Factors in Selecting Treatment for Relapsed/Refractory DLBCL

Transcript:

Matthew A. Lunning, DO, FACP: Dr Westin, I talked to Dr Rhodes about writing down her IPI [International Prognostic Index] scores on her [patients with] newly diagnosed DLBCL [diffuse large B-cell lymphoma]. Are you starting to write down when the primary induction therapy ends, when that last cycle was? Is that now a start [of] the interval or the stopwatch, if you will, for that patient, and how has that changed in your practice?

Jason Westin, MD, MS, FACP: It’s important to look at how long [it] has been from first-line therapy to that relapse occurring, and we heard about relapsed/refractory disease, but what does that relapse mean in terms of time? Refractory is obvious, patients never get a good response, they don’t achieve a CR [complete response]. But [with] relapse, time matters. Patients who relapse early on often have much more difficult to treat disease and may need different therapies. For example, in the second line, we recently saw the readout of several randomized phase 3 trials that enrolled patients who had relapsed within the first 12 months after first-line therapy. It matters when you finish therapy, how long afterward the relapse occurs, because different treatment options may work better in that early relapsed/refractory population. CAR [chimeric antigen receptor] T-cell therapy might be preferred, but someone who relapses very late, maybe they’ve got other options.

Matthew A. Lunning, DO, FACP: Dr Saeed, regarding their prior treatment, or their prior tolerance to treatment if they [had] a KPS [Karnofsky Performance Score] of 3 because of their lymphoma that improved and [went] into a CR, how do you take all those factors into [consideration] when the patient does have relapsed/refractory large B-cell lymphoma?

Hayder M. Saeed, MD: In addition to the relapsed/refractory patient status, whether they relapse within a year or they’re refractory to their frontline therapy, there are other factors that I usually look at whenever I have patients, especially in the second-line treatment of diffuse large B-cell lymphoma, such as what kind of frontline therapy [is best]. We just heard about the frontline therapy changing, and more and more patients will be treated with pola-R-CHP [polatuzumab, cyclophosphamide, doxorubicin, prednisone, and rituximab] compared with R-CHOP [cyclophosphamide, doxorubicin, prednisone, rituximab, and vincristine]. We have patients who are treated with EPOCH-R [rituximab, etoposide phosphate, prednisone, vincristine, cyclophosphamide, and doxorubicin hydrochloride]. All those things we now have to keep in mind whenever we make our decision for the next line of therapy. Like you mentioned, performance status is essential. DLBCL is a disease of the elderly, and if they can improve their performance status from frontline therapy, we still have those patients who have comorbidities, who are unable to tolerate the aggressive therapy that we wish we can push through. I keep that in mind all the time. I also keep in mind the utility and the logistics for the patient receiving therapy. If they come to see us in the clinic, how far do they live from the clinic? Whether they have the financial means to get their treatment, and whether they can drive all the way to the clinic. All those things are important in making a decision for second-line treatment of B-cell lymphoma.

Matthew A. Lunning, DO, FACP: Dr Rhodes, we just heard a lot of the intricacies and the operational aspects of this. Let’s say a patient isn’t a transplant candidate and they aren’t a CAR T-cell [therapy] candidate in the relapsed/refractory large-cell lymphoma space. What are their treatment options then? How do you have that conversation with that patient population?

Joanna M. Rhodes, MD, MSCE: As you had said before, there’s a lot of excitement because now we have therapies for relapsed/refractory diffuse large B-cell lymphoma that are not just chemotherapy. So we have loncastuximab tesirine, which is our anti-CD19 antibody drug conjugate; I’ve found that is well tolerated in patients who have other comorbid medical conditions, and it has a good dosing schedule. We have polatuzumab, which is more for a patient who didn’t get pola-R-CHP in the frontline setting; that is approved in combination of bendamustine and rituximab. I personally don’t use the bendamustine.

Matthew A. Lunning, DO, FACP: You like the plus-minus.

Joanna M. Rhodes, MD, MSCE: I like the plus-minus.

Matthew A. Lunning, DO, FACP: I think the polatuzumab was probably doing a lot of the heavy lifting.

Joanna M. Rhodes, MD, MSCE: I think so, yes. Vedotin is not great as a single agent in relapsed/refractory large-cell lymphoma. We have seen the response rate, it’s 10%, and I don’t know if it adds much, but it definitely adds toxicity. Finally, we have tafasitamab, which is an anti-CD19 antibody in combination with lenalidomide, and I find it is well tolerated and a good regimen for the right patient.

Matthew A. Lunning, DO, FACP: Those 2 drugs play well in the sandbox together.

Transcript edited for clarity.