VIDEO: Treatment considerations for relapsed, refractory follicular lymphoma

Editor’s note: This is a previously posted video, and the below is an automatically generated transcript to be used for informational purposes. Please notify editor@healio.com if there are concerns regarding accuracy of the transcription.

The way we treat follicular lymphoma, you make an upfront decision about whether you're gonna do cytotoxic chemo or whether you're going to do lenalidomide or rituximab. Those are probably the two, the two things that are competing in the frontline space right now. And so, bendamustine/rituximab or bendamustine/obinutuzumab or R-CHOP for patients that have very high burden of disease or also fit maybe who have follicular two or three. So those are the cytotoxic options that are you choosing between in a frontline. And then in relapse refractory, you kind of get whatever you didn't get in front line. So in frontline, you got a lenalidomide/rituximab. Then most people would give bendamustine/rituximab for first progression or relapse. And it's reversed, if you got bendamustine/rituximab or R-CHOP frontline, then most oncologists hematologists would give lenalidomide rituximab second line. You know, you're making considerations based on the patient's fitness, organ toxicities, other problems, but essentially it's like you get one and then you get the other. That's first relapse. Second progression. So after you progressed on chemo, immunotherapy, and you progressed on IMiD, rituximab, now you have drugs that are used much less that most people are not that familiar with, the PI3 kinase inhibitors. And we have four drugs competing in that space, Copanlisib, Duvelisib, Alpelisib and Umbralisib. And so those PI3 kinase inhibitors, they have 30 to 40% response rates, not bad. They have different ways of administering and they have daunting toxicity. So, you know like, if you live far away from the cancer center, then you'll probably be getting an oral PI3 kinase inhibitor. Those drugs all have essentially the same mechanism of action. Different number of kinases that are inhibited based on the exact molecule, but they pretty much all cause nausea, diarrhea, as their main side effects. We also have Tazemetostat which is an, which is a EZH2 inhibitor that competes with the PI3 kinase inhibitors, in the third line setting in follicular lymphoma. There's no really good rationale to choose between them. You're kind of choosing based on side effect profile and you know, you might try it and see if the patient is able to do it. And then if not try the other one, those are the low intensity treatment approaches for relapsed third line follicular lymphoma, and then in third line people are eligible for CAR T. So that is the other new approval, that follicular lymphoma is now possible to administer CAR T it's, FDA approved. That's pretty much the third line landscape for follicular lymphoma.