R2 Regimen for R/R Follicular Lymphoma

Ian Flinn, MD, PhD: I want to talk for a second about the R2 regimen. There are data on using it in the frontline setting. There are data on using it in the second line and beyond. There are various versions of R² [lenalidomide, rituximab] dosing, length of treatment, and so forth. Can you talk a little about the MAGNIFY data that were presented this year at ASH [American Society of Hematology Annual Meeting]? What do you think about this? What patient population would you use the regimen in?

Caron A. Jacobson, MD, MMSc: As you mentioned, there are clinical trials looking at R² [lenalidomide, rituximab] in the frontline setting, and there are reported trials, like the AUGMENT study, that are looking at it in the relapsed setting with prescribed regimens. The MAGNIFY trial is designed to look at not only the outcome to R² induction but also what the best maintenance therapy is following that induction. All patients enrolled on the study with relapsed and refractory follicular lymphoma get R² [lenalidomide, rituximab] for a total of 12 months. Then patients with stable disease or better are randomized to continue R² [lenalidomide, rituximab] for an additional 18 months or get R [rituximab] alone for an additional 18 months. The R² [lenalidomide, rituximab] group can then continue on lenalidomide at their discretion beyond that 18-month time point. It’s a long period of therapy. What we saw at EHA [European Hematology Association Congress] were the outcomes for all patients treated with R² [lenalidomide, rituximab] in the induction setting, which looked quite good but also quite comparable with what we have seen in the AUGMENT study. It was good to see validation of those results.

Then we saw at ASH a subgroup analysis looking at patients who were over age 70 to see if there’s any difference in outcomes or toxicity in this older population. Thankfully, the safety profile as well as the efficacy profile of the combination looked quite similar for patients over age 70 compared with those who are under age 70. What we know is that a year of Rituxan [rituximab] and lenalidomide as induction has pretty consistent results in this setting. What we still don’t know is what is the best way to maintain that response. We’ll have a couple of different things to pick from, based on the dosing on the AUGMENT study or the 2 arms on this study, once we see the readout.

Ian Flinn, MD, PhD: Right. Andy, where do you use R2 [lenalidomide, rituximab]? Do you use R² [lenalidomide, rituximab]? And if you do, where do you most commonly use it?

Andrew M. Evens, DO, MSc, FACP: Treatment is individualized, of course, but generally in the frontline I’m choosing between rituximab alone or rituximab-chemotherapy. Based on some data, I’m still in that camp. For lenalidomide-rituximab, yes, I definitely use it. It is very active and mostly well tolerated. I would say it’s coming up most common for me in the second-line setting. Obviously, if we’re meeting someone who’s already had 2 or 3 lines of therapy, it’s really at the top of the list. Yes, it’s a year or so of therapy, but it’s oral therapy, and it’s well tolerated and very effective.

Ian Flinn, MD, PhD: Great. I have very similar thoughts about where to use it. I’m using it in a similar place.

Transcript Edited for Clarity