High Risk Follicular Lymphoma: One Patient's Treatment

Targeted Oncology just did a really nice series highlighting how one oncologist treated one patient with high risk Follicular Lymphoma.

Now, of course, every one of us is different, and one patient's story doesn't tell us anything about our own disease and treatment. each of us will have to work that out with our own doctor. But I thought it was pretty interesting to see how this oncologist made decisions for this patient.

If you want to watch and read for yourself, the article/series is called "Approach to High Risk Follicular Lymphoma," and the link is here. There is a video near the top of the page, and clicking the boxes to the right of the video will let you see the next videos in the series. The transcript of the video appears below.

The doctor is Ajay Gopal from the Seattle Cancer Care Alliance, and the patient he is discussing is a 62 year old man with left axillary adenopathy (swollen nodes in his left underarm). Bloodwork was normal, and a biopsy of the nodes showed stage 2 FL. A PET scan showed FL in other areas, plus 30% bone marrow involvement.

Here's where the cancer nerd in me think it gets interesting -- if I were this patient, what kind of treatment would I want?

As Dr. Gopal points out, there are some choices here. Watch and Wait? Since he has symptoms, this was ruled out. Rituxan or other innumotherapy? Maybe, but that's more likely for a patient with low tumor burden. They went with Rituxan + Bendamustine. Interestingly, Dr. Gopal pointed out that R-squared (Rituxan + Revlimid) could also be appropriate for this patient, but it is not yet approved by the FDA for FL, so cost would be a factor -- insurance won't pay for it. It's nice to hear that patient cost is something that doctors think about.

B + R seemed to work well, but 18 months later, the patient came back with new symptoms -- weight loss and fatigue. Another scan showed that the FL had gotten worse. Dr. Gopal also points out that a short remission of 18 months should mean a new biopsy as well, to make sure the FL has not transformed. An 18 month remission puts this patient in the high risk category -- that PFS24 group that does not achieve 24 months of Progression Free Survival (about 20% of FL patients).

They decided to go with R-CHOP, but the patient did not tolerate it well. After only 2 cycles, he developed anemia (low red blood cell count) and the fatigue that goes with it. He had a Partial Response after the 2 rounds of CHOP.

Unfortunately, after only 5 months, he developed new symptoms again -- a feeling of fullness in his abdomen. An exam showed a swollen spleen and low platelet counts. This time, a new biopsy showed the FL had progressed to grade 3, with bone marrow involvement at 90%. As Dr. Gopal points out, the biopsy did not specify if it was grade 3A or 3B, which is an important distinction, since grade 3B is basically considered Diffuse Large B Cell Lymphoma, and would require much more aggressive treatment.

The question now is, which treatment to try next? Since he had trouble with reactions to chemo, a more aggressive chemo (such as RICE) was ruled out. An Autologous Stem Cell Transplant was also a possibility. Because the patient had several bone marrow-related problems, they needed to consider whether there was some kind of marrow disorder, too.

In the end, the choice was Idelalisib, a PI3-kinase inhibitor. More targeted and less harsh than traditional chemotherapy, it could do the job. Other choices were Copanlisib, another PI3-kinase inhibitor, and Zevalin, the RadioImmunTherapy.

The patient went on Idelalisib, had some side effects that were dealt with, and remains on it after about 5 months.

Dr. Gopal ends with the reminder that there are other treatments on the horizen that might be available in the future, including Revlimid and CAR-T.


Again, as I said, one patient's story really doesn't tell us much about out own. Mine has certainly been very different from this patient's -- my age, my health concerns, my stage and grade, my reactiosn to treatment. His path wouldn't work for me.

But I think it's really interesting to see what kinds of factors his oncologist considered with each step -- which health issues mattered, which treatment options were on the table, and which choices were made. It's good for each of us to consider what kind of map we might need to follow when the time comes.

And it emphasizes how important it is to have a doctor who is open to conversations about those choices. As patients, we certainly should have a voice.