Dr. Cheson on Follicular Lymphoma: Part 2

Late last month, Lymphoma Rock Star Dr. Bruce Cheson offered part 2 of his self-interview on Follicular Lymphoma and how he treats it.

Part 1 was published by Clinical Oncology News in November. In part 1, Dr. Cheson discussed several topics, including the "watch and wait" controversy (whether or not patients with no symptoms should be advised to wait, or whether they should be treated right away with Rituxan). Dr. Cheson still believes that watching and waiting is a valid option, given what research tells us. I like that he is just a little skeptical about research, and doesn't jump on whatever the latest results are. (Of course, if I'm being honest, it's probably because what he suggests is what I already agree with. I like it when a Lymphoma Rock Star validates my choices....)

He gets into more issues in part 2. Some highlights:

• He acknowledges that there is still no widely accepted standard first treatment for Follicular Lymphoma. While W & W does remain a valid option, about 15% of previously untreated patients receive straight Rituxan, which has an Overall Response rate of about 80%, median Progression-Free Survival of 24 months, and durable responses of more than 5 years in about 25% of patients. However, there is no Overall Survival benefit compared to patients who are only observed (which is a big reason he favors watching and waiting).
• Most patients receive some combination of chemotherapy + Rituxan. In the 2009 LymphoCare study, about 55% of patients has received R-CHOP, about 23% had received R-CVP, and about 15% had received Rituxan + Fludarabine. All had fairly comparable results, but other research showed R-CHOP to be superior to the other two. (That said, results that were reported in 2009 reflect some fairly old research -- patients received their treatments at least 5 years ago, and a ton has happened since then.)
• Bendamustine has emerged as an excellent alternative to R-CHOP, with better response rates and fewer side effects -- at least in some research. Other research, however, shows more similarity between them, particularly in terms of side effects. There may be less toxicity with Bendamustine (and thus less nausea and hair loss), but similar or worse chances of infection, anemia, and fatigue, for example. All things considered, Dr. Cheson still favors BR over R-CHOP.
• In perhaps the most controversial segment, Dr. Cheson discusses Rituxan Maintenance -- the practice of following up a chemo + Rituxan treatment with regular doses of Rituxan over two years. He reviews several studies of R-Maintenance, none of which seem to show definitively whether or not it is superior to observation (basically, going back to watching and waiting). Dr. Cheson does not use R-Maintenance. He calls it "expensive, time-consuming and inconvenient," and since it does not show an improvement in Overall Survival, he favors simply trying another treatment when necessary.
• He addresses FLIPI scores and their role in treatment decisions, and points to recent research that shows that the model might need to be revised or scrapped.  (FLIPI stands for
  Follicular Lymphoma International Prognostic Index, and is used as a general measure of prognosis, based on factors such as age, stage of disease, number of lymph nodes groups involved, etc.).
• Finally, Dr. Cheson addresses future prospects for Follicular Lymphoma treatment. There are a bunch, as we cancer nerds all know: R Squared (Rituxan plus Revlimid/Lenalidomide), with a 98% response rate in a phase 2 trial; and the various kinase inhibitors, which mess with lymphoma cells in different ways. These include Ibrutinib, which keeps B cells from maturing; Idelalisib, which keeps them from migrating and surviving, and ABT-199, which helps trigger cell death. 

I think this is about as good a review of the state of the field as you're going to find, complete with references to all of the research that has gone on. Obviously, Dr. Cheson has his own biases when it comes to all of this (and the title of the article makes that pretty clear), but it's all very well informed.

For me, the value comes in being able to have an informed discussion about all of these options with my oncologist -- a discussion that we will continue next week, when I have a 4 month (or so) follow-up appointment. I don't anticipate needing treatment immediately, but we can have a discussion about things like Bendamustine and some of the kinase inhibitors so we both have a sense of where we might want to go, once treatment becomes necessary.

Communication is key, after all.