Follicular lymphoma has no single overall standard of care. There are many different approaches to treating patients and many effective options available to patients. Given the chronic nature of the disease, patients and their doctors must consider not only which treatments to employ, but the order in which to undergo treatments in order to keep future options available.
“Surveillance” or “watch and wait”: The traditional approach for follicular lymphoma patients with low tumor burden and no symptoms was to monitor the patient. Under this approach, the patient is examined periodically by his or her physician with blood work taken and a CT scan every six months or year. Only when the tumor burden becomes large or when the patient becomes symptomatic, would treatment be considered. This approach is still widely followed and appropriate for many patients.
Rituximab maintenance: Some patients consider the “watch and wait” approach to be “watch and worry” and want to take a more aggressive approach. In such instances, patients may be given a single-agent treatment with a monoclonal antibody known as rituximab or Rituxan. Several studies have been conducted to determine the benefits and risks of rituximab maintenance therapy as compared to “watch and wait.” Although the science is still evolving, some information suggests that rituximab maintenance therapy may delay the time until a first chemotherapy is needed for some patients by several months, but there is no demonstrated improvement in overall survivorship. On the other hand, the overall risks and side-effects of maintenance therapy appear to be minimal for most patients.
Rituximab is a monoclonal antibody, which is a type of immunotherapy. Immunotherapy is a form of biologic therapy that uses certain parts of the immune system to fight diseases, including cancer. Immunotherapy is sometimes used by itself to treat cancer, but it is most often used along in combination with another type of treatment or agent. Monoclonal antibodies are the most widely used form of cancer immunotherapy.
Chemo-immunotherapy: Patients with a high tumor burden, tumors impacting an organ, and patients who are symptomatic generally require treatment. Many years ago, the common approach was treatment with chemotherapy. For the past several years, the approach is chemo-immunotherapy, in which chemotherapy drugs are combined with rituximab. There are many different chemotherapy drugs and regimens used, including:
R-CVP – rituximab plus cyclophosphamide, vincristine, and prednisone;
R-CHOP – rituximab plus cyclophosphamide, vincristine, doxorubicin, and prednisone;
R-Bendamustine – Bendamustine (Treanda) combined with rituximab.
Fludarabine + Rituxan (RF)
In the United States, R-CVP and R-CHOP have been the most widely used treatments. Some physician use CVP because it is highly effective and reserves the option of using the anthracycline (the Doxorubicin) in CHOP for later if required. Recent data is beginning to suggest that R-Bendamustine may be superior to R-CHOP. https://ash.confex.com/ash/2009/webprogram/Paper20178.html. Although Bendamustine has been around for many decades in Germany, it has only recently been used in the United States. Recent studies show impressive progression free survival with R-Bendamustine and lower toxicity.
Radioimmunotherapy (RIT): RIT is a very important treatment for follicular lymphomas. There are two RIT drugs currently approved for follicular lymphoma: ibritumomab tiuxetan (Zevalin) and tositumomab (Bexxar). Ibritumomab tiuxetan has recently been approved as consolidation after chemotherapy in the front-line treatment of patients with follicular lymphoma. The Efficacy of ibritumomab tiuxetan was reported in the First-line Indolent Trial (FIT) by Dr. Morschhauser in 2008. The patients who received consolidative RIT had a prolonged progression-free survival. Both drugs are also approved for relapsed follicular lymphoma. RIT has provided many patients with durable remissions for years when used for relapsed patients as well as patients given RIT earlier. RIT is one of the most effective therapies for indolent and follicular NHL and remains underutilized treatment modality.
Stem Cell Transplantation: For patients with relapsed follicular lymphoma, high dose chemotherapy and stem cell transplant may provide a prolonged disease-free interval in some patients.
Radiation: Radiation may be used in some early stage patients with localized disease.
Other promising therapies: There are many ongoing clinical trials and studies of agents that may have application to patients with follicular lymphoma. It is important that patients with follicular lymphoma and their physicians investigate and consider participating in a clinical trial.
