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Selecting Therapy for Relapsed/Refractory MCL

Insights From: Bijal D. Shah, MD, H. Lee Moffitt Cancer Center & Research Institute; Lauren C. Pinter-Brown, MD, UCI Health; Eduardo Sotomayor, MD, GW Cancer Center
Published: Tuesday, Jan 29, 2019



Transcript:

Lauren C. Pinter-Brown, MD:
The difference between the prognosis for newly diagnosed and relapsed/ refractory patients is such a moving target to me because obviously our patients live much longer than we anticipated 8 or 10 years ago. And with the advent of more and more new agents, we can see already that the outlook for somebody with their first relapse is much better than it used to be.

Eduardo Sotomayor, MD: In terms of symptomatic versus asymptomatic relapse, it depends on several factors. So if a 75-year-old patient, retired in Florida, is playing golf every day, and then during a routine CT [computed tomography] scan, they found that he has 1 lymph node in the axillary area, I’m probably going to do radiation in that area. Of course, I do all the restaging, all the studies, and if I find only 1 site, I will just do radiation oncology. And then I say, “Go out, play golf, I will see you in 2 or 3 months,” with close follow-up.

If it’s a symptomatic relapse, it depends on how many and what type of symptoms the patient has. And if the patient has relapsed, nonbulky disease but has a good performance status and is enjoying life, in some patients, I might do watchful waiting again. So it depends also on what type of response I got.

So let’s say I treat a patient with my chemotherapy induction and then put them on maintenance and then the patient relapsed, but he had a very good 2 or 3 or 4 years. If he relapses with a little amount of disease, I am not in a hurry to treat that patient. Now there are multiple clinical trials, and of course our first recommendation was “Let’s try to find a clinical trial in which you may fit.” And those clinical trials could be a combination with novel targeted agents or nonconventional chemotherapy agents that can be safely used in this elderly patient population.

In terms of the geriatric assessment, I think it’s extremely important in mantle cell lymphoma in particular because we just said that this is a disease that affects the elderly population. And probably in most of these patients, although we would like to cure them, we are not there yet. Therefore, the first question that we need to ask is, What is the goal of my treatment? And my goal of the treatment is to control the disease but with a good quality of life. So then we need tools like the geriatric assessment and other tools that are going to tell us, “Yes, I am inducing a great response with my treatment but also keeping a good quality of life on these patients.” So it’s very, very important to keep that in mind when we make a decision in terms of treatment of mantle cell lymphoma.

So what I tell my patients—and most of them are elderly—is I wish I could cure mantle cell lymphoma, but if I cannot, I want to make sure that your disease becomes chronic to the point that you will live longer, and then you are going to be able to see the new therapies that are coming at a very rapid pace. And as we are going to discuss, now we have not only 1 but up to 3 drugs of the same type, but we are looking at which of these has fewer adverse effects so I can treat my elderly patient better.

Transcript edited for clarity.
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Transcript:

Lauren C. Pinter-Brown, MD:
The difference between the prognosis for newly diagnosed and relapsed/ refractory patients is such a moving target to me because obviously our patients live much longer than we anticipated 8 or 10 years ago. And with the advent of more and more new agents, we can see already that the outlook for somebody with their first relapse is much better than it used to be.

Eduardo Sotomayor, MD: In terms of symptomatic versus asymptomatic relapse, it depends on several factors. So if a 75-year-old patient, retired in Florida, is playing golf every day, and then during a routine CT [computed tomography] scan, they found that he has 1 lymph node in the axillary area, I’m probably going to do radiation in that area. Of course, I do all the restaging, all the studies, and if I find only 1 site, I will just do radiation oncology. And then I say, “Go out, play golf, I will see you in 2 or 3 months,” with close follow-up.

If it’s a symptomatic relapse, it depends on how many and what type of symptoms the patient has. And if the patient has relapsed, nonbulky disease but has a good performance status and is enjoying life, in some patients, I might do watchful waiting again. So it depends also on what type of response I got.

So let’s say I treat a patient with my chemotherapy induction and then put them on maintenance and then the patient relapsed, but he had a very good 2 or 3 or 4 years. If he relapses with a little amount of disease, I am not in a hurry to treat that patient. Now there are multiple clinical trials, and of course our first recommendation was “Let’s try to find a clinical trial in which you may fit.” And those clinical trials could be a combination with novel targeted agents or nonconventional chemotherapy agents that can be safely used in this elderly patient population.

In terms of the geriatric assessment, I think it’s extremely important in mantle cell lymphoma in particular because we just said that this is a disease that affects the elderly population. And probably in most of these patients, although we would like to cure them, we are not there yet. Therefore, the first question that we need to ask is, What is the goal of my treatment? And my goal of the treatment is to control the disease but with a good quality of life. So then we need tools like the geriatric assessment and other tools that are going to tell us, “Yes, I am inducing a great response with my treatment but also keeping a good quality of life on these patients.” So it’s very, very important to keep that in mind when we make a decision in terms of treatment of mantle cell lymphoma.

So what I tell my patients—and most of them are elderly—is I wish I could cure mantle cell lymphoma, but if I cannot, I want to make sure that your disease becomes chronic to the point that you will live longer, and then you are going to be able to see the new therapies that are coming at a very rapid pace. And as we are going to discuss, now we have not only 1 but up to 3 drugs of the same type, but we are looking at which of these has fewer adverse effects so I can treat my elderly patient better.

Transcript edited for clarity.
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