Dr. Kahl on the Evolving Standard of Care in MCL

Brad S. Kahl, MD, professor, Department of Medicine, Oncology Division, Medical Oncology, Washington University School of Medicine in St. Louis, and medical oncologist, Siteman Cancer Center, discusses current best practices for the treatment of older patients with mantle cell lymphoma (MCL), as well as where the treatment paradigm might lead in the future.

One of the most effective and tolerable treatment options for older patients with MCL is bendamustine plus rituximab (BR; Rituxan) followed by rituximab maintenance therapy, Kahl says. The optimal duration of maintenance rituximab therapy has yet to be determined, and long-term rituximab maintenance therapy may lead to increased toxicity, Kahl explains. For this reason, stopping rituximab maintenance therapy after 2 years is common and may allow for eventual B-cell recovery, Kahl notes.

Additionally, data from the phase 3 SHINE trial (NCT01776840) showed that ibrutinib (Imbruvica) plus BR and rituximab maintenance therapy led to an increase in progression-free survival (PFS) in patients with MCL over the age of 65, Kahl says. Specifically, adding ibrutinib to this regimen resulted in a median PFS of 80.6 months compared with 52.9 months in the placebo arm. However, the investigative combination did not show an overall survival benefit, making the decision about whether to add ibrutinib to the current regimen a nuanced and patient-centric one, Kahl explains.

Going forward, the future of MCL treatment may be influenced by findings from the phase 3 ECHO trial (NCT02972840), which is investigating acalabrutinib (Calquence) in combination with BR; the phase 2 E1411 study (NCT01415752), which is looking at lenalidomide (Revlimid) plus rituximab maintenance therapy; and the phase 3 MANGROVE trial (NCT04002297), which is studying zanubrutinib (Brukinsa) plus rituximab as a chemotherapy-free approach, Kahl concludes.