Published on August 21, 2020
Approved Treatments for Follicular Lymphoma
"The discussions always come down to how did the patient tolerate the last treatment," Dr. John Leonard from the Weill Cornell Cancer Center shares with host and advocate, Ruth Fein. They discuss the many treatment options available for follicular lymphoma patients including rituximab (TRUXIMA) and newly approved tazemetostat (TAZVERIK). They also discuss genomic testing, biopsies, and making treatment decisions.
This is Part 2 of a 4-part interview on Follicular Lymphoma. Watch the full discussion in the series below:
Transcript | What are My Follicular Lymphoma Treatment Options?
Hi, thanks for joining us. I'm Ruth Fein. I'm a patient advocate and a health writer and a living well patient diagnosed with a rare blood cancer more than 25 years ago. We're here with Dr. John Leonard of Weill Cornell Medical Center in New York City. He's a world renowned expert in non-Hodgkin follicular lymphoma. And thanks so much for sharing your wisdom with us today, Dr. Leonard.
Thank you. My pleasure to be here.
Choosing the Right Treatment for Follicular Lymphoma
So today your proverbial medical bag offers so much broader a choice of treatments in terms of options than it ever did before. So how do you know what's the best treatment for each person?
Sure. So it's a complicated issue. And I will say that there's not a lot of cut and dried answers. I tell patients that some of the aggressive lymphomas I deal with are dictatorships, where I'm a dictator and I say this is what you're going to do because there aren't many choices. Whereas in follicular lymphoma, there are lots of choices. And so it's more like a partnership or a collaboration where there's a lot of discussion about pros and cons of different options. So there are a lot of tradeoffs in follicular lymphoma. You can use certain treatments that work a little better but have more side effects. Other treatments work a little less well, but have less side effects. When the long-term outcome comes, as far as how long people live, can be the same. So often it's a choice. Do you want to put up with more side effects for a longer, better response, or do you want to minimize side effects recognizing that the treatment might not work as well?
So our options and our discussions often are around as we've talked about, rituximab (Rituxan), an antibody and immunotherapy that's used by itself or in combination with chemotherapy. Those are typically the two choices or a newer version of rituximab that are used as initial treatment and are sometimes used at relapse for patients. When a patient relapses, the discussions tend to be around what did they have before? What treatment did they have before and how did it go? Did it work very well, did it work for a long time and did they tolerate it well, in which case we tend to stick with a similar type of treatment again. Versus if it didn't work well, it didn't work for a long time or they didn't tolerate it well, then we want to come after it a little bit different way. And the nice thing about follicular lymphoma is that besides chemotherapy regimens, such as regimens called R-CHOP or R-Bendamustine (Bendeka), we have some newer treatments that can work very well, going beyond more intensive treatment.
There more recently was approved a drug called lenalidomide or Revlimid. It is a pill that's used for multiple myeloma commonly, but also approved in combination with rituximab that I mentioned earlier in follicular lymphoma. So that's one option. We also have a category of drugs called PI3 kinase inhibitors. These are medications that flick switches on the cells that hit a pathway or a switch on the cell called PI3 kinase. Two of these are pills. One of these are intravenous. And these also can be useful on patients who have follicular lymphoma that's come back. More recently, just in the past few weeks, we've had a drug called tazemetostat (Tazverik) - tazemetostat is another pill. It inhibits a target called EZH2. EZH2 is what we call an epigenetic target. It affects what genes are turned on and turned off in the cell and mutations in EZH2, that gene, have been associated with a little bit better outcomes to this EZH2 inhibitor.
And then we have lots of other treatments, traditional chemotherapy. We have STEM cell transplants, very aggressive treatments. We have clinical trials with a number of new drugs, including CAR T-cell therapies, a fancy immune based therapy. But the discussions always come down to, how did the patient do with their last treatment? Do we want to stick with the same type of treatment because it worked well and was tolerated well? Or do we need to shift gears because the cells are resistant to one type of treatment, so we need to try something else, try to go around the wall rather than through the wall as far as using that sort of an analogy.
So it's really a big discussion with patients. Very rarely do we just have one possibility or one option. The less sick the patient is, the more options they have. Meaning that if they're feeling pretty well, we can sometimes use a less aggressive therapy because we don't need to rapidly and aggressively shrink the tumor immediately. Whereas if somebody is feeling pretty sick, they're in a tough spot, often we need to give them a more aggressive treatment that's going to work quicker because we need to get them out of that tough spot pretty quickly.
What Testing is Most Important for Follicular Lymphoma Patients?
Right. I'd like to go back to testing for one minute, and that's the breadth of your testing must have improved significantly. And how has that changed because so many therapies are individualized now? And part of that, are genomic tests more important than ever? And if not, what kind of testing is most important to you right now?
In lymphoma, the testing that's been most important is biopsies by the pathologist to really classify the type of lymphoma. There are a few molecular tests in certain types of lymphoma, chromosomal tests to look and see what switches or changes in the chromosomes have occurred in that patient's tumor cells that might correlate with a better or worse outcome or a response to treatment A or treatment B. So there are a number of different pathology tests in that regard that are commonly done in lymphoma. Genomic tests, where we're looking at the precise mutations that have occurred in the tumor cells, are as of right now, not hugely valuable in treating or picking treatment for patients with follicular lymphoma. There are some patterns that we see when we do genomic tests that might suggest the patient's going to do a little better or a little worse.
There are very few treatments that are picked based on genomic tests as of today. A couple of different scenarios, but for the vast majority of patients, genomic tests right now beyond the pathology, the standard and important pathology tests are not going to change how we approach that individual patient. That being said, there are many other cancers where they do have a much more direct impact. There are certain cancers where the choice of therapy might be a drug that targets a genomic change in the tumor cells. But as of now in follicular lymphoma, that's something that we're doing really as a research tool. And not something that standardly affects patient care, but something that in the future I think will be very helpful.
Remaining Optimistic about Follicular Lymphoma
So one final question, and I understand that there are so many different situations which you've discussed different patients that have different needs and particularly different needs at different stages of their disease. But if you could point out one thing you're most optimistic about what would that be?
Well, I'm most optimistic in follicular lymphoma about the fact that the time horizon is long. Most patients with follicular lymphoma live for decades, as we talked about. Most patients with follicular lymphoma don't die from their lymphoma. They die of something else. And the hitchhiker is along for the ride. That said, there are some people that do have problems and can die from follicular lymphoma. And we clearly want to prevent that.
But the time horizon is one for most people, where there is a chance to have progress happening over a patient's expected life span. So we've had a new drug this year approved for follicular lymphoma. We had new drugs approved last year for follicular lymphoma. I have every reason for optimism that over the coming years, each year, or maybe several per year, we're going to have new drugs available and approved. And those are expected to improve outcomes for patients. And so one of the advantages of the watch and wait, in some cases, is we get smarter and we're getting smarter every day and getting new therapies and I think that progress is going to continue to happen and patients can benefit from that in the near future.
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