Friday, April 17, 2015

Follicular Lymphoma Treatment Selection

The site OncLive sponsored a"Peer Exchange" that was posted online this week. The discussion is a series of videos, focusing mostly on CLL (Chronic Lymphocytic Leukemia, a slower-growing type of leukemia). Toward the end of the series, they begin to discuss other types of NHL, including Follicular Lymphoma.

In fact, I think they are releasing these videos one at a time, with some time in between. The two that focus on FL get cut off abruptly at the end. Still, there's some interesting stuff there.

Leading the discussion in the first Follicular Lymphoma video is Dr. Myron Czuczman from Roswell Park Cancer Institute. Interestingly, much of what gets discussed has to do with chemotherapy: R-CHOP, R-CVP, F-R, and Bendamustine + R, and particularly the trials like BRIGHT that have compared different types of chemotherapy. The oncologists in the exchange (especially Dr. Czuczman) seem pretty invested in chemotherapy. At first that was a little off-putting to me. I see the value in comparing traditional chemotherapies, but I think there are much more interesting things awaiting us in the future.

And, stepping back a bit, I can see that the panelists do discuss some of those current/future treatments for Follicular Lymphoma: Idilisib, Ibrutinib, and Revlimid. And they ultimately seem to favor Bendamustine over other, more traditional chemotherapies like CVP and Fludarabine, while recognizing that those treatments do have a place in certain situations.

But the big difference between more traditional chemos and those sexy new treatments is that the more traditional ones have a track record of success -- in the case of CHOP, a record that is decades long, Dr. Czuczuman reminds us. With CHOP, we have a pretty good idea of what we're getting, good and bad, short- and long-term. With something like Idilisib, we're going on some very good short-term results. And really, the same is true for Bendamustine. As superior as it seems in trials that compare it to other treatments, we don't know what the effects are over the very long-term.

So, yes, that's a good reminder (for me, who gets excited about all the new stuff out there) that traditional chemotherapy still has a place in Follicular Lymphoma.

The second video looks at some of the treatments that seem effective for CLL, and asks how well those might work on Follicular Lymphoma. It's a shorter video, and makes an important point: as exciting as things have been lately for CLL (and the last two years have been awesome), CLL and FL are different diseases, and treatments will work differently on them.

One other thing that seems exciting, besides Bendamustine, is R-squared (Rituxan + Revlimid, also known as Lenalidomide). Early results from a trial looked great, and the panelists anxiously await more results for this promising combination.

So, overall, I think these videos tell us some interesting stuff, about the past and maybe about the present. But I still would rather hear about the future. As great as it is to know that R-CHOP is there if my FL turns aggressive, I still get more excited thinking about all of the research we are seeing about the genetic basis for cancer, and about pathways and microenvironments. As great as R-CHOP is, something "decades old" doesn't (and can't) take any of that into account.

So it's nice to know R-CHOP and B-R are there for me now. But I want to know what's waiting for me in the (hopefully near) future. And "hope-fully" is the key word there.

Myron Czuczman

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