Assessing symptoms is the first step when approaching a patient with newly diagnosed follicular lymphoma, states Brad S. Kahl, MD. Some individuals with follicular lymphoma remain asymptomatic and may be a candidate for a watch-and-wait strategy, where treatment is not needed immediately. Tumor burden is assessed via computerized tomography or positron emission tomography imaging to determine whether to defer or begin treatment.
First-line treatment is typically a combination of bendamustine and rituximab, says Kahl, which is a well-tolerated regimen for most patients. Dose reductions of bendamustine may be needed for older patients who have reduced creatinine clearance, notes Kahl. Two years of maintenance therapy with rituximab is often recommended. Although maintenance therapy can prolong the duration of remission or progression-free survival, it has not been shown to have an impact on overall survival, comments Kahl.
Long-term data are needed to determine whether there is a difference in these regimens in terms of adverse effects, such as secondary myelodysplastic syndromes, acute myeloid leukemia, or disease transformation. Transformation from a low-grade follicular lymphoma to an aggressive lymphoma can be very problematic, says Richard R. Furman, MD.
Newer regimens that avoid chemotherapy, such as combination therapy with lenalidomide and rituximab, afford an opportunity to effectively control the disease for long periods of time without toxicity, comments Furman. If patients progress on lenalidomide and rituximab, there is still an opportunity to manage their disease at that point in time with chemotherapy.