Frontline Treatment Approaches to Follicular Lymphoma


Nathan H. Fowler, MD: Patients have many different frontline options. To date, I think there has yet to be definitive evidence that one regimen is better than the other. What I mean by that is there are randomized trials looking at CVP [cyclophosphamide, vincristine and prednisone] versus CHOP [cyclophosphamide, doxorubicin, vincristine, and prednisone] versus fludarabine-containing regimens. It appeared the fludarabine option is more toxic. CHOP had a longer progression-free survival, but if you look at the overall survival of these 3 different regimens in randomized trials, it’s very, very similar.

If you look at randomized studies of bendamustine-rituximab versus R [rituximab]-CHOP, there’s a German trial that suggests there’s significantly longer progression-free survival using bendamustine instead of CHOP. There was another randomized study called the BRIGHT trial where they also looked at R-CHOP, R-CVP versus bendamustine-rituximab, and there appeared to be very similar overall responses and very similar complete remissions. There was maybe a little bit longer progression-free survival with bendamustine-rituximab, but again, no dramatic difference in overall survival. What that tells me is that many of these combinations are very active in patients. The timing of one agent versus the other may not matter as much. What I mean by that is if a patient gets CHOP first followed by bendamustine or vice versa, the long-term outcomes may be very, very similar.

So, when I’m thinking about how to treat a patient, I think all options are on the table. That means explaining to the patient the different side effects of different regimens, talking to the patient about the length of treatment, and talking to the patient about the different studies is important. It’s also important to look at the patient’s comorbid conditions: Clearly, a patient who has preexisting cardiac disease would not receive an anthracycline that is contained in CHOP. Unfortunately, there’s no great answer. In my opinion, there’s not definitive evidence that one regimen is better than the other. They all look efficacious in this type of disease, and the treatment decision should really be individualized to the patient.

Carla Casulo, MD: The subcutaneous form of rituximab is called Hycela. It’s a very exciting development in lymphoma management, because it lowers the time needed to administer rituximab for patients. That’s really important because the first infusion of rituximab typically takes 4 to 6 hours, and depending on the reactions that a patient has, they may need to pause the infusion. Subsequent therapies of rituximab go for 90 minutes. But the nice thing about Hycela, which was recently FDA approved in June, is that in a matter of minutes, 7 to 10 minutes or less, a patient can receive rituximab under their skin. That’s because it has a special molecule in it that permits absorption under the skin.

Patients love it. It lowers their time in the office dramatically. In my opinion, it actually lowers the infusion reaction because there’s no infusion. Patients do, in my experience, have a small area of redness on the skin and a little bit of discomfort, but in a matter of days that completely disappears. For patients who are getting maintenance Rituxan [rituximab] and have to come in often, it’s a life-changing event because they are actually in and out of the office really quickly. The studies have shown that there’s absolutely no difference in survival between subcutaneous Rituxan and IV Rituxan. So, that make it really appealing for everyone, including myself.

Nathan H. Fowler, MD: Recently, we saw an approval by the FDA of biosimilar rituximab, and this could change the market. I do think we are going to see some practices switching to generic rituximab based upon data that really looks very, very similar between the 2. I think that with the rising cost of pharmaceuticals, we’re going to see a lot of people, both in clinical practice and in academics, switching to generic forms of several drugs. We’re seeing several generic versions of drugs emerging in the market. I honestly think it’s just a matter of time before we’ll see practices switching to generic forms of these drugs, especially with randomized phase III trials suggesting that there’s similarity with regard to both primary and secondary outcomes with these drugs.

Transcript Edited for Clarity

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