Insights From:Bruce D. Cheson, MD, FACP, FAAAS, Georgetown University Hospital; Shuo Ma, MD, PhD, Northwestern University Feinberg School of Medicine; Richard R. Furman, MD, Weill Cornell Medical College
Shuo Ma, MD, PhD: Most follicular lymphoma patients after first-line treatment can achieve good remission, and those patients can be, again, going through the "watch and wait" stage. Upon detection of early progression, the treatment indication is pretty similar to the first-line treatment, meaning that you can still watch and wait for patients who are having asymptomatic disease and only consider treatment if patients are developing symptomatic or bulky disease that's causing impending organ compromise. However, the one exception is that if you're noticing a patient who is having rapid progression of disease. Even if they have not developed bulky disease, you may want to consider early treatment. So, that's the timing of the treatment.
In terms of considering their options of treatment, I think besides thinking about what the available agents are, the other important thing to consider is how well the patient responded to their first-line treatment, what kind of quality of response they achieved, and how long the treatment response lasted. So, if someone had a very good response, like a complete response that lasted for 4 or 5 years, it's good to consider repeating the same therapy or chemotherapy as their first-line therapy. So that's one option. But there are also a lot of emerging options, novel treatment options, for relapsed follicular lymphoma.
Bruce D. Cheson, MD: The treatment of patients with relapsed or refractory follicular lymphoma depends on a number of factors. Number one, what was their initial treatment? If they had R-bendamustine up front, I'm unlikely to use it again. If they had R-CHOP up front, you can't give it again, but you might consider R-bendamustine.
There are a number of factors I take into consideration in the decision as to what to offer patients with relapsed or refractory follicular lymphoma. The first of these is, what did they receive as their initial treatment and what was the quality of the response to that therapy? There is a distinction between relapsed and refractory disease. Refractory disease suggests that the patient got less than a partial response, or got a response but it lasted less than six months. That's the operative definition that we currently use.
If a patient had, for example, bendamustine/rituximab and relapsed three or four years later, you could theoretically use it again. You can't use R-CHOP again. If the patient had R-CHOP, you could salvage them with R-bendamustine. If they started with R-bendamustine, there are no data on the efficacy of R-CHOP in that context.
But things are completely changing. Now, with the availability of some of these novel drugs, the best choice for relapsed or refractory patients is unequivocally a clinical trial. That will get these new drugs to market. That will test combinations of these new drugs. In the absence of an available clinical trial, idelalisib has become a very common drug that I prescribe for patients with relapsed or refractory follicular lymphoma.
Richard R. Furman, MD: Often our patients will have very good responses to one therapy, and a very important question that arises is whether or not we can use that therapy again. The most important factor in deciding whether or not a therapy is worth being used again is really going to be the response duration. And if a patient has a sufficient duration of response, then it certainly is a viable option to use that therapy again. It's also important to add to that consideration of the toxicities associated with these agents because using the same agent a second time does allow the patient to be exposed to overlapping toxicities a second time.
Transcript Edited for Clarity