Update on Upfront and Maintenance Therapy in Follicular Lymphoma

Los Angeles, California—At the 2019 Great Debates and Updates in Hematologic Malignancies meeting, John P. Leonard, MD, Associate Director, Meyer Cancer Center, Executive Vice Chairman, Weill Department of Medicine, New York, NY, presented an update on upfront and maintenance therapy in follicular lymphoma (FL).

The general framework for initial therapy for FL is to examine the patient and based on staging and symptoms and put them into categories of watch-and-wait or radiotherapy (RT) in the localized disease setting, single-agent rituximab in advanced indolent disease, or combination treatments in patients with more advanced and more symptomatic disease.

“It is not always easy to put a patient into one category or the other and the consequences of under-treating or perhaps over-treating a patient are not quite clear,” explained Dr Leonard.

The initial approach to limited stage FL appears to affect progression-free survival, but the impact on overall survival is unclear.

When explaining his own approach to initial treatment of limited stage FL, Dr Leonard explained that data exists that suggests that selected patients who don’t get radiation can often go 10 years or longer without needing treatment. In some scenarios he will use the watch-and-wait approach with limited stage patients and sometimes RT depending on the size and location. He explained that he generally does not use combined modality therapy for these patients but sees the pros and cons of this approach.

For advanced stage FL, Dr Leonard stated that he uses single agent rituximab both up-front and in the relapsed setting. If he uses single agent rituximab, he will often treat these patients without maintenance. He still uses the watch-and-wait approach with these patients often for at least some time to allow the patients to understand the disease and so that he can get a pace for the disease over time. Lastly, in a minority of patients, he will use chemoimmunotherapy or other emerging combinations if the patient prefers a longer remission and accepts toxicity.

For higher tumor burden, advanced stage FL, Dr Leonard explained that he will use bendamustine plus rituximab induction, which had less toxicity, but similar efficacy to R-CHOP. In cases where there is concern for occult transformation, he will consider R-CHOP. He noted that obinutuzumab and maintenance rituximab are of limited value but are also acceptable treatment options in this setting.

In his final talking point, Dr Leonard shared his approach to following patients in remission. He will tailor follow-up to the risk of relapse for the patients taking into account the extent of prior disease, CR vs PR, and possibility of occult transformation. He recommends periodic history, physical exams, and labs every 4 to 6 months initially, and extending that interval over time, and minimalizing surveillance imaging in asymptomatic patients.—Janelle Bradley