ASH Preview: Rituxan Maintenance

Here we go -- time to start looking at some of the Follicular Lymphoma abstracts from this year's ASH conference.

Before I get into the first one, a couple of important reminders.

First, I don't think there's anything really ground-breaking at ASH this year, in terms of Follicular Lymphoma. Occasionally, there's some big news that everyone is talking about before the conference begins (on December 11), I'm just not seeing anything online. Maybe something will show up on this year's Leonard's List, but so far, I'm not hearing about anything major. And that's OK. It means there will be lots of interesting articles about existing treatments and other FL-related topics that help us better understand our disease and our options for treatment. That's usually how science works, anyway -- baby steps.

Second, even the presentations that I do excited about are not necessarily all that exciting. A lot of what I see are results from phase 1 and phase 2 clinical studies. That means they are still pretty early in the process, and there is plenty of time for things to go wrong (the treatments being studied are not as effective or as safe as they seemed). Looking back at my old ASH and ASCO previews, there are lots of things that got me excited that never made it to the clinic. Remember that. My excitement is about hope for the future, not reality in the present. It's kind of like looking through the Sears Wish Book as a kid -- I knew I was never going to get most of the stuff that got me excited, but it was fun anyway. 

(And if you don't understand that reference, sorry. If you do understand it, you'll know why I still have happy memories of a purple Chuck Foreman #44 Minnesota Vikings jersey from Christmas 1976.)  

**********************************

So which one are we looking at first?

Let's go with "3544 Rituximab Maintenance Benefits Less for Follicular Lymphoma Patients with Low Risk of the Follicular Lymphoma International Index."

Some background for this one: As many of you know, Rituxan Maintenance (RM) is a common practice. After receiving immunochemotherapy (like R-B or R-CHOP), some FL patients are then given Rituxan every 3 months for 2 years. (There are other possibilities for how often and how long the patient might get RM, but every 3 months for 2 years is most common.) Research has shown that RM can increase Progression-Free Survival (PFS) is many patients. 

The other important part of this study has to do with the Follicular Lymphoma International Prognostic Index, or FLIPI. The FLIPI is kind of a misunderstood thing. It uses information about a patient like age, disease stage, and how many places in the body the disease is found. Using that information, the index classifies a patient as low, intermediate, or high risk. It was created to help classify patients in clinical trials, not to tell an individual patient what their future is, which is now many use it. 

All of that said, the study has some interesting things to say about Maintenance.

The study involved 203 patients who were diagnosed with FL between 2003 and 2020. Of those patients, 192 received immunochemotherapy and had either a Complete Response or Partial Response. 96 of those patients then had RM (every 3 months for 2 years). The other 96 received no Maintenance, or had fewer than 4 rounds of Maintenance (less than a year). Follow up was a little over 3 years. The 5 Year Overall Survival rate for the whole study was 95%, and the PFS was 83%. Both excellent numbers. But FL patients who received RM, the numbers were even better for the PFS -- 92%, instead of the 70% for patients who did not have RM. Clearly, the study confirms what we've known -- Maintenance helps prolong PFS. It keeps the disease from coming back, at least for a while.

However, when the patients were looked at again according to their FLIPI score, the PFS was a little different, when compared to those who didn't have RM. Patients classified as low-risk had a 95% PFS, intermediate had an 84% PFS, and high risk had a 67% PFS. The conclusion here? Maintenance works well for intermediate and high risk patients, but there is no difference for low-risk patients between those who had RM and those who didn't.

It's a small study that involves a small percentage of FL patients (not all of us have immunochemotherapy, and not every oncologist recommends RM). But I think it brings up the bigger issue of just how much treatment we need. RM is clearly an effective strategy for a lot of patients. But as with any treatment option, it has risks. Rituxan destroys B cells, and those are an important part of the immune system (as we're all being reminded of lately). Lots of patients put off RM because of the effects it has on the immune system during the pandemic. I think those patients, especially those who were low-risk, can feel better about that decision.

The study also highlights some important issues related to our treatment choices. At my oncologist appointment this week, Dr. H again pointed out how pleased he was that Rituxan did such a good job for me. He said maybe 10-20% of FL patients get the long-term results I got with Rituxan, and he kind of imagined how different things would have been if I had been given R-CHOP instead. Probably the same result, but with much more toxicity and the possibility of more long-term side effects. I was fortunate to have an oncologist back then who was willing to try something less aggressive as a first treatment.

So that's the larger lesson for me, though it might not be obvious. No one is lucky to get cancer, and no cancer is "the good kind," even though you may have heard someone use that language. But one upside to having FL is that we usually have a little more time than people with a more aggressive cancer have, and we can use that time to get a second opinion from a Lymphoma specialist who can hep us think through our options. Even small bits of research like this might be something that a specialist can use to say "Maybe RM isn't the best choice. It will bring side effects without adding much effectiveness. Let's skip it and see how you do." That's the value of a lot of the research at ASH, I think.

I'll keep reading and reporting, and keeping an eye out for other commentaries from experts. More to come soon.