LRF Forum: Follicular Lymphoma Advice

Last week, attended some of the sessions for this year's Virtual Annual North American Educational Forum on Lymphoma, sponsored by the Lymphoma Research Foundation. Like so many events, this one usually takes place in-person, letting many lymphoma patients gather to learn and to meet one another. Unfortunately, this one was all online this year. Unfortunate, because it's usually a chance to meet others, and that's often a great way to get some support. Fortunate, on the other hand, because it lets people who couldn't travel get to attend. People like me.

The forum took place over the weekend, so I wasn't able to attend every session I wanted to. But I was pleased to get to two of them. The first was a break out session on Follicular Lymphoma, led by Dr. John Timmerman of the UCLA Jonsson Comprehensive Cancer Center. Much of the session focused on treatment options, and Dr. Timmerman gave a very clear overview of treatments that are available and that are making their way through trials.

A couple of other points he made are worth mentioning. He used the work "unfortunate" in saying the disease is considered incurable (as in "it is unfortunately called incurable.") Many patients die with th disease, rather than from it, which complicates the idea of "curable." He says survival rates are rising for FL patients, though he doesn't like to talk about how long the median survival rate is. He'd rather focus on the prognosis for each individual patient. I understand that way of looking at things -- statistics about all of us as a group don't say anything about each of us individually. Maybe it's better to just say "it's rising" and keep it at that. 

That means many of us have to focus on living with the disease. He had advice for this, too -- 

• Diet is important. Lymphoma is not caused by diet. he recommends a low fat diet to his patients, with lots of fresh fruits and vegetables.
• Exercise is also important. It helps to relive stress and can improve immune functions.
• Supplements are not necessary, and can be toxic or interfere with some treatments, so it;s important to make sure they are on your "medications" list with your doctors. (He gave an example of a patient of his who found an herbal supplement online that ended up causing liver damage. Best to talk these over with a doctor.
  

Another bit of advice -- he says a it takes about a year to get used to the idea that you are living with a chronic cancer. We should make plans, and give ourselves something to look forward to. I'm very much in favor of this advice. I think it's natural, when we are diagnosed, to panic and not want to think about the future, since we're so focused on the present. But with a chronic disease like Follicular Lymphoma, one that we might live with for many years, we have the freedom to look to the future. That's a little harder to do right now, when we are so restricted in what we can do. But my wife and I are already looking forward to what comes next -- some travel to see family and lots of hugs. It's nice to remind ourselves about when that will happen, not if it will.

And one final bit of advice from Dr. Timmerman -- someone asked what the cause of Follicular Lymphoma was, and he said he wasn't sure. There is some evidence that people who use pesticides can develop NHL, but they need to have used large amounts over a long time. For most of us, the cause is harder to figure out, and it's something he doesn't worry about. Whatever the case, it's going to be treated the same way, anyway.

I'm all for this, too. Don't worry about the cause of your FL. As I wrote a few years ago, all this does is cause guilt. We think about things that we did or should have done that may have caused our cancer. There's no changing the past, and most of us had good reason for doing the things we did anyway. Focus on the present and the future, not the past.

I attended a second session on Survivorship, too. I'll get into that one in my next post. Lots to think about in that one, too -- similar advice to Dr. Timmerman, but with a few other issues worth writing about.

Trends in Treatment and Survival in Follicular Lymphoma

The journal Leukemia recently published an article online called "Stage-specific trends in primary therapy and survival in follicular lymphoma: a nationwide population-based analysis in the Netherlands, 1989–2016." Unfortunately, I can only see the abstract (the paragraph summary that highlights what the authors think are the main ideas). But there's still some interesting things to see there.

The article looks at a very large group of Follicular Lymphoma patients -- 12,372 of them, who were diagnosed in the Netherlands between 1989 and 2016.

That's an interesting group -- it includes some who were diagnosed before Rituxan made its way to the Netherlands (which was 2003, according to the article, a few years after the U.S., in 1997). But, of course, it doesn't include patients who were diagnosed in the last few years, which I think is significant.

 The researchers were interested in primary therapy (the first treatment that patients received), and in Overall Survival. Given the large number, and the fairly large span of time they looked at (27 years), they also broke the data down into age groups (18-60 years old, 61-70 years old, and over 70), and time periods (1989-1995, 1996-2002, 2003-2008, and 2009-2016), and then looked at trends within those periods, and for those age groups.  

