The website OncLive is doing one of their video series on CAR-T and Lymphoma. It's a follow up to the discussions of CAR-T from the ASH conference a couple of weeks ago. The conversation is between DR. Marc Hoffman from the University of Kansas Cancer Center and Dr. Loretta Nastoupil from MD Anderson Cancer Center.
The series looks at CAR-T in all lymphomas (especially DLBCL), but two of the videos are devoted to Follicular Lymphoma.
The first video is called "Available Treatment Options for R/R Follicular Lymphoma." At the start of the video, Dr. Nastoupil asks Dr. Hoffman to walk her through current treatment options for Relapsed/Refractory FL and where CAR-T fits in. Dr. Hoffman smiles and "This is a really complicated question."
That seems like a bad sign for Follicular Lymphoma -- none of us want our cancer to be complicated. (But we also know how true it is.)
But there's a good reason for it being complicated -- basically, there are lots of options. With an aggressive lymphoma like DLBCL, CAR-T makes a lot of sense. It's probably the best option for an aggressive lymphoma. But for patients with FL, that might not be the case -- some of us have a more aggressive version when it returns, and some of us don't. And it's hard to identify those patients from the beginning. For a patient who is transformed or POD24, then CAR-T makes sense. For other R/R patients with FL, maybe another option would make more sense, and save CAR-T for those who need it later (maybe because they are refractory to Rituxan or to a chemo like Bendamustine or CHOP).
So, according to Dr. Hoffman, about 20% of R/R FL patients will need CAR-T right away. About 35% or so would do fine with a less aggressive treatment -- maybe just Rituxan. The complication comes for those "in the middle." They don't have an aggressive disease, but don't have an indolent one, either. there's no easy answer. Dr. Hoffman says in those cases, his question is "What's your appetite for toxicity?" In other words, there are probably going to be options that have more mild side effects (more mild -- every treatment has side effects), but won't last as long, but CAR-T may have harsher side effects but last longer until another treatment is needed (if it's ever needed).
All of those percentages are based just on his experience with FL patients, but I think the approach makes sense, and I appreciate his involving the patient in the decision. He says that he has "very few takes" for CAR-T in Follicular right now. If he presents it as a kind of risk/reward decision, I can see why. They seem to want something milder that allows for a decent Quality of Life, rather than taking a chance with one big shot.
It's a very interesting insight. I think most of us who have been able to watch and wait have a kind of mindset that lets us live with the disease and be at peace with it. It will be interesting to see how many patients choose CAR-T in the future, when the options are laid out for them in this way.
The second video in the series is called "CAR-T Cell Therapy for Patients with R/R FL," and gets more directly into what happens when patients do make the choice to go with CAR-T. There are now two options for CAR-T for R/R FL, and while the two types are very similar, there are some differences. Dr. Hoffman finds that when people are ready to make the choice, they have already done their homework and know a lot about the choice they are making. He thinks more patients will pt for bi-specifics than for CAR-T, based on what we know about the two choices right now.
The final challenge is how to sequence treatments -- what to offer first, and then second, and then third (if a patient needs a series of treatments over time). One issue, for example, is how Bendamustine might affect T cells. The order becomes important.
I think there are probably one or two more videos in this series. It's worth watching. Dr. Hoffman and Dr. Nastoupil seem like great oncologists who focus a lot of their patients' needs. If nothing else, they are a great reminder that we should be making sure our doctors ask what we want and need from treatment, and listen to us when we tell them.
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