Dr. Javier Munoz, the director of the Mayo Clinic’s Lymphoma program in Phoenix, has recently conducted an interview with Kristie Kahl, the Vice President of content for the Cancer Network. The discussion centered on updates for current therapies for relapsed and refractory follicular lymphoma.
Relapses
Dr. Munoz explains that the majority of patients relapse. Therapies are palliative, not curative, meaning relapse is inevitable.
Those with stage 1 disease do often have long-term remissions, typically following radiation therapy. These can be such long periods of remission than some consider these individuals cured.
Another potential for a cure is allogenic stem cell transplants. That said, it comes with high risks.
Further, CAR T-cells were just recently FDA approved. However, due to its recent approval, more time is needed to understand how long-term remissions from this therapy may last. CAR T-cells are specifically approved for individuals who have already been given at least two lines of a systemic therapy.
Prognosis
Of course, relapse influences prognosis. The faster a relapse, the worse the prognosis. The longer the time to relapse, the better the prognosis. This has been demonstrated in a study by Dr. Carla Casulo which showed that relapse within 2 years of diagnosis is correlated with a poorer outcome.
However, Dr. Munoz explains that the type of treatment also matters.
In the RELEVANCE Trial, published in the New England Journal of Medicine, the three year progression free survival rate for rituximab with lenalidomide was 77%. For rituximab with chemotherapy, it was 78%.
Treatment Options
Dr. Munoz emphasizes that different treatments will work best for different patients. Thankfully, there is more than one treatment option. Second-line therapy options include lenalidomide and obinutuzumab, tazemetostat, and lenalidomide and rituximab.
Chemotherapy options include rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) and rituximab, cyclophosphamide, vincristine, prednisone (R-CVP). Dr. Munoz says that personally, he avoids the chemotherapy options except when it is suspected that the condition is transforming to diffuse large B-cell lymphoma.
Finally, there are P13 kinase inhibitors. These include copanlisib, idelalisib, as well as duvelisib. Patients receiving one of these therapies should have already been given two lines of a systemic therapy.
Umbralisib was just recently approved by the FDA for those who have had at least three other therapies prior.
Ultimately, Dr. Munoz explains that the plethora of treatment options, and the continuing development in new therapies, brings hope for this patient population. You can read more from this interview here.