I'd love to see the full set of data, but the article is behind a pay wall, and I don't want to spend $10 to read it (though I might get free access to it a little later). Still, what the abstract says is pretty interesting anyway.

As far as primary therapy goes, one of the trends they noticed was that, for stage I patients, radiation has always been a very popular treatment. This makes sense -- because stage I disease is only present in one place in the body, very often a beam of radiation can reach it and get rid of it. That dosn't work as well with later stages.

For stage II, III, and IV, the trend they noticed was that starting chemotherapy within 12 months after diagnosis became less popular over time. They see this as showing that watch-and-wait was becoming more popular as time went on.  This is kind of interesting to me (especially as someone who watched and waited for two years). I don't know what trends are in different parts of the world, but there are a lot of oncologists in the U.S. who say we shouldn't watch and wait anymore, since there are so many options now for treatment, especially non-chemotherapy options. (The argument for watch and wait has always been that there were limited options, so it was best to hold off on using them until it was necessary.) 

I think it's kind of interesting that they say "before starting chemotherapy," specifically. This is where I'd love to see the full set of data. For much of that 27 year period, traditional chemo was really the only option. But I don't know if this study accounts for other first treatment options, like straight Rituxan, or RadioImmunoTherapy, or some newer inhibitors. I have no idea of those treatments are even available in the Netherlands, though I'm guessing they are, since they have had EU approval. But the wording is pretty interesting to me, none the less.

As far as survival trends go, the news is very good -- "Relative survival improved considerably over time." They say this is especially true since 2003 (thanks, Rituxan), and in older groups.

They look at five-year relative survival rates for this study. For the time period 2009 to 2016, the 5 year survival rate for stage I and II patients was 96% for the 18-60 year old group, 93% for the 61-70 group, and 92% for the 70+ group. The numbers are lower for stage III and IV patients, but still good -- 90%, 83%, and 68%.  

This makes sense; as patients get older, they are more likely to have co-morbidities -- other health issues that may impact their lymphoma, or may have nothing to do with their lymphoma. In other words, it's very important to remember what Overall Survival measures -- death by any cause (cancer, but also heart attack, getting hit by a bus, choking on food, whatever). As we age, we typically accumulate health issues. It doesn't necessarily mean the lymphoma is worse is older people. 

(Please read this post on Overall Survival if you're not sure what that statistic means, or if you need a refresher on how to read cancer statistics without being thrown into a panic -- especially you folks who have been recently diagnosed.)

It's noteworthy, though, that the numbers for the oldest group (over 70 years) is different in stage I and II patients (92% five year survival) and stage III and IV patients (68% five year survival). Remember, these numbers are measurements for 2009-2016. And this where I think that few years makes a difference.

The authors say "There remains, however, room for improvement among elderly stage III-IV FL patients." They're right, if you look at those statistics. But some of those patients in that 68% were diagnosed in 2009, 2010, 2011 -- the options available to them were so different from what we have today. (I know, as someone diagnosed in 2008, who pays attention to these things.) Someone with stage IV disease in 2009 was likely going to get CHOP chemotherapy, a treatment which does a great job, but has some nasty side effects, including potential damage to the heart. So a doctor who is deciding how to treat that patient, say a 72 year old with some health issues (pretty likely in a 72 year old) has to consider giving, perhaps, fewer rounds of the chemo (less effective, but also fewer side effects) or full chemo (more effective, but greater side effects that could harm someone who already has health issues). 

In other words, there are lots of reasons why that 70+ group has a lower survival rate. And, 10 years later, my guess is that some of those 72 year olds from 2009 would not get CHOP today. They'd get R-Squared, perhaps, or an inhibitor, something that is less taxing on the body and may extend their survival by a few years. 

The big lesson from this study, for me as a patient, is this -- it's interesting to look back at what happened in the past, because it's almost always going to show how much things have improved. We are so much better off now than we were 27 years ago, or even 10 years ago, with newer, better, and more treatments available. And even the best study that looks back on history (and this one is pretty good, looking at 2016) is still out of date. 

Care to guess how many treatments the FDA has approved for Follicualr Lymphoma since the beginning of 2016?

The answer is seven: 

Obinutuzuman + Bendamustine (2016), Rituxan Hycela (2017), Copanlisib (2017), Obinituzumab + Chemo + O Manintenance (2017), Duvelisib (2018), R-Squared (2019), and Tazemetostat (2020). 

And that doesn't count the CAR-T treatment for transformed FL, or any biosimilars for Rituxan.

