Dr Lunning on Treatment Considerations for Relapsed/Refractory Follicular Lymphoma

Matthew Lunning, DO, FACP, assistant vice chancellor, Clinical Research, associate vice chair, Research, Department of Internal Medicine, associate professor, Division of Oncology & Hematology, University of Nebraska Medical Center, discusses considerations for community oncologists who treat patients with relapsed/refractory follicular lymphoma (FL).

Community oncologists are familiar with using lenalidomide (Revlimid) plus rituximab (Rituxan) in patients with relapsed/refractory FL, Lunning says. The creatinine clearance levels of individual patients may determine the optimal dosing of this regimen, and dose reductions should be considered when necessary, Lunning notes. For instance, the optimal dose of lenalidomide in patients with creatinine clearance levels of less than 60 mL/min may fall from 20 mg to 10 mg, Lunning explains. The goal is for patients to derive the most benefit from lenalidomide plus rituximab for the longest amount of time, Lunning emphasizes. As lenalidomide is an inherently potent agent, patients should receive it at tolerable doses, according to Lunning.

Treatment decisions in the third line and beyond are influenced by the agents administered to patients in the first and second lines, Lunning notes. Importantly, several therapies currently under investigation in the second line may guide treatment sequencing in the future, Lunning says. For example, the EZH2 inhibitor tazemetostat (Tazverik) is currently FDA approved for patients with relapsed/refractory FL who have received 2 or more prior lines of systemic therapy. Tazemetostat appears to stabilize disease, and research aiming to move this agent earlier in the treatment sequence may also evaluate whether patients need to display an EZH2 mutation to benefit from this therapy, Lunning explains.

Mosunetuzumab-axgb (Lunsumio), a bispecific CD3- and CD20-directed T-cell engager, is also FDA approved in the third-line setting for patients with FL. Although oncologists should monitor this drug’s high levels of activity in patients with FL, mosunetuzumab is associated with low rates of cytokine release syndrome and neurologic adverse effects, according to Lunning. In the future, this agent may be used in the second- and first-line settings in patients with FL, Lunning concludes.