Friday, January 27, 2017

More on Follicular Lymphoma Treatments

Following up on the OncLive Peer Exchange that I wrote about a couple of posts ago.

As I said then, Peer Exchange is a video series with a panel of experts on a particular cancer-related topic.The current series is called "Evolving Paradigms for B-Cell Non Hodgkin Lymphoma," and it focuses on treatments for Follicular Lymphoma. The series releases a new video every few days. They have released a few since that first one I described.

Here's a quick summary of the stuff I found interesting in those videos:

Follicular Lymphoma: Consolidation and Maintenance
The panelists have some doubts about Maintenance Therapy, and discuss two studies that have mixed results. The first is the RESORT study, which showed that patients who have treatment and then wait until they need another treatment, do just as well as those who have treatment and then immediate Maintenance. The other study, the PRIMA study, found that a percentage of patients (15%) get a longer Progression-Free Survival with Maintenance than those do don't get it, but no Overall Survival benefit. This comes as the results of the GALLIUM study were being presented at ASH -- this study showed that Obinutuzumab + chemo + maintanence did have an imporved PFS over Rituxan + chemo + maintenance. It was also controversial, though, in showing higher toxicity compared to Rituxan. This only seemed to add to the mixed reaction that the panelists had.
obinutuzumab

Sequencing Therapies for Follicular Lymphoma
I have always found the idea of sequencing pretty fascinating. It's tough enough to know which treatment to try first for FL, and harder still to know what to try second and third. Panelists discussed things like FLIPI scores to help figure out which patients are high-risk, and more importantly, m7-FLIPI, which uses genetic markers to make that identification even more accurate. Dr. Leo Gordon discusses the GADOLIN study, which compared Obinutuzumab + Bendamustine with Bendamustine on its own. The results showed some good results for O + B, but Dr, Gordon also had some problems with the way the study was set up that might make the results better than they seem. He also talks cautiously about Idelalisib, especially after other treatments like Bendamustine (it is approved for patients who have already had another treatment). Because Idelalisib leads to suppressing the immune system, it's important that treatments before that have also not affected the immune system too much, which can lead to very serious side effects. At the end of the video, he mentions RadioImmunoTherapy; he says he has patients who had one treatment 15, 16, or 17 years ago and are still in remission......

R2-CHOP for Relapsed Follicular Lymphoma
I was hoping the panel would continue the discussion of RIT, but alas, they didn't. Instead, they jumped to R-Squared, Lenalidomide (or Revlimid) + Rituxan. The R-squared study being discussed was with Relapsed patients (who had the disease go away and then come back), not Refractory patients (who had a treatment fail to get rid of all of the disease). R-squared worked very well on relapsed patients, with about 75% responding and a PFS of about 2 years. Nice. Another phase III trial is looking at the R-squared combo as well. And despite all of the "new toys" we have (as Dr. John Leonard puts it), for some patients, a treatment like a Stem Cell Transplant might be the best thing.

I get the feeling that this series isn't finished yet, so there may be a few more videos coming with discussion of even more treatments.

I'm finding it very interesting because of the critical nature of their comments. These are genuine Lymphoma Rock Stars, and it's fascinating to hear them talk about some of the concerns they have with the results of trials. That isn't something that I see very often; it's not like there's a "comments" section on a medical journal article, like there is on an internet article, where readers can bring up questions. So I've been enjoying hearing these folks talk about various treatments that all sound great when I read about them in other places.

I'll post more if I see more videos from the series.

2 comments:

William May said...

I am surprised that this series so far has not mentioned CAR-T. CAR-T works great for many follicular lymphoma patients. And at least one commercial CAR-T regimen is up for FDA approval in 2017.

Here is some good news I learned from Dr. Steven Schuster (one of the gurus in CAR-T) during a November 17, 2016 Lymphoma Research Foundation “Advances in Immunotherapy in the Treatment of Lymphoma” teleconference Q&A. This teleconference is posted at http://www.cancercare.org/connect_workshops/555-advances_immunotherapy_treatment_lymphoma_2016-11-17

Results from his UPENN Abramson Comprehensive Cancer Center follicular lymphoma CAR-T clinical trial showed:

* Of 14 follicular lymphoma patients 10 (72%) achieved a complete remission.
* No follicular lymphoma patient achieving a CAR-T complete remission has relapsed.
* As of today the average time in complete remission is about 2 years.
* If your complete remission is 2 years or greater you have the same survival odds as someone who never had follicular lymphoma.
* After one year about 50% of his follicular lymphoma CAR-T patients have their non-lymphoma B-cells come back and no longer need IVIG infusions.

Lymphomaniac said...

William,
I am surprised, too. Another video was added today, and while it does get into some inhibitors, there's still no mention of CAR-T: http://www.onclive.com/peer-exchange/nhl-treatment-paradigms/emerging-therapies-for-follicular-lymphoma

There's at least one more video in that series. I have to think this group, so cutting edge, is going to get to it at some point.

Great statistics from the UPENN study -- thanks for sharing. I'm guessing the results will still be good as they keep reporting long-term.
Bob