubicin, vincristine, prednisolone], or the other way around, and after that there was only 1 agent before this was approved—which was, as you mentioned, idelalisib—and now copanlisib is approved. People tend to use lenalidomide plus/minus rituximab off-label, but by the NCCN guidelines. But once you use these agents, there’s really not much outside of clinical research that we use. So, I think the addition of copanlisib is a major option that will be offered to patients who are unwilling to participate in clinical trials or who don’t have the option to participate in clinical trials.

Bruce Cheson, MD: I’m going to make you smile. You forgot Y-90 ibritumomab tiuxetan.

Anas Younes, MD: I know, I did not forget them. That is true. There are 2 single agents—for those who are not old enough to remember them—Bexxar [tositumomab] and Zevalin [ibritumomab tiuxetan], the radioimmunotherapy conjugate. Unfortunately, despite their high response rates, they’re not used widely anymore because of issues related to administration, toxicity, etc. They’re good drugs, and they’re not used chronically. They’re just a one-shot deal.

Bruce Cheson, MD: They’re 1-day day agents, and you’re done.

Anas Younes, MD: Yes, you’re done, but they just vanished.

Transcript Edited for Clarity 
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