Again, the point is -- history is interesting, but this study doesn't tell us everything we need to know. And as much as I'd like to see the full data for this study, what I really want to see is the historical study of patients from 2016 to 2026. Because it will be about 2030 then, and I'll be older and grayer but still saying the same thing -- "Interesting, but it doesn't account for the treatments that were approved last year!"

(I also assume that I won't have to type any more in 2030, and I can just use brain waves or whatever to write my blog.)

 Lots  to be hopeful about, folks. Lots.

 

Invisible Illness Awareness Week

This week (October 18-24) is Invisible Disabilities Week, an awareness campaign sponsored by the Invisible Disabilities Association.

The IDA describes itself this way: "IDA is about believing. We believe you! The frequently invisible nature of illness and pain may lead to disbelief about that illness or pain by those surrounding the person who lives daily with invisible disabilities. This disbelief can lead to misunderstandings, rejection by friends, family and health care providers. It may also lead to accusations of laziness or faking an illness."

Part of the awareness campaign is to have people post about their invisible disabilities on social media, so I have seen lots of stuff on Facebook and Twitter over the last couple of days (and probably will see more during the rest of the week). I have some people who are very close to me who have invisible disabilities -- physical problems that people can't see (at least at first) but that affect their lives.

It all sounds very much to me like Follicular Lymphoma. As we all know, FL is a cancer that doesn't always show up the way other cancers do. Not all of us have traditional chemotherapy, for example, with the kind of "obvious" signs that show we have cancer, like a bald head.

I wrote a piece last year for Blood-Cancer.com called "Not Your Typical Blood Cancer Patient," where I looked at what kind of pictures show up if you do an online search for "Cancer Patient." Lots of bald heads and head scarves and very sad expressions. But not all of us look that way on the outside.

In the title for this blog entry, I'm using the term "Invisible Illness" rather than "Invisible Disability." I think it's more encompassing of out experience, though I fully support the goals of the IDA and its awareness week.

Many Follicular Lymphoma patients do indeed have invisible disabilities. Whether from symptoms of the disease, or side effects of treatment, or even side effects of the medicines that help us deal with the side effects of the treatments, our bodies have changed in ways that make it hard to do the things we used to do. Those changes aren't visible to everyone right away. And, like the IDA says, that can lead to misunderstandings, rejection, and accusations of laziness or faking. I feel for those folks.

And then for many of us, we don't have the invisible disability, but we do have an invisible illness. We don't have the bald head of chemo treatment, for example, or other signs of cancer. (A woman in one of the online FL support groups I am in recently said a friend accused her of faking her cancer because she "didn't walk like a cancer patient." I can't even begin to imagine what that means.)

Those of us with invisible illnesses like FL might not have symptoms or long-term side effects that have affected our physical abilities. But that doesn't mean we don't live with physical pain every day, in some way, that we quietly ignore or cover up so we can get on with what we need to do, and, maybe "try not to be a bother to anyone."

And we most certainly live with the emotional illnesses that come with Follicular Lymphoma, like the fear that it will come back, or get worse, or transform into something else. That fear never really goes away (even after almost 13 years, as I can unfortunately tell you). And it's even worse during a pandemic.

And the guilt. You know this if you're like me, in a weird state of being in-between -- you haven't had a clean scan in almost 13 years, but you're also living a "normal" life, working and laughing and going for walks, and not really being "sick" but not exactly being "well" either. There's some heavy guilt that comes with that, sometimes. You maybe "don't walk like a cancer patient," and you wonder why you're lucky and others aren't.

The message of Invisible Disability Week is that you are not alone. It's easy to feel like you are, especially when you think you "look like everyone else" but don't feel like they do (or like how you suspect they do).

So take this as a reminder, my dear fellow Follicular Lymphoma patients, that you are not alone. There are approximately 70,000 people in the world with a Follicular Lymphoma diagnosis. There are readers of this blog from about 80 countries. And most of all, I'm here if you want to ask a question, share some good news, learn some new stuff, or just rant about people saying you don't "walk like a cancer patient."

Enjoy the week. 

Who Should Get CAR-T?

A few days ago, a video was released called "Who Should Receive CAR-T Therapy for Lymphoma."

It's a presentation by Dr. Caron Jacobson, from the Harvard Medical School and Dana-Farber Cancer Institute in Boston. She gave the presentation as part of the Great Debates and Updates in Hematalogical Malignancies virtual conference this past summer.

