Options for Relapsed/Refractory FL (Videos)

Cancer Network has recently added to their video series called "Growing Options for R/R Follicular Lymphoma."

The series features several short videos of a conversation between four Lymphoma specialists: Dr. Brian Hill of the Cleveland Clinic; Jennifer Garson, a physician assistant at Rush University Cancer Center; Dr. Muhamad Alhaj Moustafa of the Mayo Clinic; and Dr. Tycel Phillips of the City of Hope Cancer Center.

The series actually begins with a written interview (not a video) with Ms. Garson, who talks about dealing with some of the side effects of treatment. Episode 2, the first video, introduces the speakers and focuses briefly on the evolution of treating FL, with each participant talking about how the field has changed. Ms. Garson, for example, talks about Rituxan and the ways it changed treatment and improved Overall Survival. Dr. Moustafa talks about the changes from the last 5 years or so, with the introduction of treatments like R-squared and bi-specifics. Dr. Phillips adds CAR-T to the list, and says he is "excited to see where things are going."

(I will add that one of the reasons I like video series like this is for just what Dr. Phillips says. It's always great to see Lymphoma experts get excited about the work they do and what we might see in the future.)

Episode 3 looks more specifically at a case study -- a 65 year old woman with Follicular Lymphoma. Dr. Hill goes through her symptoms (some of them will sound familiar!), and her diagnosis of stage 4 grade 3A FL, and the panel suggests what they might have done if they had seen this patient. 

I enjoy this kind of thing, too. I'm not a doctor -- it's been a little bit since I have reminded you all about that -- but I like to guess what the doctor may have suggested. I guessed R-squared for a first treatment -- a cancer that's not too aggressive, but chemo seems old-fashioned for this group. And then CAR-T or a bi-specific if it returned. 

And I was wrong. The actual patient was given Bendamustine and Rituxan, which Dr. Moustafa called "the standard of care right now" (which is probably accurate). They debated whether or not R-CHOP would be appropriate, if it had been more aggressive on the PET scan, and transformation was a possibility.

Then they asked about what to do next, and they debated R-Maintenance, which they agreed was controversial and appropriate for some, but not all, patients. (Part of that decision has to do with the pandemic, and being more careful about messing with patients' immune systems. It has apparently changed quite a bit since the pandemic, with more oncologists being cautious with Maintenance.)

And if the FL returned? In the case study, the patient relapsed after 4 years, with grade1/2 FL coming back. They had several possibilities -- one chose R-Squared (or maybe Revlimid with Obinutuzumab instead of Rituxan). They wanted to hold off on R-CHOP until it was needed for transformation. Other possibilities were plain Rituxan or possible pathway inhibitors, though they are usually used for a 3rd round of treatment, or a clinical trial.

The lesson here, everyone? Be glad that I'm not your doctor. I'd probably get your treatment plan wrong. 

They do also talk about CAR-T, though they thought this was a fairly aggressive treatment, as was Stem Cell Transplant, and bi-specifics. Some of those would probably come later, as a 3rd or 4th line of treatment. Additional videos talk about some of these other options. You can find all of them on the page linked above.

It's very interesting to me that the doctors in this series were much more conservative than I had guessed they would be. Reading so much about newer treatments, it's easy to get caught  up in the excitement about them. But when it comes to actual doctors treating actual patients, the tried-and-true treatments, the ones that they know will actually work, are the ones that they recommend. The newer, more exciting stuff comes later on, when they patient has fewer options.

Change comes slowly in lots of places, including oncology. I don't think that's a bad thing. There's a big difference between getting excited about bi-specifics at a conference with other oncologists, and deciding whether to recommend a treatment that was approved just a few months ago to a scared patient who is sitting in your exam room. The conservative approach makes a lot of sense to me (and, to be honest, was the approach my own oncologist took, and which I happily agreed to.)

The series continues with more discussions of newer treatments, and then with a return to the case study of the 65 year old woman who had B-R. But this time they imagined that she didn't get a 4 year remission. Instead, it was only 4 months.  That makes her POD24 -- immunochemotherapy that stopped working within 24 months. These patients have a much lower median OS. What to do?

I won't share what my guess is with this one, or whether it lined up with what the doctors on the panel recommended. 

But I will say that the whole series was a great reminder that a laptop isn't a treatment room, and a patient-blogger isn't an oncologist. Remember that -- the best source of information about Follicular Lymphoma, and how it affects you as a patient, is your own doctor.