R/R Follicular Lymphoma: Second-line Treatment Selection

Ian Flinn, MD, PhD: We should probably spend a couple of seconds talking about treating people in the second-line setting. We have these criteria, Loretta, for frontline therapy: big, bulky lymph nodes; organ compromise; cytopenias; things like that. Do these same criteria vie in the second line? Do you wait that long? Are you treating people earlier? What are your thoughts?

Loretta J. Nastoupil, MD: I tend to agree with you. There’s a more systematic approach to patients who are untreated. Most clinicians follow the GELF [Groupe d’Etude des Lymphomes Folliculaires] criteria for tumor burden when deciding when to subject someone to chemoimmunotherapy. In the relapsed setting, it’s much more heterogeneous. That makes it incredibly challenging when we start looking at the outcomes across studies, because there are not consistent criteria applied despite who is in need of therapy. Oftentimes, you’re restricted by the eligibility criteria of a lymph node of 2 cm or larger. In my general practice, I do tend to follow the GELF criteria when deciding who should be exposed to potential toxicity with treatment and who is in need of therapy. But I don’t think that is consistently followed.

Ian Flinn, MD, PhD: Yeah, there is a lot of heterogeneity. There is even inconsistency within institutions. Maybe I’m inconsistent in my own practice.

Krish, there are a number of things that are important to think about when choosing therapy for patients in the relapsed setting: Rate of progression, whether the patient has transformed, young, old, fit, unfit. Can you walk us through some of that? What are some of your thoughts? We may get some other people to weigh in here as well.

Krish Patel, MD: Sure. As you all pointed out, there are a number of factors that help inform our choice of second-line therapy. In particular, if we think about the length of time somebody has had a remission after frontline therapy, as Caron pointed out, we’re expecting most patients to have very long remissions. Those who have much shorter remissions—recurrence within 24 months of initial chemoimmunotherapy—have particularly poor outcomes. Those are patients who we may want to adapt our therapies to and are often the types of patients we think about clinical trials for. We really don’t have a consensus on what is the best approach for those patients.

For some of those patients, other factors like age and fitness become important. For example, is this a patient who could tolerate an intensive approach, including an autologous stem cell transplant? Has this patient previously had an anthracycline-based therapy, appreciating that some of our early progressors may harbor occult transformed disease, especially if they weren’t staged by PET [positron emission tomography] scans? It is really important to get in the weeds, if you will, about the details of this patient’s follicular lymphoma. How did they respond to therapy? What kinds of therapy did they have? We have a number of different pathways that we might follow.

Transcript Edited for Clarity