In the presentation, Dr. Jacobson goes through the results of some of the clinical trials for CAR-T use for lymphoma patients, as well as some "real world" studies of CAR-T that happened after it was approved by the FDA. Based on that data, she has some suggestions for which lymphoma patients might benefit from CAR-T.

I'm not going to go too deep into the data -- the video does that well, and it's fairly dense in the material presented, and a lot of packed into the 22 minute video. But I'll offer some highlights.

The message that I think Dr. Jacobson wants to get across is that CAR-T is "quite revolutionary" and more patients should be encouraged to try it. The message that I am getting is sightly less positive. More on that below.

Dr. Jacobson first looks at three trials, two of which (the Zuma-1 trial and the Transcend-CORE trial) involved patients with B-cell lymphomas. (The other involved patients with T-cell lymphomas, so I'm going to ignore that, since Follicular Lymphoma is a B cell lymphoma). Both trials involved patients with aggressive lymphomas (like transformed FL).

The Zuma-1 trial's CAR-T was Axi-cell, and 82% of patients in the trial had a Response, with 54% having a Complete Response. After 6 months, 41% maintained that Response, including 36% that has a CR.

The numbers for the Transcend-CORE trial, which used the CAR-T treatment called Liso-cel, 73% of patients had a Response, and 53% had a CR. There was not enough data to give a 6 month follow-up.

Dr. Jacobson also commented on the Zuma-5 trial, which looks at patients with Relapsed/Refractory indolent FL -- not aggressive or transformed, but just your regular old FL, the kind that most of us probably have. That data was presented at ASCO over the summer.  Results are great. After about a year of follow-up, 93% of patients had a Response, with 80% having a Complete Response. Of the FL patients in the trial, the response was even better -- 95% Overall Response, with 81% getting a Complete Response.

Those numbers stayed roughly the same in "real world" studies -- doctors who kept track of how patients were doing outside of clinical trials, after FDA approval. See the video for more on the actual studies, but the Overall Response/Complete Response for them were 70/50, 82/64, and 74/54, with one of them finding 41% of patients maintaining the response after 6 months (same as the Zuma-1 trial).

All of this sounds excellent, and it is. However, it gets trickier when we look at  toxicity -- the side effects that come with CAR-T.

In the Zuma-1 trial (the trial for aggressive FL), 93% of patients experienced Cytokine Release Syndrome, with 16% having grade 3 or higher (that is, very serious). 70% experienced neurological toxicities, or nerve issues, with 35% at grade 3 or higher. In the Transcend-CORE trial, 83% had CRS (9% grade 3 or higher), and 53% had neurological toxicities (17% grade 3 or higher).

As with all treatments, there were side effects, and sometimes very serious side effects. The good news, according to Dr. Jacobson, is that doctors have learned how to manage those side effects much better, and those numbers seem to be going down.

Dr. Jacobson also looked at data from patients who were not included in the trial. They received CAR-T, but the results weren't included in the data for lots of reasons, including that they had a "bridging therapy" -- that is, in between the time their T cells were collected and the time they were put back into their bodies, they received another treatment. This makes sense to not include them -- they got something "extra" that might have messed with showing how well the CAR-T worked. 

Those patients who received a bridging therapy were tracked anyway, and the data shows that the CAR-T didn't work as well for them, though it worked better than lots of other treatments. This might have been because their disease was already very far along, and the CAR-T was getting to them too late to hep as much as it could have.

That's really important information to have.

So, based on all of the data, which lymphoma patients should get CAR-T?

Well, CAR-T gave a durable remission (one that lasted longer than 6 months) to about 41% of patients with aggressive lymphomas. Among the reasons it didn't work? Patients has elevated LDH (the disease was behaving aggressively) or had co-morbidities (other health issues that might have influenced the outcome). 

So it seems like CAR-T works well for many patients with aggressive FL, but not too aggressive or too advanced. 

And for patients in the Zuma-5 trial (relapsed/refractory FL), 83% had a response that remained after 15 months. Longer follow-ups and a larger study are necessary, but it seems kind of intuitive here -- CAR-T works better on disease that isn't too aggressive, so maybe indolent, slow-growing FL is an even better target than aggressive FL? [That's a complete guess by me, someone who, I should remind you, is not a doctor or a cancer researcher.]

Dr. Jacobson is calling for more "real world" study of CAR-T, beyond trials, because trials can sometimes be too restrictive. That makes sense -- to compare patient responses accurately, you need clinical trial participants to be as alike as possible. But outside of a trial, after a treatment has been approved, it's easier to pay attention to other variables. Expanding access makes a lot of sense.

