Follicular Lymphoma: Changes in the Treatment Landscape - Episode 9
Bruce Cheson, MD: In our last few minutes, we have some questions from the audience, some of which I think we got to. Such as, in which patients are we using obinutuzumab in place of rituximab? I think we got to that. The GADOLIN data I think would support it, and perhaps the GALLIUM data; we talked about those. For maintenance therapy in follicular lymphoma, you said you’re not a maintenance fan. And you?
Nathan Fowler, MD: I do use it in select patients, in patients who only achieve a PR. In other words, they’re responding, but we have a little bit of disease left. Maybe 70% of the tumor burden is gone. I often will add an extended maintenance phase. It’s based upon the PRIMA data showing that there was a higher percentage of patients who could actually achieve CR.
Now I also—and there are not a lot of data for this—think that with standard chemoimmunotherapy, there is a group of patients who are at risk for relapsing early. These are the high FLIPI patients who tend to have not the greatest outcomes long term. I sometimes will add rituximab maintenance for a patient who I think is at high risk for early relapse.
Bruce Cheson, MD: Now, what you’re doing with maintenance is you’re trying to clean up failure in resistant patients. That’s essentially what you just said.
Nathan Fowler, MD: Yes.
Bruce Cheson, MD: So, why not switch to a different drug at that point if they get positive PET imaging, if they are still MRD-positive when we get to some assay that everybody agrees upon? Wouldn’t that be the time to switch to something with a different mechanism of action instead of more CD20?
Nathan Fowler, MD: Again, it’s hard to know. I understand the argument. However, we saw even without change in the antibody that there was a higher percentage of patients who will achieve CR. In other words, they were still deriving benefit from an anti-CD20 long term. Again, the counter argument is that the patients who did not achieve a remission in the first 6 cycles are the patients who have clones that are CD20 resistant or have some resistance mechanism to the chemotherapy that you gave. Switching to an alternate therapy would be the right choice.
But it’s not clear, at least in the first-line setting, that those patients have yet declared themselves. I think that, again, there are a group of patients who relapse early and are refractory to the first-line or the second-line. Those patients definitely need novel strategies. This is maybe wishful thinking, but I think that there still may be a group of patients who, with maintenance therapy, you can get in a deep remission and achieve a prolonged disease-free interval.
Bruce Cheson, MD: Next question: How are you treating older patients in the salvage setting?
Anas Younes, MD: It’s a good question. Not all patients are created equal. Some old patients are really fit and play tennis every other day and travel. Those patients, I treat them like anyone else. They get BR [bendamustine and rituximab] if they haven’t been to exposed to it before. The frailer patients usually end up getting single-agent therapy, rituximab, sometimes in combination with lenalidomide, depending on how much they can tolerate that.
Nathan Fowler, MD: I totally agree. I think it also really depends on the length of their last remission. Many times, in patients who are elderly and who have a remission lasting more than 24 months, I’ll just give them CD20 again. And many times, you can really get quite a lot of disease control just by re-expressing CD20s.
Bruce Cheson, MD: And how do you give it again?
Nathan Fowler, MD: I usually give 4 doses, then stop. I don’t usually add maintenance. That’s it.
Bruce Cheson, MD: In the early relapses, we’ve already talked about the national trial and doing what we do in the clinical trials. What’s the role of transplant in the early relapse setting?
Anas Younes, MD: That’s a good question. I don’t know, and again, I don’t think people should start jumping to using transplant as standard of care for these patients.
Bruce Cheson, MD: They should not.
Anas Younes, MD: They should not, outside of the clinical trials, because we don’t know if this will change the outcome. I think if there’s a clinical trial that is looking at the role of the transplant in these patients that will answer a specific question, it’s a great idea. But I don’t think it’s a standard of care just because you failed early on. I’m going to intensify therapy. I’m going to give you more chemotherapy and then a high-dose therapy because I think this will do you better. I think we may be shooting ourselves in the foot.
Bruce Cheson, MD: Do you think this is a setting where CAR T cells may come into play?
Nathan Fowler, MD: Absolutely. I think that, as Anas mentioned, it’s unclear. There are patients who we’ve all seen in practice, who become chemorefractory in short order. And unfortunately, despite the activity in most of these novel agents, most patients, as we talked about, have remission times lasting a year at best. And those patients are still at high risk of dying from their disease. For patients who relapse in short order within the first couple of regimens, novel therapy is really just prolonging remission. It’s not curing anybody. Their CR rates are very, very low.
So, in those patients, I, like Anas, usually look for a trial that includes stem cell transplant because there are fairly decent data from both allogeneic as well as autologous transplant that durable remissions can be obtained with that type of consolidation. In fact, there are data from consortiums, data from using transplant in patients who were refractory to 2 lines of therapy, and the 10-year remission rate’s over 50% in those patients. Again, it was a select group of patients who could tolerate transplant, patients who responded.
Bruce Cheson, MD: And had very little disease.
Nathan Fowler, MD: But I think that in the absence of a novel combination or a clinical trial, it’s just going to change the natural outcome of those patients. I still tend to send them to transplant.
Bruce Cheson, MD: This has been a great discussion. We hope that you found the information to be valuable to your clinical practice, and we welcome your feedback on what we covered here today. Please send your suggestions to OncLiveNN@OncLive.com.
Thank you all for watching the OncLive® News Network® live broadcast from MJH Studios. And my particular thanks to my good buddies here, Anas and Nathan. Have a great day.
Transcript Edited for Clarity