Does Chemo Still Have a Role in FL?

Healio posted a short debate a few days ago, asking the question: Does chemotherapy still have a role in follicular lymphoma treatment?

The idea behind the debate is to look at where we are with Follicular Lymphoma treatments.  Newer treatments approved n the last few years are not traditional chemotherapies. Chemo tends to take a broader approach to killing cancer cells, killing some normal healthy cells as well. Newer treatments are more targeted, and focus their efforts on the cancer cells themselves, and mostly leave healthy cells alone. If we have so many of these newer, targeted treatments available, is it time to stop using traditional chemo? Does chemo still have a place in treating FL?

Answering "Yes" is Dr. Stephen M. Ansell of the Mayo Clinic in Minnesota. He points out that clinical trials of R-squared (Rituxan + Revlimid/Lenalidomide), this non-chemo combination got great results (overall response of 90% of patients, with a complete response for 63%). However, that trial had only a small number of high-risk patients, the kind that chemo will benefit. Comparing results from trials means paying close attention to which type of FL patients were being treated (those with lower risk, slow-growing FL, versus those with higher-risk, extensive, aggressive FL). It's hard to do a real comparison, otherwise.

In other words, for a fairly large part of the Follicular Lymphoma population, chemotherapy might be a better choice.

Answering "No" is Dr. Bruce Cheson of Georgetown University. He points to the many new treatment options that have become available in the last few years (or are in trials) that are more focused, very effective, and with fewer side effects. He, too, talks about R-squared, and uses it an example of a focused, non-chemotherapy treatment that has great results. And there are others, too, like possible improvements on Rituxan such as Obinutuzumab, pathway treatments like Ibrutinib, Idelalisib, and Venetoclax, CAR-T therapies, and others. With those targeted treatments available, there's no reason to put patients through traditional chemo.

So where do I stand on this?

Well, if you've read Lympho Bob for a while, you know how fond I am of  Dr. Cheson. And you also know that I get frustrated when I see clinical trials for traditional chemo, because, as a patient, I'd rather see resources being put into testing newer treatments, because they are without a doubt our future.

With that said, I have to say there's still a place for chemotherapy in Follicular Lymphoma, mostly for the reasons that Dr. Ansell points out. Again, as a patient, I like to keep my options open. There is still plenty of evidence that R-CHOP, for example, is a great option for transformed FL. And as I have seen in lots of patients, more aggressive types of FL (even if they haven't transformed) seem to do better with chemo. I want R-CHOP and Bendamustine available to me if I ever need them.

Now, can I see a time in the future when they aren't necessary any more? Sure. But that means more clinical trials that test newer treatments on more aggressive types of FL, ideally in trials that put those newer treatments up in direct comparison to older chemos that we know will work. But that means chemo needs to stick around until we know for sure that we don't need them any more.

So it's my hope that one day they'll be gone. But for now, I like having those options -- I like having those arrows in my quiver (as I have liked to say for a long time).

Of course, any treatment choices are best discussed with your doctor. The good news is, with lots of treatment options available, it could be a nice long conversation.