Insight to the factors that help select optimal third-line treatment for patients with follicular lymphoma in the context of available novel therapies.
Lori Leslie, MD: In a relatively young patient who’s fit, who’s had relatively short remissions following chemoimmunotherapy, and who’s had 2 prior lines of therapy, my favorite approach is to offer CD19 CAR [chimeric antigen receptor] T-cell therapy. Some of the features that would make me think CAR T-cell therapy would be a good option are the fitness and age of the patient. Because CAR T-cell therapy is a little more intensive, it’s a 1-and-done approach. You get the CAR T-cell infusion, and then assuming the patient responds, they can enjoy a significant period of treatment-free interval. Treatment-free interval is very important for all patients with cancer, but particularly for those with follicular lymphoma because the treatment landscape is changing very rapidly. If you can do an approach like CAR T-cell therapy and get remission for even a few years, as shown on the ZUMA-5 study, then you may even shift into a new landscape, where you can figure out how to use PI3 kinase inhibitors, EZH2 inhibitors, or whatever else is in the pipeline in a more time-limited way.
If this patient came to me and said, “CAR T cells sounds too overwhelming. I just want to take a pill,” then tazemetostat would be a great alternative. Let’s say there’s a patient who was concerned about compliance with an oral pill, liked coming to the infusion room to hang out with the nurses once a week. Copanlisib is also a very good option for this type of patient, but for the reasons stated, I’d offer CAR T-cell therapy.
Anytime a patient with follicular lymphoma is relapsing, it’s always important to do a PET [positron emission tomography] scan and hunt for the transformation. Patients with subsequent lines of therapy have increased risk for developing a transformation to a more aggressive process, most commonly DLBCL [diffuse large B-cell lymphoma]. If there’s any hint of transformation, based on new B symptoms, aggressive growth of a lymph node, or a high SUV [standardized uptake value], I’m quick to do a biopsy to make sure we understand what we’re treating before we talk about relapsed/refractory disease treatment options.
Transcript edited for clarity.