VIDEO: Exploring available treatment options in DLBCL

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With large cell lymphoma, at least in the frontline setting, there's still the old standard bearer, which is R-CHOP, which is rituximab (Rituxan; Genentech, Biogen), [cyclophosphamide (Cytoxan, Bristol-Myers Squibb)], adriamycin, vincristine, and prednisone. This past year we added to the NCCN Guidelines R-CHP-Pola, which is similar, rituximab, Cytoxan, adriamycin, and prednisone. But they replaced the vincristine with a drug called polatuzumab (Polivy, Genentech), which is a CD79B drug antibody conjugate. So because of the POLARIX trial that was indicated a progression of survival benefit compared to R-CHOP, this was added to the NCCN Guidelines. Sort of as far as that diagnostic dilemma, it appears that R-CHP-Pola is more effective, at least in subset analysis, in patients who have what we consider to be a non-germinal center subtype, which is the closest we can get to making a true diagnosis of activated B-cell subtype without seeing sending off molecular testing. The trial and the label itself does not specifically say that any patient with an IPI score two or higher does qualify for R-CHP-Pola.

There's been a lot of controversy in the medical, sort of, field, at this point of how to use R-CHP-Pola. Some people are using it universally across the board, some people are only using it for the non-germinal center subtype, and some people are just not using it. But at least for large-cell lymphoma without sort of IRS features, this is what we would use. Patients who have double hit-lymphoma meaning they have a FISH translocation of BCL2 plus or minus BCL6, depending on how you look at that and C-MYC, those patients I generally treat with R-dose-adjusted EPOCH that is really based off a retrospective trial. We don't really have any true prospective studies looking at treatment outcomes in that patient population.