OK, so my take on all of this (again, recognizing that I am not an expert, just a patient who reads a lot):

I agree with Dr. Jacobson that CAR-T is "quite revolutionary," and has the potential to really change things for Follicular Lymphoma patients. I look forward to seeing what the FDA thinks about CAR-T for R/R FL patients, those with less-aggressive disease. I know my oncologist s excited about this, too, and thinks it could be a game-changer for FL.

However, we can't ignore a bunch of things: there needs to be more long-term follow-up for the Zuma-5 trial. Side effects of CAR-T, while becoming more manageable, can still be very serious. CAR-T is really expensive, and some health insurers may not like the idea of paying almost a half-million dollars for a treatment when cheaper options exist.

I'm saying this from a patient advocate perspective. I see lots of patients online who think CAR-T will solve all of our problems. And you know, it just might. But we have lots of hurdles to overcome until then. It might not work for everyone, it might not remain working for everyone, and it might not be available to everyone. 

That said, there is lots to be excited about, if we can keep a long-term perspective on things. 

(And since I plan to be around for a very long time, I think I can do that. I hope you can, too.)

 

Tazemetostat: The Official Numbers

Last June, the FDA approved Tazemetostat for Follicular Lymphoma patients with the EZH2 mutation who had already had treatment, and for FL patients who were essentially out of other options.

The approval was based on the results of a phase 2 clinical trial involving patients in 38 clinics or hospitals in France, the UK, Australia, Canada, Poland, Italy, Ukraine, Germany, and the United States. 

This week, the results of that phase 2 trial were published in The Lancet Oncology journal. This is important, because the data has now been peer-reviewed -- other experts in the field have looked at the data and have given it their approval. The study was designed and conducted well, and the results are valid. 

The article, "Tazemetostat for Patients with Relapsed or Refractory Follicular Lymphoma: An Open-Label, Single-Arm, Multicentre, Phase 2 Trial," presents data that is similar to what was reported when Tazemetostat was approved: 69% of patients with the EZH2 mutation had a response to Tazemetostat, and it lasted a little under 11 months.

EZH2 is an enzyme that controls the EZH2 gene, which controls whether a cell should die like it is supposed to. When EZH2 mutates, the cell doesn't know it is supposed to die which, of course, leads to cancer. Tazemetostat is an EZH2 inhibitor, which means it inhibits or stops mutated EZH2 from keeping cancer cells alive.

Roughly 25% of FL patients have the EZH2 mutation, so Tazemetostat might not be in everyone's future. But for those who do have the mutation, it seems like it should give them some hope. It works on FL in ways that no other treatment does, currently. 

It will be interesting, too, to see how Tazemetostat works in combination. As you probably know, there are lots of treatments for FL and other cancers that do a decent job on their own, but then do a much better job when combined with other treatments that work on cancer cells in a different way (like Rituxan, which works well on its own but also makes some chemo even better). I look forward to seeing results from some of those trials soon.

I also look forward to seeing results from the phase 3 trial that will look at how Tazemetostat works on a larger group. 

Lots to be hopeful about.

  

 

 

Integrative Medicine, Covid-19, and Cancer

Earlier in the year, I wrote about a radio program/podcast called Yale Cancer Answers, which did an episode on its Integrative Medicine program. Integrative or Complementary Medicine involves practices that help traditional oncology practices (as opposed to replacing them). So, for example, while a patient might have chemotherapy, the Integrative Medicine practice might also suggest CBD for nausea, or yoga for pain. The idea is to rely on standard medical practice, but to consider ways to make it better that don't necessarily involve taking more drugs.

A couple of weeks ago, the podcast did another episode with the Yale Integrative Medicine expert, Dr. Gary Soffer. He is a specialist in pediatric allergies and immunology,. but also runs Yale's Integrative Medicine office. You can listen to the podcast episode here.  I've been waiting to write about it until they posted the written transcript, which you can find here.

This episode is called "Dealing with Cancer During Covid-19," which is a little more specific than just a general discussion of Integrative Medicine. I'll leave it up to you to listen to (or read) the whole thing (the podcast lasts about 30 minutes), but I'll comment on a few things.

