Director of the Weill Cornell Lymphoma Program, Richard T. Silver Distinguished Professor of Hematology and Medical Oncology and Associate Dean for Clinical Research, Weill Cornell Medical College
Would you briefly describe follicular lymphoma?
Lymphoma is a tumor of the lymph tissues. Lymph cells typically grow up, help fight infections, and then die off. When the switches that regulate the growth of the cells break down, the lymph cells either grow faster than they normally should, and/or don’t die. This causes the lymph cells to accumulate. The lymph node glands that are commonly affected are in the neck, under the arms, and in the groin; but lymphomas can pop up in many other places. Follicular lymphoma is a very common, slow-growing type of lymphoma that gets its name from the cells it originates from, which are called follicular center B-cells. It is the second most common subtype of lymphoma and the most common of the indolent (slow-growing) forms of lymphoma.
How is follicular lymphoma typically treated?
Follicular lymphoma, for most patients, is something that is chronically managed. We generally expect that it will come back and be managed on and off with several different therapies over the course of many years. It is treated with a number of different regimens, but often it doesn’t need treatment at the time of diagnosis if it is not causing any problems or symptoms.
What chemotherapy regimens do these patients usually receive?
Most patients are treated with a combination of two or more drugs, and the treatment often includes rituximab (Rituxan), which is a monoclonal antibody. Common combination regimens include: R-CVP (rituximab, cyclophosphamide, vincristine, prednisone), and R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone).
What are the current main areas of research for follicular lymphoma?
In no particular order, current research areas include studies to understand risk factors, predispositions, causes, and genetic and environmental issues that relate to lymphoma development. There are studies that look at long-term effects of treatment on patients and quality of life for patients with follicular lymphoma, which is an important aspect of things. Prognostic studies try to understand why some patients do better and some do worse. Some studies look at why a treatment will work in one patient but not in another patient. There are then a variety of different studies focused on transformation, which is when the follicular lymphoma changes to a more aggressive type of lymphoma. Understanding why that happens and the factors that contribute to it will help determine if it is possible to prevent transformation from occurring.
There is a great deal of research looking at new therapies and improving current therapies, making them more effective, and/or less toxic with fewer side effects. Research is helping to identify how to better choose what the best treatment is for an individual patient and understand why certain treatments work for different subsets of patients. These insights will allow us to better provide patients with the best treatment option for them and develop new, better therapy options.
Please discuss the importance of clinical trials and mention any specific trials you wish to discuss.
Clinical trials are essential in making progress. Any time a patient goes into a room with a doctor and discusses the disease, the prognosis, the treatment, all of those issues are informed by clinical trials. Clinical trials guide individual patients on what to do and what to expect out of the disease and treatment. Patients themselves can contribute to our understanding of lymphoma by participating in clinical trials. The trials also grant patients with an opportunity to get access to new treatments that could potentially benefit patients in some situations.
Please discuss some new and emerging treatments for follicular lymphoma.
There are a number of new treatments for follicular lymphoma that are quite exciting. They fall into a variety of different categories. One category is monoclonal antibody-based treatments. These are immune-based proteins that can help to fight lymphoma by activating the immune system and interacting with lymphoma cells. The earliest of these was rituximab, which has been commonly used for lymphoma patients for over 15 years, particularly in follicular lymphoma. There are a couple of new antibodies similar to rituximab (ofatumumab [Arzerra] and tositumomab) that are being tested in clinical trials. There are also new immunoconjugates (ibritumomab tiuxetan [Zevalin] and tositumomab [Bexxar]) where the antibody is hooked to a toxic molecule or a drug to more specifically deliver the toxic molecule to the tumor cells, potentially causing less toxicity to healthy tissue and the patient as a whole.
Another category is immunomodulatory drugs, particularly lenalidomide (Revlimid), a cousin of thalidomide (Thalomid). Lenalidomide is a pill that activates the immune system and has a number of direct and indirect effects against the lymphoma cells. It is being studied both alone and in combination with other treatments.
There are a whole category of drugs called kinase inhibitors. These are drugs that impact a number of the different switches on the lymphoma cells that regulate various pathways that are involved in lymphoma cell growth and resistance to treatment.
There is another category called pro-apoptosis drugs. Apoptosis is the process where cells normally die off. In lymphoma cells, these pathways can be broken or disrupted. There are a number of different drugs that can induce the cell to die off like it was supposed to in the normal state. This can have positive effects against the lymphoma.
What advice would you give to a newly diagnosed patient?
Make sure the lymph node biopsy results are reviewed by an experienced hematopathologist to be sure of their diagnosis. These are the pathology experts that focus on lymphoma and related diseases. Try to be seen by a lymphoma expert, somebody who specializes in lymphoma and is experienced in seeing lymphoma patients. Many subtypes of lymphoma are uncommon. Certainly having a second opinion from a lymphoma expert, if possible, is a good idea. Learn about the disease and clinical trials. The Lymphoma Research Foundation (LRF), among others, is a great source for that information. It is important to explore the possibility of clinical trials and whether or not a clinical trial might be appropriate for, and helpful, to an individual patient.
How are you involved with the Lymphoma Research Foundation, and why would you recommend that a patient become involved with the organization?
I’ve been involved with LRF for many years. I’m currently the Chairman of the Scientific Advisory Board for LRF. The Scientific Advisory Board is involved in various aspects of the medical and scientific activities of LRF. We review LRF funded grants and provide guidance to the Foundation leadership with respect to scientific and research directions, as well as medical issues with which the organization should be involved. I’ve also been involved in various aspects of the patient education programs that LRF organizes, and I think these are great resources for patients.
I think that supporting and getting involved with thLRF is a great idea. LRF is a way to connect with other patients. It is a way to learn about the disease, and to contribute to the progress that’s being made in lymphoma. LRF is a great organization that makes a tremendous impact upon the lives of patients with and their families with lymphoma.