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Frontline Treatment Regimens in Follicular Lymphoma

Insights From: Alexey V. Danilov, MD, PhD, Oregon Health & Science University; Carla Casulo, MD, University of Rochester, Wilmot Cancer Institute
Published: Friday, Jul 19, 2019



Transcript:

Alexey V. Danilov, MD, PhD:
Chemoimmunotherapy has been the mainstay in the treatment of follicular lymphoma in frontline setting for over a decade now. We have used combination chemotherapy regimens such as R-CHOP [rituximab/cyclophosphamide/doxorubicin/vincristine/prednisone] for a few years. It really still remains the standard of therapy in this disease. Another standard chemoimmunotherapy that we frequently use in this disease is bendamustine/rituximab. The StiL [Study Group Indolent Lymphomas] and BRIGHT trials, which were reported several years ago, demonstrated an improved progression-free survival in bendamustine/rituximab over the R-CHOP combination regimen, as well as a somewhat better tolerability and fewer adverse events with bendamustine/rituximab. The update of the BRIGHT study showing that was just presented a couple of years ago at ASCO [American Society of Clinical Oncology annual meeting] as well. Those regimens, historically, have been used and remain the mainstay of therapy of follicular lymphoma in frontline setting. R-CVP [rituximab/cyclophosphamide/ vincristine/prednisone], which is sort of an abbreviated R-CHOP, is also sometimes used in patients who have comorbidities and will not tolerate Adriamycin.

At this point, I think the choice between R-CHOP and bendamustine/rituximab is often a matter of the personal preference and personal experience of the oncologist. Many would consider those treatments as somewhat equivalent, despite the data presented by the BRIGHT and StiL trials. Many oncologists are very comfortable with R-CHOP. Certainly, there are several factors that speak in favor of R-CHOP, including long-term experience with  R-CHOP in follicular lymphoma and lymphoma in general.

A lot of recent data on the use of bendamustine in relapsed follicular lymphoma indicate it may be associated with opportunistic infection, so R-CHOP still remains a good frontline therapy option. I believe that in the United States, bendamustine/rituximab, because of those 2 trials, has replaced  R-CHOP in many practices. It’s very easy to use, and it’s very easy to adjust the dose. It remains my frontline therapy standard. I would use bendamustine/rituximab for most patients with advanced follicular lymphoma who require therapy. However, I would consider  R-CHOP sometimes in patients where I suspect transformed disease, even if I couldn’t prove it, or patients who have extensive bulky disease with extranodal involvement for whom I remain very worried. Certainly, for patients with grade 3b follicular lymphoma, I would use R-CHOP.

Furthermore, a recent retrospective analysis that we presented at ASH [American Society of Hematology annual meeting] in 2018, led by Brian Hill, MD, PhD, of Cleveland Clinic, actually suggests at least that patients with grade 3a follicular lymphoma may not enjoy quite the same outcomes with bendamustine/rituximab. This is still hypothesis-generating, but that’s another potential area where there may be better use of  R-CHOP over bendamustine/rituximab. However, this is still investigational. I still don’t quite have that answer.


Transcript Edited for Clarity
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Transcript:

Alexey V. Danilov, MD, PhD:
Chemoimmunotherapy has been the mainstay in the treatment of follicular lymphoma in frontline setting for over a decade now. We have used combination chemotherapy regimens such as R-CHOP [rituximab/cyclophosphamide/doxorubicin/vincristine/prednisone] for a few years. It really still remains the standard of therapy in this disease. Another standard chemoimmunotherapy that we frequently use in this disease is bendamustine/rituximab. The StiL [Study Group Indolent Lymphomas] and BRIGHT trials, which were reported several years ago, demonstrated an improved progression-free survival in bendamustine/rituximab over the R-CHOP combination regimen, as well as a somewhat better tolerability and fewer adverse events with bendamustine/rituximab. The update of the BRIGHT study showing that was just presented a couple of years ago at ASCO [American Society of Clinical Oncology annual meeting] as well. Those regimens, historically, have been used and remain the mainstay of therapy of follicular lymphoma in frontline setting. R-CVP [rituximab/cyclophosphamide/ vincristine/prednisone], which is sort of an abbreviated R-CHOP, is also sometimes used in patients who have comorbidities and will not tolerate Adriamycin.

At this point, I think the choice between R-CHOP and bendamustine/rituximab is often a matter of the personal preference and personal experience of the oncologist. Many would consider those treatments as somewhat equivalent, despite the data presented by the BRIGHT and StiL trials. Many oncologists are very comfortable with R-CHOP. Certainly, there are several factors that speak in favor of R-CHOP, including long-term experience with  R-CHOP in follicular lymphoma and lymphoma in general.

A lot of recent data on the use of bendamustine in relapsed follicular lymphoma indicate it may be associated with opportunistic infection, so R-CHOP still remains a good frontline therapy option. I believe that in the United States, bendamustine/rituximab, because of those 2 trials, has replaced  R-CHOP in many practices. It’s very easy to use, and it’s very easy to adjust the dose. It remains my frontline therapy standard. I would use bendamustine/rituximab for most patients with advanced follicular lymphoma who require therapy. However, I would consider  R-CHOP sometimes in patients where I suspect transformed disease, even if I couldn’t prove it, or patients who have extensive bulky disease with extranodal involvement for whom I remain very worried. Certainly, for patients with grade 3b follicular lymphoma, I would use R-CHOP.

Furthermore, a recent retrospective analysis that we presented at ASH [American Society of Hematology annual meeting] in 2018, led by Brian Hill, MD, PhD, of Cleveland Clinic, actually suggests at least that patients with grade 3a follicular lymphoma may not enjoy quite the same outcomes with bendamustine/rituximab. This is still hypothesis-generating, but that’s another potential area where there may be better use of  R-CHOP over bendamustine/rituximab. However, this is still investigational. I still don’t quite have that answer.


Transcript Edited for Clarity
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