Sunday, January 24, 2016

Narrowing Down Our Choices for Follicular Lymphoma Treatment?

Researchers from MD Anderson Cancer Center just published "Factors Influencing Outcome in Advanced Stage, Low-Grade Follicular Lymphoma Treated at MD Anderson Cancer Center in the Rituximab Era" in Annals of Oncology.

The title was a little misleading to me -- the focus isn't on a whole lot of factors other than certain treatments that patients received, although their conclusions do get into some wider issues.

Still, what they have to say is definitely worth taking a look at.

The researchers looked at patients from their facility only -- 356 of them who received certain treatments from 2004-2014 (a few years after Rituxan was introduced). As they point out (and as we all know), there really isn't an accepted first treatment for FL patients -- lots of disagreement about what to do first. So they hoped to look back at patients and see what treatment they received and how well they did, and figure out what seemed to work best. Thet used 3 year Progression-Free Survival as their measurement (that is, the disease didn't get any worse for at least 3 years).

Here is what they found:

For patients receiving R-CHOP, the 3 year PFS was 60%.

For patients receiving R-CHOP with Rituxan Maintenance, the 3 year PFS was 72%.

For patients receiving Bendamustine + R, the 3 year PFS was 63%.

For patients receiving Bendamustine + R with Rituxan Maintenance, the 3 year PFS was 97%.

For patients receiving Lenalidomide + Rituxan [R-squared], the 3 year PFS was 87%

While Bendamustine + R had the best number, the researchers also point out that R-squared had a very high number AND fewer "high risk features" than chemotherapy (which includes Bendamustine). We're seeing some very positive stuff about R-squared in the last few months, and this adds to it.

The researchers also looked at Overall Survival, and found that patients who had disease progression within two years after treatment had a lower OS (something we have been hearing more of in the last few months, too), and patients who transform have a lower OS (which we already knew).

Personally, I find the B + R + Maintenance number pretty impressive, but that R-squared statistic is also something that we can be happy about. The general trend seems to be moving away from chemotherapies, even one like Bendamustine that had fewer and less aggressive side effects than CHOP. R-squared, like other targeted therapies, are really what Follicular Lymphoma's future looks like.

As always, we need to think about all of this carefully -- it's a relatively small study, of patients in just one center, so other factors can also play a part in the results. But if we think about it all as part of some larger trends, this is all something to be happy about.


Anonymous said...

I'm trying to understand the statistic. For the people receiving maintenance, does the 3 year PFS include the maintenance time? My wife completed 6 rounds of B + R at the end of March 2015. We are 7 months into a 2 year R-Maintenance period, which is one infusion every two months. We are due to end maintenance in June of 2017. So, does the study suggest that we have a 97% chance of 3 year PFS after maintenance, or is it from the end of the initial B + R treatment? The statistic makes it sound like that B + R + Maintenance consists of one treatment. By the way, I love the high percentages for the treatment my wife received and for the R squared.



Lymphomaniac said...

Kevin, I believe that statistic is measured from the date of first treatment, so there is consistency when they make those comparisons. I don't see that information specifically in the article, but I have seen that explained somewhere else.
Good luck to you and your wife. I hope the maintenance goes smoothly.

Rodrigo Carvalho said...

I have the same question: when we start counting The PFS: after The diagnosys, after the complete remission, or the rituximab maintence (2 years) . This information is very important to understand these datas

Rodrigo Carvalho said...

Bob. When you said "first treatment ", it includes the rituximab maintenence (two years) or not?

Ruben said...

It's going to take quite a number of years before that R+R group will reveal their median Overal survival rate. I must say, I am very pleased with that number. The big question is now, what can we add to that R+R regimen in order to attack the Lymphoma from all directions and kill it once and for all ;-) What's your best guess, Bob?

Thanks for your work, looking forward to your next post!

Anonymous said...

Thanks for the reply. That makes total sense in order to have a baseline comparison.


Lymphomaniac said...

Rodrigo -- Just to be clear, PFS is typically measured at the beginning of the process, not the end. It might be at diagnosis (if the "treatment" is watching and waiting), or the day of the first treatment, or the day of enrollment in a clinical trial, but it won't be at the end of treatment. All of the days of treatment are included in that measurement.
PFS is kind of controversial as a measure of success for a treatment, though so are most measures, including Overall Survival. Lymphomation wrote up a thoughtful piece on PFS a few years ago in response to the PRIMA study on Rituxan Maintenance:

Lymphomaniac said...

I agree -- it's going to take a while to measure OS, which is probably why they are using PFS instead.
I have no idea what will be added to make R + R even better. Researchers seem to understand that combinations seem to be effective, since the different treatments attack the cancer cells in different ways. Right now, there are trials that combine R + R with Bendamustine, with Ibrutinib, with Idelalisib....I'm guessing that anything that works will be combined with something else that works until we know which combinations work best.
Of course, that means we need more people willing to join clinical trials to test all of these combinations. Something for us all to consider....

Rodrigo Carvalho said...

Thanks, BOb!