Follicular Lymphoma Treatment

Follicular lymphoma (FL) is one of the most common types of non-Hodgkin Lymphoma, or NHL. It is a slow-growing lymphoma, and often it’s not immediately life threatening. Because it grows slowly and inconspicuously, most people do not recognize any problems while the disease is in its early stages. By the time the disease is diagnosed most patients (80%-85%) have widespread disease that often involves many lymph node areas, the bone marrow, spleen or other organs.

Slow Growing, but Difficult to Cure Completely

Even in the advanced stages, people with FL often survive for many years with standard treatment, due to its slow-growing nature. However, the disease is not curable. Most people respond well to treatment, and the disease can be stabilized for a few years before relapsing and requiring treatment again. Many patients require to be treated many times, with intervals of a stable disease after each treatment that may last months to many years.

Few people are lucky to be diagnosed while the disease is still in its early stages. These individuals can usually be cured. Radiation treatment is oftentimes used as monotherapy. It has been seen that moderate doses of radiation given to affected areas of the body in those with localized disease can control the disease permanently. There is no additional benefit of adding chemotherapy or biological agents.

Treatment Depends in Part on Staging

A variety of tests may be done for the purposes of staging, including:

• Blood tests
• Bone marrow biopsy—taking a small sample of tissue from the bone marrow
• Computed tomography, or CT scan
• Positron emission tomography, or PET, scan

Staging refers to the extent of spread. Different staging systems have been in use, but here is one commonly used system that has four stages:

• Stage I: Only one lymph node region is involved, or only one structure is involved.
• Stage II: Two or more lymph node regions or structures on the same side are involved.
• Stage III: Lymph node regions or structures on both sides are involved.
• Stage IV: There is widespread involvement of a number of organs or tissues other than lymph node regions or structures, such as the bone marrow.

About 15% to 20% of people with FL have stage II or I disease at diagnosis.

Over 40% have stage IV disease at diagnosis.

Grading refers to how aggressive the FL appears to be based on microscopic characteristics. FL can be graded as either 1, 2, or 3, with grade 3 being the most controversial in terms of what it means for the outcome.

Approach to Treatment

Oftentimes, FL is slow growing and lacks aggressive characteristics. Both the decision to treat as well as the first-line treatment of choice may be influenced by a number of factors, including a person's candidacy for clinical trials, overall health and the manner of presentation of the disease. Specific preferred treatments may vary for different individuals and for different kinds of FL—and even for two individuals with the same kind of FL.

According to the 2019 National Comprehensive Cancer Network (NCCN) guidelines, observation—rather than treatment—may be appropriate in certain circumstances. When treatment is pursued, with regard to first-choice treatment, NCCN guidelines include a variety of options for different situations. Use of bendamustine plus rituximab is one such option. Radiation therapy may also have a role. In fact, stage I FL may be treated using radiotherapy alone.

Treating doctors may suggest alternatives for first-choice therapy based on expectations regarding how well a person might be expected to tolerate a given therapy.

Treatment options generally include the following:

• Active surveillance
• Chemotherapy in the form of pills
• Infusion chemotherapy
• Chemotherapy and biological therapy
• Bone marrow or stem cell transplants
• Radioimmunotherapy
• Immunotherapy, such as monoclonal antibody treatment, immunomodulators, kinase inhibitors, and chimeric antigen receptor (CAR) T-cell therapy

How Is the Treatment Decided?

Treatment is decided based on a number of different factors, including the goal of treatment and the presence of symptoms from the disease. Guidelines from the National Comprehensive Cancer Network offer a number of different approaches to the treatment of FL at varying stages, however, different practices may be followed at different institutions, and patient wishes and goals are also involved.

What About Gazyva for Follicular Lymphoma?

Gazyva is a monoclonal antibody receiving attention for its use in FL. “People with follicular lymphoma whose disease returns or worsens despite treatment with a Rituxan-containing regimen need more options because the disease becomes more difficult to treat each time it comes back,” said Sandra Horning, M.D., Genentech's chief medical officer and head of Global Product Development. “Gazyva plus bendamustine provides a new treatment option that can be used after relapse to significantly reduce the risk of progression or death.”

The Food and Drug Administration (FDA) approval of Gazyva was based on results from the Phase III GADOLIN study, which showed that, in people with FL whose disease progressed during or within six months of prior Rituxan-based therapy, Gazyva plus bendamustine followed by Gazyva alone demonstrated a 52% reduction in the risk of disease worsening or death (progression-free survival, PFS), compared to bendamustine alone.