A 69-Year-Old Woman With Follicular Lymphoma - Episode 5
Ajay K. Gopal, MD: Not every patient will need third- or fourth-line therapy. It somewhat depends on the underlying disease, but also the age of the patient at diagnosis. If we think about patients with early progression, about 20% of all patients with follicular lymphoma have progressive disease within 2 years. Then we think of the median age of diagnosis being in the early 60s, although this patient is a bit older. Those factors come into play in terms of the likelihood of having to ever get to third-line therapy. In my practice, in an academic referral center, I do see many patients needing third-line therapy or beyond, so this is a common situation, unfortunately, in our clinical practice.
Fortunately, we have a number of agents and approaches for patients needing third-line therapy. It somewhat depends on what they’ve had previously. If they haven’t had lenalidomide, that’s still on the list. I mentioned before ibritumomab tiuxetan as a potential option for the appropriate patient. But we have an entire class of drugs now called the PI3-kinase inhibitors. There are 3 drugs approved. The first was idelalisib, and this was evaluated in the DELTA study.
The PI3-kinase inhibitors probably have 2 mechanisms of action. The initial thought was that this was primarily a drug that blocks the B-cell receptor signaling pathway. PI3 kinase is part of that. However, more recent data suggest that these drugs are probably also immunomodulatory. They tend to suppress regulatory T cells, probably reflected somewhat in their adverse effect profile, and may also suppress myeloid-derived suppressor cells. So the actual function is not completely clear, but there’s probably a combination of direct effect on B-cell receptor signaling and some immunomodulation.
Transcript edited for clarity.
Case:A 69-Year-Old Woman With Follicular Lymphoma