Dr. Evens:
Hi. My name is Dr. Andy Evens at the Rutgers Cancer Institute of New Jersey.
Graphic: What is follicular lymphoma and is it more treatable than other less common lymphomas?
Dr. Evens:
Follicular lymphoma, thankfully, is quite treatable, and that word "treatable" can mean a few different things. When I say treatable, meaning, you give a treatment, it shrinks down, and hopefully completely away. In other words, a complete remission.
Generally speaking, when we talk about follicular lymphoma, which is an indolent lymphoma or a low-grade lymphoma, there are others within that category or umbrella. We say, yes, they are treatable but, generally, not curable. Meaning, give a treatment, it goes away and never comes back. And that's an important concept, and that's part of the reason for patients who have follicular lymphoma, or other indolent lymphomas, why we don't need to rush into treatment always. I have many patients who have gone 5 to 10 more years. Very small. living their life, and we know, yes, it's potentially treatable, and yes, treatments are good. But of course, anything, even targeted immunotherapy, has side effects. And so, of course, we want the benefits to outweigh the side effects.
And so, it's really that individual patient. And of course, once it comes to that time, if it is getting really large or causing symptoms, then yes, we will treat it. And depending on the treatment, whether we use a targeted therapy by itself, or targeted with low-dose chemo, it really gives us expectations of how well it's going to work.
Graphic: What are the signs of treatment resistance that patients should be aware of?
Dr. Evens:
Yeah. We're always hopeful, of course, to avoid treatment resistance or have a prolonged remission. But to your point, it usually happens in most situations. Thankfully, we're usually tracking patients quite closely, whether it's intermittent office visits; of course, history, physical, blood testing, along with intermittent imaging of the body. We try not to do too often of imaging. It's, again, a little bit individualized. But in most cases, we're able to see it happening before a patient feels it, or at least before it's severe.
And if and when that time happens, and there's a progression or the lymphoma's growing, then yes, you have a discussion with the patient. It depends on what have they received so far. What haven't they received? What are the available FDA-approved options? Are there new exciting options through clinical trials? And it's really going through all that host. Because in many situations in follicular lymphoma, there's not one right treatment for every patient. It's usually options, and you run through the different options and what's best for that individual patient.
Graphic: If a resistance to maintenance therapy develops, does the full-blown lymphoma come back or is there time for different treatment options to be explored to keep the patient in remission?
Dr. Evens:
With maintenance therapy, the first thing I'll mention, it's individualized. There are certain doctors, or even lymphoma experts, who debate benefits versus not benefits. Usually, if you do give maintenance therapy, it is time-limited. In other words, the FDA-approved option, for many of them, at least in the first-line remission setting, is one dose every two months for two years. It's uncommon to have disease progression during that time – not impossible – but thankfully, that's a small minority of cases. And certainly, every patient's unique in their own individual aspect. But in general, if we treat patients with an antibody low-dose chemo and give two years of rituximab (Rituxan) maintenance, the average first remission is 10 years. Now, that's an average. It's a bell-shaped curve with that median average.
And so, if there's a relapse or progression, whether it's at 3 years, 8 years, or 12 years, we reassess that situation. And we don't always rush to treatment. We talk about it. And it's almost always, there are options to think about at that time, but then it gets individualized to that patient, what makes the most sense for them? Could you re-treat with the antibody again? In some cases, you can. Even the antibody by itself. Do we want to do a different targeted therapy? There are other targeted therapies.
And as we talked about before, there's CAR T-cell therapy that's FDA-approved now for follicular lymphoma, and there is a newer class of agents, just approved, called bispecific antibodies. It's a double antibody: not just to the CD20, but also to CD3, so it's attracting T cells to the lymphoma. One is now FDA-approved, and there will likely be several more approved in that class of agents in the near future.
