Thursday, February 25, 2016

Follicular Lymphoma: Future Strategies

New video from OncLive, posted a few days ago:

Dr. Richard Furman of weill Cornell and Dr. Bruce Cheson of Georgetown University discuss where we might be headed in treating Follicular Lymphoma.

Dr. Furman points out that Idelalisib seems to work better in CLL than in Follicular Lymphoma, so perhaps using it in combination will improve results. He mentions combining it with Rituxan and Bendamustine, which is getting good clinical trial results, though the combination also has some unpleasant side effects.

Dr. Furman also discusses Lenalidomide/Revlimid + Rituxan (R-squared). Like other combinations, this one improves the performance of the two individual treatments, and makes them last longer.

Dr. Cheson (you know I'm fond of him) discuss Ibrutinib, and the results that we are just seeing in Follicular Lymphoma. Ibrutinib is also being combined for better results. He mentioned combinations with Bendamustine, with R-squared, with anti-CD20 antibodies (like Rituxan, probably, and I'm not sure what else. Maybe Ofatumumab? Obinutuzumab? Ocaratuzumab?).

Dr. Cheson also points out that newer treatments like these two are expensive, and we really need biomarkers to use them most effectively -- something that can be tested so we know if a certain treatment is likely to work. Knowing which patients will benefit most from the treatments will make them all the more effective (and cost-effective).

Finally, Dr. Cheson points out that we are coming to the end of traditional chemotherapy, which kills lots of healthy cells as it kills cancer cells. Instead, we will see targeted agents like R-squared. We can envision targeting Follicular Lymphoma:

First, by targeting the surface of the cell with treatments like Rituxan, which finds a protein on the surface of the cell.
Second, by targeting pathways within the cell, with inhibitors that keep the cell from performing certain tasks that it needs to perform in order to survive. Idelalisib is an example of an inhibitor.
Finally, by targeting the microenvironment -- the area that surrounds the cell, where things happen that are necessary for the cell to survive. Lenalidomide is an example.

And here's the bombshell -- Dr. Cheson thinks that, if we find the right combination of treatments, we can eventually find a cure without needing chemotherapy. (Now do you see why I'm fond of him?)

Of course, we don't have a cure now, and won't (probably) in the near future. Maybe some of the treatments we have  now will be part of the cure, but maybe we haven't discovered them yet, and the ones we have now are just helping us figure out what works and how to make it better.

And of course, we do still have chemo, and it does have a place in our menu of options. But if you believe Dr. Cheson, it is on its way out, and our future is in the kind of combinations that he and Dr. Furman describe here.

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