John M. Burke, MD:I think there are several patient-related factors that affect a physician’s choice on what to use. The modalities that are used are immunotherapy, which means an anti-CD20 antibody either rituximab or obinutuzumab and chemotherapy. Generally that’s 1 of 3 choices, either the CHOP [cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone] regimen, CVP [cyclophosphamide, vincristine, and prednisone] regimen, or bendamustine. Then there’s what we callimmunomodulating therapyor lenalidomide, which is the drug in that category that has good activity in follicular lymphoma. Those are the 3 categories of drugs that are generally considered for a newly diagnosed patient with follicular lymphoma.
One’s choice of therapy can depend on a number of patient-related factors. The first factor that comes to mind is the patient’s age. The older a patient gets, they may become frailer and the physician is less likely to choose an aggressive difficult toxic chemotherapy regimen, for example, in that patient. Age is a factor, as are comorbidities. If a patient needs chemotherapy but has underlying cardiac conditions, then you might not want to use CHOP. If a patient has renal dysfunction, you might not want to use bendamustine. Depending what comorbidities the patient has, I think the patient’s personal preference is critically important. Many patients will have the option of all these treatments, and certainly when I sit down with a patient who has newly diagnosed follicular lymphoma, I’ll talk about all these options and let the patient be involved in that shared decision-making process. So, patient preference is important. Those are the main factors that go into the decision on initial therapy.
In terms of the specific options, I think for the majority of patients, the main option is chemoimmunotherapy. That means choosing 1 of those 2 antibodies, rituximab or obinutuzumab and combining it with 1 of those 3 chemotherapy regimensCHOP, CVP, or bendamustine. For some patients, we will use immunotherapy or an antibody treatment alone. That strategy is relevant in elderly patients, more frail patients in whom a 10-year remission may not be feasible. Just getting their disease under control is going to be a perfectly acceptable goal, so immunotherapy alone certainly is reasonable.
The other category of patients in whom immunotherapy alone is reasonable is in those patients with low tumor burden who are not comfortable with the watch-and-wait strategy. There are patients who come in and have low-tumor-burden disease. We suggest a watch-and-wait strategy, but they don’t feel comfortable with that. In those patients, something like rituximab alone can certainly be used without putting the patient through the toxicities of chemotherapy.
Some doctors might also choose a combination of rituximab plus lenalidomide. That is a newer tool in the arsenal that we have, and there is a randomized trial that demonstrates similar outcomes between that strategy and the chemoimmunotherapy strategy. That strategy of lenalidomide plus rituximab is not FDA approved but could still be reasonably chosen as an initial strategy for some patients, although it’s not my go-to for the majority of my patients.
Transcript edited for clarity.