ASCO: Most Effective First Treatment for FL?

ASCO Abstracts are here!

ASCO is the American Society of Clinical Oncology, an organization for cancer doctors who work directly with patients. Every year in late May/early June, they hold their annual conference. It's a big one, attended by thousands of people, so it's often where researchers and pharmaceutical companies will announce their big news, knowing it will get lots of attention.

A few weeks before the conference, ASCO published the abstracts of all of the presentations. It's an exciting time for cancer nerds, as we look through all of the summaries, trying to find the most interesting ones. And as I have been doing for a while, I want to share with you some of the things that are most exciting to me.

(To be clear -- it's the stuff that's exciting to ME. It's not necessarily the stuff that makes the news. So it's lots of Follicular Lymphoma research, of course, but also some general stuff about Quality of Life for cancer patients. Like, if I find something that says drinking scotch is good for cancer patients, you can be sure I will let you know about it.)

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Right off the bat, one of the first things I see in the list of Follicular Lymphoma abstracts is a session called "Efficacy of Frontline Treatment Regimens in Follicular Lymphoma: A Network Meta-Analysis of Phase III Randomized Controlled Trials."

It's a big question for FL patients -- when it comes time for treatment, which is the best one? Or, for those of us who already had treatment, was the one I had the best choice, or should i have had another one?

Really, the questions comes down to, which treatment is the best one?

I'd like to tell you that this research answers that question, but it doesn't really, for a couple of reasons. I'll get to those soon.

The researchers noted that, in the last few years, there has been a lot of change in front-line treatment for Follicular Lymphoma -- the first treatment that patients receive after diagnosis. Since I have been diagnosed, we've seen approvals for Bendamustine, Obinutuzumab, and Lenalidomide.

Clinical trials involving these treatments have led to the approvals for these treatments, and have also prvided lots of data about their effectiveness. The researchers looked at the data from seven trials (FOLL05, StiL NHL1, BRIGHT, PRIMA, GALLIUM, StiL NHL7, and RELEVANCE) and then compared the results to one another.

The trials were all phase 3 (the largest numnber of patients involved), and were all randomized controlled trials. This is important -- a randomized controlled trial means that a group of patients is divided into two smaller groups, with one getting the standard treatment and the other getting the newer one that's being tested. It's the best kind of trial, since it lets researchers do a direct comparison between two treatments.

The measurement they used was Progression-Free Survival  -- how long it took before the patient's disease got bad enough to need a new treatment. Ideally, they's use Overall Survival, but with FL, there's usually not enough difference in OS to matter -- no matter which treatment, patients usually stay alive for about the same amount of time. But PFS can be very different.

First, they compared everything to B-R, Bendamustine plus Rituxan.

Here's what they found:

R-CHOP had a lower PFS.

These treatments had a similar PFS:
R-CHOP with Rituxan Maintenance,
Obinutuzumab + CHOP + Obinutuzumab Maintenance
R-Squared + Rituxan Maintenance

These treatments has a better PFS:
B-R with Rituxan Maintenance
B-Obinutuzumab with O Maintenance.


Then they did the comparison to R-CHOP with Rituxan Maintenance.

O-CHOP with O Maintenance, and R-Squared with Rituxan Maintence, had similar PFS.

B-R with R Maintenance and B-Obinutuzumab with O Maintenance had a better PFS.

Their conclusion is, basically, that some kind of maintenance is usually better than no maintenance -- if the measurement you are looking at is PFS, and only PFS.


So why doesn't this answer that important question, Which treatment is the best one?

Well, first of all, this data is limited to a particular set of recent trials. It's great information, but it also leaves out a bunch of older treatments (like straight Rituxan and Stem Cell Transplants, among others) and a bunch of newer ones (lots of inhibitors and CAR-T, among others). The choices here are great, but they're not the only choices.

Second, the research also looks at Progression Free Survival as its only way of measuring success. But it doesn't say anything about something like Quality of Life. A treatment could give you a PFS of 10 years, but have side effects (maybe nerve damage, for example) that make your everyday life less happy than it might have been with a treatment that gave you a PFS of 5 years, but with fewer long-term side effects.

So "best" isn't the same for everyone. It's important for us as patients to think of our own life goals. For some, the "best" treatment is the one that results in the longest time between treatments, no matter what. For others, "best" might mean frequent maintenance treatments, and the anxiety and inconvenience that might go with them, but an otherwise "normal" physical life (whatever that means).

To me, the lesson is the same it's been for 11+ years:

Stay educated and informed. Keep an open dialogue with your doctor. Know what matters to you. Advocate for yourself, and make sure that the treatment you get is the one that lets you live the life you want to live.

I'm looking forward to going through the ASCO abstracts some more. The conference starts on May. It's usually around that time that press releases start to come out, as people brag about their research results and measure the reaction that their presentations got. In the weeks that follow, experts will give commentary about which research they thought was most important.

We'll see if there's any Follicular Lymphoma news in all of that bragging.