Indolent Non-Hodgkin's Lymphoma Treatment Selection

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The treatment of patients with non-Hodgkin’s lymphoma (NHL) has undergone a dramatic and exciting transformation, with many novel and emerging agents providing new hope for patients, Myron Czuczman, MD, states. There are several subtypes of NHL, including follicular lymphoma (FL), mantle cell lymphoma, and diffuse large B-cell lymphoma. Treatment approaches for each of these subtypes vary, based on effective agents and patient characteristics.

Various clinical trials have contributed to current standards of care for the frontline treatment of patients with indolent NHL, notes Czuczman. The BRIGHT trial compared bendamustine/rituximab (BR) to either R-CVP (rituximab, cyclophosphamide, vincristine, prednisone) or R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) in patients with indolent NHL and mantle cell lymphoma. The study found that the complete response (CR) rate with BR therapy was noninferior to the standard therapy by independent review committee assessment. In the BR arm, the CR rate was 31% compared with 25% in the standard therapy treatment group (CR-rate ratio = 1.26; P = .0225).

These results, coupled with the positive safety profile of BR, suggest this combination may be a good alternative to the standard R-CHOP/R-CVP regimens. Czuczman states that it can be very difficult to differentiate between stage IIIa and IIIb FL. In a patient with symptomatic bulky stage IIIa FL, treatment with an anthracycline-based regimen should be considered.

In addition to this regimen, many of the agents being used for chronic lymphocytic leukemia (CLL) are also being utilized for patients with indolent NHL. These novel agents are helping patients achieve remission, thereby delaying the need for an immediate autologous stem cell transplant, Czuczman notes.

In July 2014, the FDA approved idelalisib in combination with rituximab as a treatment for patients with CLL, FL, and small lymphocytic lymphoma (SLL). In patients with relapsed indolent NHL, treatment with single-agent idelalisib demonstrated an overall response rate of 54% for patients with FL and 61% for patients with SLL. Additionally, ibrutinib in combination with R-CHOP has demonstrated striking response rates in patients with NHL.