Predicting Progression Free Survival in Follicular Lymphoma

I'm about a month late to this, but it's very interesting news for Follicular Lymphoma patients.

Researchers believe they have found a gene expression model that can predict which FL patients are high risk and which are low risk.

Some background and reminders: one of the big pieces of news about FL in the last few years is the discovery of PFS24 -- patients who receive Immunochemotherapy (usually a monoclonal antibody plus chemo, like R-CHOP or R-Benda) but then do not get to 24 months of Progression Free Survival (the disease comes back or gets worse within 2 years) have a lower rate of Overall Survival.

It's good that researchers have identified that. The problem is, they don't know if someone is on that PFS24 group until they get the Immunochemo and then get worse.

The research suggests that looking at a genetic profile of the patient's cancer cells mighty help them make that prediction right away, at diagnosis.

The researchers looked at biopsies from patients who were in the PRIMA trial, which is examining the effectiveness of maintenance. They identified 395 different genes that were related to disease progression. Some of the genes are directly involved with Follicular Lymphoma, and some affect the microenvironment of the cell (that is, they allow things to happen or not happen that keep the cancer cell alive longer than it should be).  Using some statistical analysis, they were able to figure out which 23 genes affect the cell in a way that make a patient "high risk."

They could then go to the patients who were biopsied, and see what their results were. They found that those who were considered high risk in their model had a 5 year PFS of just 26% (only a quarter of the patients had not had their disease progress in 5 years). The low risk group had a 5 year PFS of 73%.

They then used this model of 3 other groups who were participating in different trials, and the model held up -- the media PFS for the high risk group was 3.1 years, and the low risk group was 10.8 years.

So there seems to be some validity with the model. At the time a patient is diagnosed, they can be categorized as high risk or low risk. No need to wait to see how they respond to treatment.

The big question is, of course, How does this actually play out in the doctor's office? If I find out I'm high risk, what can I do about it?

Well, the researchers here seem to suggest that there's not much you can do -- at least not yet.

According to the researchers, "Despite recent progress in the stratification and management of patients with follicular lymphoma, a substantial proportion of patients are still underserved by existing standard treatment and have rapid progression of their disease...Our gene-expression predictor could be valuable in the clinical setting to identify patients at high risk or low risk of progression so as to adjust the therapeutic strategy and enrollment for innovative treatments....For patients with high-risk FLIPI and 23-gene scores, having a 50% risk estimate of lymphoma progression at 2 years, new treatment options should be developed."

Note the wording: this is a first step. For now, doctors might be able to "adjust the therapeutic strategy" and suggest a more aggressive treatment right from the start, or encourage "enrollment for innovative treatments" such a clinical trials. But in the end, "new treatment options should be developed," suggesting they aren't here yet.

Or maybe they are. There are already treatments based on gene expressions. Possibly combining them might target several of the gene expressions in that group of 23. Or perhaps newer treatments will be developed instead.

Whatever the case, it seems to be another piece of the fabulous puzzle that we call Follicular Lymphoma. It brings us a little bit closer to understanding how it all works and what we can do to bring it under control.

And while it probably won't help those of us who have already been diagnosed, this knowledge might help some of those folks who aren't yet diagnosed, and make their lives just a little bit better.