First, a lot of the discussion with Dr. Soffer focuses on the anxiety that so many of us are feeling during the Covid pandemic. I'm certainly feeling it myself. Dr. Soffer talks about some mindfulness and meditation practices that are really helpful to lots of people in overcoming anxiety. Such practices, unlike some other methods, are non-invasive and safe. They're not going to hurt you.

But, as he recognizes, they're also hard to do, at least for some people. Maybe meditation won't be helpful, but perhaps, as he suggests, a short walk without a cell phone can be a good mindfulness practice -- just shutting off the outside world and being focused for a short time. (Here in Connecticut where I live, the weather is beautifully cool, and the leaves are starting to change colors. Lots to focus on besides Covid.)

I'll also admit, though, that I am lousy at meditation. I just can't turn off my brain. At night, I fall asleep almost instantly (which makes my wife very angry). But then, once I wake up, no matter how early, my brain kicks in again, and that's it -- I'm awake. So shutting it down during meditation just doesn't work for me. (Dr. Soffer says no one is really good at it, which is why it's called "practicing meditation" -- always trying to get a little bit better at it.)

So while I'm not going to use meditation to get past my anxiety, I have found that I can go in almost the opposite direction -- turning to science. During the early spring, when Covid was really bad where I live, and we knew so little about it, I was also dealing with what turned out to be bad spring allergies. Chest congestion, a little breathing trouble, etc. overlaps with some Covid symptoms. I was tested, and it was negative. So I turned to small instruments to help me -- I'd take my temperature almost every day. No fever, no Covid. I have a finger-tip pulse meter and blood oxygen monitor. Every time 99% or 98% blood oxygen. I'm good. No breathing issues and no fever must mean no Covid. It really lessened my anxiety, much  more than meditation would have done.

And that's Dr. Soffer's point -- Integrative Medicine techniques don't work for everyone. We find ways to cope that make the most sense for us, whether we're coping with anxiety, pain, nausea, or any other symptoms that come with being cancer patients, physical or mental. I really liked his brief discussion of how cultural background can affect our approach to Integrative Medicine. I've had readers from over 80 countries over the years. I am very aware that my perspective on cancer is very Western, and I recognize that readers might approach all of this very differently from me. I hope we're all able to find what we need.

The podcast is 30 minutes well spent. Maybe you'll find something in there to make you feel a little better about things.

Updates on Follicular Lymphoma from SOHO 2020

Last month, the virtual meeting for SOHO (The Society of Hematologic Oncology) held its annual meeting online.  Dr. Nathan Fowler from MD Anderson in Texas posted a video with a summary of what was said about Follicular Lymphoma.

Dr. Fowler is a certified Lymphoma Rock Star; he was the researcher who presented the data for R-Squared. He was one of the main speakers at SOHO 2020 for lymphoma.

(By the way, cool name for a group of cancer doctors -- SOHO.)

The SOHO meeting isn't like ASCO or ASH, where people are presenting brand new research. It's more about education -- collecting all of that recent research and showing doctors why it's useful.

I mention this because it's kind of the spirit of Dr. Fowler's video. He very nicely sums up some of the more recent research on Follicular Lymphoma (and he's doing it for the website Lymphoma Hub, a site for oncologists).

So what does Dr. Fowler think are the major developments in FL that oncologists should know about?

There are some new options for untreated FL (the first treatment a patient receives):

Obinutuzumab has been shown to be a good substitute for Rituxan in combination with chemo (a little better Progression Free Survival, balanced with slightly worse side effects).

The RELEVANCE trial, which compared R-Squared with Rituxan + Chemo, showed that a non-chemotherapy option could work as well as chemo (though with a different set of side effects).

As Dr. Fowler says, we're seeing new options for first treatments, but it's important to consider side effects, since they can be different for different treatments, and the choice of treatment might not depend so much on effectiveness (since they are about the same), but Quality of Life (how side effects will play out).

For Relapsed FL, there are some recent options, too, including a third Kinase inhibitor Umbralisib, curently under review. All three have PFS of about a year (not great, but another option for people who need the option).

R-Squared is also approved for relapsed FL.

And then there is  Tazemetostat,the EZH2 inhibitor approved this summer.

And of course, there is CAR-T.

The various newer treatments, he says, have different mechanisms of action -- they work on the cancer cells in different ways. That's important -- we still don't now why exactly, but some patients' Follicular Lymphomas do very well with certain types of treatments, and others do better with a different type of treatment. Options are good.

Once again, this video isn't presenting anything new, but I always like seeing a Lymphoma expert getting excited about what's happening in his world.