Treating Follicular Lymphoma With Early Progression

Ian Flinn, MD, PhD: I’m going to end this section by bringing us back to sequencing. Andy led off about this earlier. I don’t think any 1 patient is the same as the next, and we do customize our approaches based on age, comorbidities, and everything else. But I often start with chemoimmunotherapy—perhaps BR [bendamustine, rituximab]—as frontline therapy for many patients with follicular lymphoma.

If I have 1 go-to regimen for second-line therapy, it’s often an R2 [rituximab, lenalidomide] regimen. Maybe some of you agree or don’t agree with that approach. What about for those POD24 [progression of disease within 24 months] patients—who are progressing early, whose natural history of the disease suggests they’re going to have a major impact in survival compared with those who have a longer initial remission?

Andy, do you buy into that sequence for the non-POD24s? How do you modify your therapy, your approach in patients who do have early progression?

Andrew M. Evens, DO, MSc, FACP: I have a similar overarching—I guess you could say treatment paradigm. That said, we always think about low tumor burden, high tumor burden. Sometimes you have these gray zone patients who don’t fit. They aren’t quite low, but they aren’t quite high. Maybe you’ll think about single-agent rituximab in this case. Besides that, yes, I agree.

Just to circle back to our discussion, Ian, about biopsies, we finally published our ECOG-ACRIN E2408 study. We tried to add bortezomib and lenalidomide to BR [bendamustine, rituximab], and it was a negative study from that standpoint. The PFS [progression-free survival] was not improved. Actually, trying to give 20 mg of lenalidomide right on the heels of full-dose BR [bendamustine, rituximab]—6 cycles—was tough. There were a lot of cytopenias.

We looked at POD24 patients. Among the patients in this follicular lymphoma frontline study with POD24, almost all of them were biopsied and half had transformed. That’s something that is always important to consider. They would require different treatment, as we talked about, if they are transformed. Let’s say they’re not transformed. Then our approach would be similar to what we talked about. We would at least think about autologous stem cell transplant. If that’s not an option for 1 reason or another, I would really look at targeted therapy. There is an ongoing national study looking at PI3 kinase–based therapy, and that would be a valid option as well.

Ian Flinn, MD, PhD: OK, great. Thank you for those points.

Transcript Edited for Clarity