MCL Treatment Associated With Adverse Events, High Costs

What Patients Should Know About Mantle Cell Lymphoma Treatment

A study of nearly 400 patients with mantle cell lymphoma (MCL) found that hypertension, anemia and infection were the most common medical problems associated with treatment, while liver damage, stroke and renal failure were the most expensive.

The retrospective study, which used data from the Optum Research Database and the Social Security Administration, also found that the most common MCL treatments were the combination of the chemotherapy drug bendamustine and the antibody therapy rituximab (Rituxan) and rituximab by itself.

“This study shows that AEs (adverse events) are common during treatment and expensive,” the authors wrote in the February issue of Anticancer Research. “Therefore, as new treatments and combinations are being developed and recommended, there must also be focus on management of AEs to achieve the best outcomes for patients.”

The data was for patients enrolled in Medicare Advantage plans with multiple claims for MCL, with their initial claim submitted between July 2012 and May 2017. On average, patients started therapy 72 days after diagnosis. Nearly all (95%) underwent systemic therapy within the first year. The median age of patients in the study was 72.

Hypertension (40.5%) was the leading medical issue associated with MCL treatment, followed by anemia (37.7%), infection (36.1%), neutropenia (a decline in white blood cells) (36.1%) and thrombocytopenia (low blood platelet count) (13.4%).

Because of inpatient care, hepatotoxicity (liver damage caused by exposure to drugs) had the highest cost per patient per month (PPPM) ($19,645) along with stroke ($18,893), according to the study. The PPPM for renal failure was $9,037, followed by atrial fibrillation ($5,751) and anemia ($5,097).

The authors said the study was conducted in part because of the limited real-world data available on MCL. There have been two other recent studies, but the data was slightly older, or the patients were limited to those younger of age, AJMC reported.

After Rituxan, the next most common treatment was cyclophosphamide, doxorubicin, vincristine and rituximab with or without prednisone (known as R-CHOP; 13%), followed by ibrutinib (Imbruvica) (3%).

The Challenges of Treating MCL

Despite recent treatment advances, including FDA approval of the first CAR T-cell therapy for patients with MCL, the disease is difficult to treat. It tends to grow faster than slow-growing lymphomas, but it doesn’t usually respond to treatment as well as aggressive lymphomas. It commonly returns after periods of remission. According to the Leukemia & Lymphoma Society, the median overall survival for MCL is between 5 and 7 years.

One of the biggest challenges is that the median age of diagnosis is in the mid-to-late 60s, according to Dr. Andre Goy, physician-in-chief of the Hackensack Meridian Health Oncology Care Transformation Service in N.J. That makes it particularly difficult for healthcare providers to administer intensive therapy, such as a stem cell transplant or chemotherapy, he told OncLive in a 2019 interview.

In addition, he said investigators are unsure if a transplant is beneficial after first-line therapy — especially in patients who are minimal residual disease (MRD)-negative, meaning no disease was detected after treatment.

“There probably is no single standard of care in mantle cell lymphoma,” Dr. Peter Martin, assistant professor of medicine in the Division of Hematology/Oncology at Weill Cornell Medical College told Patient Power last year. “And as oncologists, our job really is to learn as much as we can about the person who has the lymphoma, about the lymphoma itself, and about the constant evolution of potential treatment options, and to try to merge all of those areas to come up with a treatment that makes the most sense for the person that's sitting in front of us at that point in time.”

Getting Closer to a Mantle Cell Lymphoma Cure

Despite the challenges of treating MCL, Bruton's tyrosine kinase (BTK) inhibitors and immunotherapy are transforming the treatment landscape. In November 2019, the FDA approved zanubrutinib (Brukinsa) for the treatment of patients with MCL who have received at least one prior line of therapy. Acalabrutinib (Calquence) received FDA approval in October 2017, and ibrutinib (Imbruvica) in 2013.

In addition to these targeted drugs, brexucabtagene autoleucel (Tecartus) — the first and only approved chimeric antigen receptor (CAR) T-cell therapy for the treatment of adult patients with relapsed or refractory mantle cell lymphoma — was approved by the FDA in July 2020.

“There is hope,” said Dr. Michael Wang, a professor in the department of lymphoma and myeloma at MD Anderson Cancer Center, in an interview with Patient Power Co-Founder Esther Schorr. He was the lead investigator of the ZUMA-2 trial on which the FDA based its approval of Tecartus. “There's I think a fraction of patients who could even be cured very soon, and we would like to work so hard to increase the speed of the curability that a fraction of people would get cured.”