Rituxan and Transformation (Part 2)

As I wrote in my last post, there have been two recent medial journal articles that have looked at the effect of Rituxan Maintenance on Follicular Lymphoma transformation. The one I looked at last time suggested that taking Rituxan as part of a first treatment might reduce the risk of transformation.

The second study was published in Blood Advances, and is called "Up-Front Rituximab Maintenance Improves Outcome in Patients with Follicular Lymphoma: A Collaborative Nordic Study."

 The study looked at more than just transformation. It looked at the effects of Maintenance on Overall Survival and Progression Free Survival as well.  Researchers looked at two groups of patients. The first included 733 patients from Denmark who had R + chemo. About half of them went on to receive R Maintenance. The group who had Maintenance showed an improvement in 5 year Overall Survival (89%, versus 81% who did not have Maintenance). There was also an improvement in 5 year PFS (72%, versus 60% who did not have Maintenance).

The researchers then looked at a similar group of patients from Finland (190 of them) to see if the results were the same. In this smaller group, the 5 year Overall Survival was about the same (89% versus 81%), as was PFS (70% versus 57%).

The difference in OS should be important. One of the real challenges for FL researchers has been finding a treatment that improves Survival for us. This one (R-chemo followed by R Maintenance) seems to do that, but the researchers aren't ready to get overly excited about that (which I appreciate). They say, after discussing the results from a bunch of other studies, "In conclusion, the role of MR as part of the first-line standard of care strategy in treatment requiring FL is still debated. The present study adds to the existing data by showing that, in 2 independent cohorts of FL patients, the use of MR leads to an improvement of not only PFS, but also OS."

They're not claiming that the debate is over (as some researchers do), just that they are adding more to it.  They acknowledge that there are a bunch of other factors that may have contributed to the results they got (such as which type of chemo they go in the R-chemo they first received -- CHOP patients did better then CVP, and there weren't enough Bendamustine patients to really show anything).

Now, as far as Transformation goes, the researchers found in the larger Danish group that Maintenance did seem to have an effect on Transformation. Of the 733 patients in that group, 60 transformed (about 8%). There may have been a benefit for patients who received Maintenance (that is, they were a little less likely to transform), though that might have been influenced by the chemo they took. However, the smaller Finnish group did not show any benefit -- the risk of Transformation was the same whether they had Maintenance or not.

The lessons here?

Well, first off, let me remind everyone that I am a patient, not a doctor, so what I say can only come from that perspective.

What I get out of all of this is this -- there's still no magic formula. I'd love to read something that says, "Yes, absolutely, have this treatment and chances are very good that your life will be longer." Unfortunately, that's not what we have here, from either study.

But that's not to say there's nothing good from either one. There's actually lots of good news, if you look at it with a wide-angle lens.

It seems that, overall, Transformation  numbers are better than what I've seen in the past. The risk is certainly still there, and it's still something that a little piece if me fears (even 10 years after diagnosis), but maybe Rituxan has played a role over the last 20 years in making that risk a little smaller.

I also think that Maintenance remains an important tool in the toolkit. Maybe not for everyone, but maybe for some of us, and certainly something that is worth discussing with a doctor. The Blood Advances study looked at efficacy only -- how much Maintenance helped with Survival and Progression. It didn't look at Toxicity at all -- what kind of side effects people had, and how they effected Quality of Life. That's certainly something to include in a conversation with an oncologist -- Maintenance might improve Survival or time between treatments, but what is the cost?

So, overall, the two studies give me things to be hopeful about, but they weren't likely to change everything I thought I knew about FL -- and they didn't. As the researchers from this study said, the information adds more to the discussion.

That's a good thing. No answers, but more information t help us make decisions. I'm OK with that.