Follicular Lymphoma: Where We Are Now

Many thanks to the commentor who (just this morning) provided a link to a session on Follicular Lymphoma at the European Society for Medical Oncology meeting last week. (The commentor is listed as "Unknown," which is kind of cool -- we have lots of mysteries with FL, but The Unknown Commentor is kind of a fun mystery.)

ESMO 2016 took place in Copenhagen, and has tries to "bridges the gap between researchers, clinicians and patients and unites all stakeholders focused on finding the most effective cancer treatment solutions available today."

The link to the session is from LymphomaHub, and includes photos of slides from the presentation, as well as commentary. The presenter was Dr. Michele Ghielmini from the Oncology Institute of Southern Switzerland. The presentation is called “Follicular Lymphoma (FL): Novel Developments Beyond Chemotherapy.” Since it took place last week, it's probably about as up-to-date a discussion of Follicular Lymphoma as we'll find.

The link to LymphomaHub is pretty easy to read, and you can read the whole thing on your own, but I'm going to list a few things that I think are highlights.

• Dr. Ghielmini is a big advocate of Rituxan. Chemotherapy does not provide much benefit as a first treatment for FL, especially when long-term side effects are taken into consideration. Chemo is best reserved for later treatments. That seems pretty well in line with what a lot of people are saying, though there are still plenty of oncologists who recommend R-CHOP or R-Bendamustine as a first treatment.
• The current median Overall Survival rate for Follicular Lymphoma patients is about 15 years. He gets this from some recent published data. He also gives some other OS figures: FL patients younger than 40 have a median OS of about 24 years. There are lots of factors that determine whether a patient is on the plus or minus side of that 24 years, but it's a very encouraging number for those of us who were diagnosed at a young age.
• Rituxan Maintenance is still controversial. There's lots of evidence that says it's a good thing, and lots that says it's not necessary. Tough decision for those who have to make it. Like many decisions with FL, I think it will come down to Quality of Life -- do you have the time and money to do it? Will doing it give you peace of mind?
• R-Squared (Rituxan + Revlimid/Lenalidomide) seems to be as effective as Rituxan + Chemo, though there needs to be more long-term follow-up to see if the great response rates mean a long Progression-Free Survival (it helps lots of people at first, but will it keep helping them for a long time?).
• "Small Molecules" or pathway treatments such as Idelalisib, Ibrutinib and Venetoclax. Dr. Ghielmini showed the most recent results for Idelalisib and Ibrutinib. We've known about these results for a while -- nothing new presented here. A little less well-known, though, are results from early trials for Venetoclax (also known as ABT-199). It's a BCL-2 inhibitor, and the latest data is from a very small phase 1 clinical trial for Follicular Lymphoma. (Maybe we'll see updated results soon?)
• There are lots of trials that are investigating combinations of various treatments. There are lots of folks who think this is the best way to go. Single agents might work well, but cancer is sneaky enough to find ways around those successes. Blocking more than one path or attacking in more than one way seems like the best way to go.
• Finally, the LymphoHub piece concludes with: "In future, we need to develop combinations based on the oncogenic alterations of each individual tumor." This is also probably true. As much as we can find general approaches that seem to work for lots of people, in the end, we'll probably need to find treatments that are based on biomarkers for each individual patient to give the best chance of success.

So, overall, this was a nice article for summing up much of what we know about Follicular Lymphoma and its treatment, as of last week, anyway.

But as Dr. C, the lymphoma specialist I saw a week after I was diagnosed, told me almost 9 years ago, "Anything you see online is already out of date." As up-to-date as Dr. Ghielmini's presentation is, it doesn't include everything (no mention of CAR-T, for example). And it doesn't include results from trials that we'll probably see in 6 weeks or so when ASH takes place.

And that's not a criticism of Dr. Ghielmini. It just means that we all have lots more to be excited about as Follicular Lymphoma patients. As great as things look right now, especially compared to 9 years ago when I was diagnosed, there's still lots more great stuff to come.

(Thanks again, Unknown Commentor, wherever you are......)