Associate Professor of Medicine, Director of the Lymphoma Program, University of Chicago
Please describe follicular lymphoma (FL).
Follicular lymphoma is an indolent, or slow-growing, non-Hodgkin lymphoma (NHL). The disease can have a variable course. In some patients it can stretch out over decades—something that patients live with, similar to a chronic disease—and in other patients it can be somewhat more aggressive, requiring repeated treatments over a period of several years.
How common is FL?
FL is the second most common type of NHL in the United States. Of the approximately 70,000 new cases of NHL diagnosed in the United States, about 20% are FL. Because it is often a slow-growing disease that does not cause symptoms, there are thousands of patients who are living with the disease.
How is FL typically treated?
Appropriate management varies, and patients should always discuss options with their physician.
For people who are newly diagnosed, initial treatment decisions depend on the degree of patient symptoms and how quickly the lymphoma is growing. Management options range from “watch and wait,” to radiotherapy for patients with very early stage disease, to the use of monoclonal antibodies, or to chemotherapy plus monoclonal antibodies or radioimmunotherapy.
If the lymphoma returns, there are many options. Some patients whose disease returns still experience a very low volume of disease. Again, “watch and wait” may be appropriate, or treatment with monoclonal antibodies, radioimmunotherapy, chemotherapy, or the combination may be warranted. For many patients, a form of treatment called “maintenance” is appropriate. Maintenance therapy currently uses periodic doses of rituximab (Rituxan) for two years after a patient is in remission in order to keep the disease under control for as long as possible.
Transplant is also an option for appropriate patients in first or second relapse. It is very important that patients discuss stem cell transplantation options with their physician and an experienced transplant center. Once there have been more than two relapses, many patients are often symptomatic; at this point, cycles of treatment and remission are common. Many new drugs are being tested in this context.
What are some of the current areas of research for FL?
FL is one of the most exciting areas of current NHL research. We are learning new ways to use existing tools like the monoclonal antibody, rituximab—looking at maintenance schedules to prolong the duration of response to different chemotherapies. In addition, there have been some very important advances, recently, in our understanding of FL biology, which have led directly to multiple new agents being studied. New chemotherapy drugs over the last few years, such as bendamustine (Treanda), are generally better tolerated than many drugs used in the past. Bendamustine has a more favorable side effect profile compared to other chemotherapy, and its duration of response is very impressive. There are new agents that target some of the most important pathways in FL. For example, PCI-32765 is a new agent that is currently being tested that can block the B-cell receptor signaling pathway. CAL-101 is an agent that blocks a different pathway called PI3 kinase, which is also very exciting. There are multiple new monoclonal antibodies, such as GA-101 and ofatumumab (Arzerra), that hold promise, either following rituximab or even preceding rituximab. In addition, there are many “antibody-drug conjugates” that link a monoclonal antibody to either a toxin or to a radiolabelled compound. Finally, lenalidomide (Revlimid), which is an immunomodulatory agent, is extremely active in FL, particularly when combined with rituximab. Over the last five or six years, we have come to understand that it is not just the cancer cell itself that contributes to lymphoma progression, but also the cells that surround that cancerous cell, which support and nurture the lymphoma cell and keep it from responding to chemotherapy. Lenalidomide targets this lymphoma “microenvironment.” There are now several studies of rituximab and lenalidomide in combination, both in patients who have already had multiple therapies as well as patients who have never been treated.
Do you recommend enrollment in clinical trials to your patients?
Yes, absolutely. Right now at my institution there are about 15 clinical trials available for patients with different types of lymphoma and different phases of the disease. Offering clinical trials is a major mission of our program.
Do you recommend that your patients become involved with the Lymphoma Research Foundation (LRF)?
I recommend to all of my patients that they visit LRF’s main page on the web as well as their new disease-specific follicular lymphoma site, Focus On FL, particularly those who are newly diagnosed, but also patients whom I’ve known for years. As I’ve come to know the organization more and more, I’m really impressed by their dedication to patients and to patient education. They also have a scientific mission through their grants and workshops for physicians.
The local chapters are great. They have helped my patients network with other patients who have been through similar situations. They provide one extra measure of comfort to my patients to know that there are people out there who have gone through this experience before and can provide support. LRF also holds patient education forums throughout the country; I encourage my patients and their family members to attend so that they can gain a general knowledge about this complex disease and the major treatment approaches.
Is there anything else you would like to add?
I would like to emphasize the importance of enrolling into clinical trials. All of the progress made so far is because scientists, physicians, and patients are in a partnership to improve the management and treatment of FL. There are excellent resources available with lists of clinical trials, including www.clinicaltrials.gov. Many academic centers also list active trials on their websites.
Updated: March 14, 2012