A 69-Year-Old Woman With Follicular Lymphoma - Episode 3
Ajay K. Gopal, MD: One important consideration when approaching any patient with an indolent B-cell malignancy, most commonly follicular lymphoma, is to ask the question of whether the patient needs to be treated. In this case, I think it was pretty clear-cut. The patient was symptomatic. The patient had cytopenias, and there was really a clear-cut indication for treatment. But this approach really applies at every relapse. This is a chronic disease, and none of the therapies that we’re discussing today are primarily curative. We’re trying to relieve symptoms from the disease. At every time point when there’s disease progression, one has to ask the question, is there an indication for treatment? I think there clearly was for this patient.
There are a couple of other important points illustrated in this case. One question is, after initial remission induction—in this case, R-CHOP [rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone]—are there prognostic factors that we can look at? This patient did not achieve a complete remission after rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone induction, and this bodes quite poorly for patients. We really have to be on guard that this patient is going to have a short remission, with or without maintenance therapy.
A second major question is whether there is a benefit to using maintenance therapy. To date, there’s really been no trial in follicular lymphoma that showed an overall survival benefit associated with rituximab maintenance, or any anti-CD20 antibody maintenance, for that matter, as part of initial therapy. For this reason, I think one can go either way on maintenance, and it comes down to a long discussion with patients about the pros versus cons of maintenance.
The pro to using maintenance therapy might be that you would extend their remission duration. However, this may come with chronic B-cell depletion and some low-grade infections and hypogammaglobulinemia.
For the vast majority of my patients, I don’t give maintenance therapy based on the fact that there is no overall survival advantage. And there are some data that demonstrate you actually get the same amount of mileage with fewer doses of rituximab by not giving maintenance therapy.
Transcript edited for clarity.
Case:A 69-Year-Old Woman With Follicular Lymphoma