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Follicular lymphoma (FL) is a common type of non-Hodgkin lymphoma (NHL) that remains difficult to cure
.
In recent years, FL treatment has made many progress, but there are still about 20% of patients with early progression or recurrence and poor prognosis, and how to further optimize treatment strategies and use appropriate prognostic models to better evaluate the prognosis of patients remains to be explored
.
To further explore the benefits of anti-CD20 monoclonal antibody maintenance therapy in FL patients in China, the Department of Internal Medicine-Lymphoma Treatment Team, Cancer Hospital of the Chinese Academy of Medical Sciences, conducted a single-center retrospective study
with follow-up of more than 5 years.
Yimaitong sincerely invited Professor Liu Peng from the Cancer Hospital of the Chinese Academy of Medical Sciences to share the research situation and the progress and development direction of FL treatment, in order to bring enlightenment to the clinical diagnosis and treatment of hematological tumors
.
*R-CHOP, rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone
Yimaitong: In the era of immune-targeted therapy, the survival prognosis of FL patients has been greatly improved, how do you think about the status of chemotherapy in FL treatment?
Professor Peng Liu
With the advancement of immuno-targeted therapy, especially the era of rituximab, the treatment model of lymphoma has changed greatly, including FL, which is generally considered incurable, and its 10-year survival rate has also increased from about 50% to 70-80%1
.
Although some researchers are trying the "chemo free" treatment model, chemotherapy is still an indispensable part of
treatment for most FL patients who need treatment.
At present, the classic regimen of FL treatment is immuno-targeted therapy combined with chemotherapy, and the combination regimen is constantly improving and optimizing, exploring the benefits of bendamustine-containing chemotherapy regimen and the rationality of anthracycline-free therapy, in order to bring higher quality long-term survival
to patients.
Yimaitong: It is understood that your Chinese Academy of Medical Sciences Cancer Hospital Internal Medicine-Lymphoma Treatment Team conducted a real-world study (RWS) with more than 5 years of follow-up for the first time in the era of rituximab in the era of advanced FL in China, and explored the impact of
anti-CD20 monoclonal antibody maintenance therapy on patients' treatment outcomes.
How did you consider and design the study? And what are the results of the treatment?
Professor Peng Liu
The rationality of FL treatment has been a hot topic, such as which first-line treatment option to choose, whether patients need maintenance therapy after achieving remission, and how to evaluate the treatment economics of FL in the context of medical insurance; And so on
.
Since the publication of the long-term follow-up results of the PRIMA study, most clinicians have reached a preliminary consensus on maintenance therapy, believing that FL patients need maintenance therapy after first-line treatment, and receive at least anti-CD20 monoclonal antibody maintenance therapy every two months for two years
。 However, the lack of large-scale Chinese data in existing studies may be related to the relatively lower incidence of FL in China, and the results of FL patients in China may be different from those in Europe and the United States, and we have no way of knowing whether there is a definite survival benefit
for FL patients receiving maintenance therapy in real life in China.
Moreover, there is no consensus
on whether these FL prognostic models developed based on European and American patient data are applicable in the prediction of efficacy in Chinese patients, and which prognostic model is better.
Therefore, it is interesting and interesting to conduct a retrospective study of long-term follow-up in Chinese patients with advanced FL
.
The results of the study showed that after adjusting for baseline factors, rituximab maintenance therapy was associated with longer progression-free survival (PFS; HR = 0.
212; 95% CI, 0.
097-0.
462; P<0.
001) and overall survival (OS; HR=0.
120; 95% CI, 0.
024-0.
592; P=0.
009) significantly correlated, demonstrating that maintenance therapy with rituximab confers a better survival benefit for patients with FL2
.
At present, the new anti-CD20 monoclonal antibody obinutuzumab has been approved in combination with chemotherapy for patients with treatment-naïve FL, and in the global phase III GALLIUM study with a median follow-up of 8 years, patients receiving obinutuzumab plus chemotherapy and receiving maintenance therapy for two years still had more PFS benefit than rituximab group (7-year PFS rate 63.
4% vs 55.
7%, P=0.
006), 74.
1% In patients who have not started their next antineoplastic therapy within 7 years, maintenance therapy with obinutuzumab further reduces the risk of disease progression and death by 23%3,4
.
There is currently no ideal model to accurately predict the prognosis of FL patients, and this study compared the four most commonly used models in FL (FLIPI, FLIPI2, PRIMA-PI, and LDH+β2M) to determine the best model
for Chinese FL patients receiving immunochemotherapy.
Could you please briefly introduce the results of the study and what the results mean for the treatment of FL in China?
Professor Peng Liu
In the pre-rituximab era, researchers have explored prognostic models of FL, and the four most commonly used clinical models are FLIPI, FLIPI2, PRIMA-PI and LDH+β2M
.
FLIPI and FLIPI2 have different emphases, with FLIPI likely to consider the prognosis of the patient's lymph node region, while FLIPI2 focuses on the impact of the patient's tumor burden on the patient's survival, including the maximum diameter of the largest lymph node, the presence of bone marrow invasion, and the level of
β2 microglobulin.
