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5-Year Follow-Up Confirms Efficacy of Frontline Bendamustine Plus Rituximab in MCL, iNHL

Angelica Welch
Published: Thursday, Jun 15, 2017

Ian W. Flinn, MD, PhD

Ian W. Flinn, MD, PhD

The BRIGHT study compared the safety and efficacy of bendamustine plus rituximab (BR) versus R-CHOP or R-CVP in patients with indolent non-Hodgkin lymphoma (iNHL) and mantle cell lymphoma (MCL).

In the phase III, open-label, non-inferiority study, 447 patients were randomized to receive BR, RCHOP, or R-CVP. The median follow-up was 65 months for BR and 64.1 months for R-CHOP/R-CVP.

5-year updated results of this study were presented at this year’s ASCO annual meeting, with progression-free survival (PFS), event-free survival (EFS), and overall survival (OS) being compared using a stratified long-rank test.

Results for the overall population showed that the 5-year PFS rate was 65.5% (95% CI, 58.5-71.6) for BR versus and 55.8% (95% CI, 48.4-62.5) for R-CHOP/R-CVP. The 5-year OS rate was 81.7% (75.7-86.3) versus 85% (79.3-89.3), respsectively.

The hazard ratio (HR) for PFS was 0.61 (95% CI, 0.45-0.85; P = .0025), HR for EFS was 0.63 (95% CI, 0.46-0.84; P = .0020), and HR for OS was 1.15 (0.72-1.84; P = .5461), comparing BR vs R-CHOP/R-CVP.

Although similar results were found in iNHL and MCL, the stronger effect was observed in patients with MCL. In patients with MCL, BR reduced the risk of progression or death by 60% (HR, 0.40; 95% CI, 0.21-0.75; P= .0035), whereas in patients with iNHL, the reduction was 30% (HR, 0.70; 95% CI, 0.49-1.01; P = .0582)

In an interview with OncLive, lead author Ian W. Flinn, MD, PhD, director, Blood Cancer Research Program, principal investigator, Sarah Cannon Research Institute, discussed the 5-year update of the BRIGHT study.

OncLive: Please provide an overview of this follow-up analysis.

Flinn: The BRIGHT trial is a randomized phase III trial in patients with previously untreated low-grade lymphoma and MCL. It was a study that starting in 2009 and it is a randomized trial comparing BR to R-CHOP or R-CVP. The basic design of the study was once patients were deemed eligible, their treating physician chose a standard chemotherapy for R-CHOP or R-CVP. And then they were randomized…to receive that standard chemotherapy or BR. 

What has been observed 5 years later?

Our study was initially designed to be a noninferiority trial so, the primary endpoint of the trial was complete remission rate, which was judged by an independent review committee. In 2014, we published that it was noninferior; the complete remission rate was 31% with BR versus 25% for the standard chemotherapy. That clearly met the noninferiority endpoint of the trial. During this year's ASCO, we updated those results for the event-free survival and the time to event analysis such as OS and PFS and duration of response.

These results showed that it’s very consistent that there was superiority to BR in regards to PFS, EFS and duration of response. But, we did not see a difference in OS between the 2 arms, which looked very similar. 

There were some unexpected results—it looked like there was increase in second malignancies in patients treated with BR. When we dove down into that in more detail, we found that a lot of these second malignancies were actually skin cancer, such as squamous cell carcinoma of the skin and basal cell carcinoma of the skin. So, when you excluded those, it was really just progression of the underlying disease. We found that while that it is no longer statistically significant, there was still, numerically, an increase in the number of malignancies that we need to understand. 

What does this update mean for the treatment landscape?

I think that BR in the last 5 years has become the standard frontline therapy for many patients in the United States. It is interesting to talk to people around the world, as they do not always necessarily share our perspective. There are regional variations of whether BR, R-CHOP, or R-CVP is used, but in the United States, I think it'll remain BR.

This data confirmed many previous thoughts toward this regimen, especially if you did not like R-CHOP or R-CVP. So, I think this regimen is here to stay for a while.

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