PRIMA-PI and LDH+β2M can determine tumor status more comprehensively, for example, PRIMA-PI is based on β2 microglobulin level and bone marrow involvement, LDH+β2M can assess tumor burden and tumor activity
.
However, in clinical care, physicians often need to consider which prognostic model to choose under specific conditions to evaluate more likely outcomes, such as for patients
receiving first-line chemotherapy combined with immunotargeted therapy.
The study found that compared to the other three models, FLIPI2 not only covered the age of the patient, but also more comprehensively evaluated the patient's overall condition, including the patient's physical performance and tumor burden.
Therefore, it is believed that FLIPI2 is superior to the other three models in Chinese advanced FL patients receiving first-line immunochemotherapy, and can better stratify
patients at risk.
Yimaitong: The new anti-CD20 monoclonal antibody obinutarzumab has been approved for use in combination with chemotherapy for treatment-naïve FL patients, and monotherapy for maintenance therapy, how do you see the relationship between rituximab and obinutarzumab?
Professor Peng Liu
The ancient Greek philosopher Heraclitus once said, "Man cannot step into the same river
twice.
" "Nowadays, science is constantly improving, and FL's therapeutic drugs are constantly being optimized and upgraded
.
A GLOBAL PHASE III GALLIUM STUDY WITH A MEDIAN FOLLOW-UP OF 8 YEARS SHOWED BETTER SURVIVAL AND A CLEAR IMPROVED RISK OF POD24 IN PATIENTS WITH ADVANCED FLO WHO RECEIVED FIRST-LINE OBINUTUZUMAB AND SUBSEQUENT MAINTENANCE THERAPY COMPARED WITH RITUXIMAB.
As far as the results of the current study are concerned, there is no doubt that obinutuzumab is superior to rituximab, but given that FL patients have a long survival period, it is necessary to evaluate different dimensions of treatment in the future, such as whether there are long-term advantages of treatment and treatment economics, which deserve further study
.
Yimaitong: In recent years, the emergence of many new drugs and new therapies is constantly changing the treatment strategy and treatment pattern of FL, please make a look forward
to the development direction of FL treatment.
Professor Peng Liu
In recent years, with the emergence of more small molecule targeted drugs and immunotherapy represented by CAR-T, the survival prognosis of FL patients has been further improved
.
Researchers are very interested in the mechanism of action of small molecule-targeted drugs blocking the signal transmission process in tumor cells, thereby effectively controlling tumor progression, and will carry out more explorations
in this area in the future.
In the future, FL treatment must be a treatment option
that combines better efficacy with better safety.
It is believed that with the advent of the era of precision diagnosis and treatment, more treatment options suitable for FL patients have come out, giving FL patients a longer future
.
brief summary
At present, there is no cure for FL, and how to further optimize treatment strategies and use appropriate prognostic models to better assess the prognosis of patients remains to be explored
.
Maintenance therapy with anti-CD20 monoclonal antibody has a significant survival benefit in Chinese patients with advanced FL receiving first-line immunochemotherapy, and most clinicians have agreed on
the need for maintenance therapy.
The advent of the new anti-CD20 monoclonal antibody obinutuzumab is expected to further improve the survival of patients on the basis of rituximab, and will continue to explore treatment options with better efficacy and higher safety in the future, benefiting more FL patients
.
Professor Peng Liu
Doctor of Medical Oncology, Chief Physician, Master Supervisor
Department of Internal Medicine, Cancer Hospital of Chinese Academy of Medical Sciences/National Cancer Center
Vice Chairman of the Youth Committee of the Oncology Branch of the Chinese Medical Doctor Association
Vice Chairman/Deputy Secretary-General of Medical Oncology Branch of China Medical Promotion Association
Member of the Standing Committee of the Lymphoma Special Committee of the Chinese Anti-Cancer Association
Member of the Standing Committee of the Cancer Chemotherapy Special Committee of the Chinese Medical Education Association
Chairman-elect of the Lymphoma Immunotherapy Committee of the Beijing Cancer Control Society
Member of the Cancer Prevention and Treatment Committee of the Cross-Strait Medical and Health Exchange Association
Member of Clinical Pharmacy Committee of Beijing Medical Association
Editorial Board Member of "Cancer Prevention and Research" and "Cancer Pharmacy"; Corresponding editorial board member of Chinese Medical Journal (CMJ English Edition) and Journal of Chronic Diseases and Translational Medicine
References:
1.
Bachy E, et al.
J Clin Oncol.
2019 Nov 1; 37(31):2815-2824.
2.
Zhou Y, et al.
Asia Pac J Clin Oncol.
2021 Jun; 17(3):289-299.
3.
Hiddemann W, et al.
J Clin Oncol.
2018 Aug 10; 36(23):2395-2404.
4.
Townsend W, et al.
EHA 2022 Oral #S206.
Editor: Chole Reviewed: Evelyn Typesetting: Moly Execution: Moly
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