Blood cancers

Follicular lymphoma: new guidelines should take focus off overtreatment

Associate Professor Judith Trotman

Updated guidelines on the management of follicular lymphoma point to ever increasing personalised medicine for a condition where survival has increased substantially over the past 30 years.

Advances in imaging and understanding of disease staging as well as calculation of prognosis based on response to first-line therapy are all important in tailoring a management plan for the individual patient, according to new recommendations from the British Society of Haematology.

Yet a “watch and wait” approach remains a good option in asymptomatic patients with “little justification for immediate treatment in patients with advanced stage, asymptomatic disease” where toxic side effects can be deferred or avoided, they advise. Induction rituximab monotherapy may also be considered as a safe and cost‐effective therapy in these patients.

FDG‐PET/CT is the preferred staging modality for FL but contrast‐enhanced CT is an acceptable alternative, the guidelines  – updated from previous 2011 recommendations – suggest.

For newly diagnosed patients with symptomatic FL it is clear that an anti‐CD20 monoclonal antibody should be added to chemotherapy, but there is less consensus over which chemotherapy it should be paired with, according to the guidance.

Clinicians need to be guided by the individual patient in making decisions over treatment options and patients wherever possible should be enrolled in clinical trials – especially those with early progression following primary therapy where more research is needed, the guideline panel recommended.

Meanwhile, more evidence is needed for several emerging novel treatments before they can be adopted in routine practice – including the addition of lenalidomide and potentially CAR-T cell therapy.

Professor Judith Trotman, a haematologist at Concord Repatriation General Hospital, Sydney, said in an accompanying editorial that the update was welcome as there had been significant developments in understanding of FL and therapeutic approaches in the last decade.

“With advances in immunochemotherapy and supportive care, these 2020 guidelines reflect a subtle yet powerful change in emphasis. They avoid this usual adjective ‘incurable’, pointing instead to patients’ long overall survival,” she said.

The updated recommendations  charted a way to finesse a personalised approach to maximising patient chances of healing while minimising toxicity of therapy, she added.

“The guidelines highlight that initial therapy is part of a long-term strategy and should be developed after multidisciplinary peer review, reflecting that now we no longer have a ‘one-size-fits-all’ approach for patients with good fitness and cardiac function but numerous treatment options, some of which may compromise future choices.

“As clinicians both within and beyond the UK adopt these guidelines let us focus in 2020 not on overtreating too many patients in an effort to reduce a small risk of early progression or transformation.”

“Let us properly acknowledge, but not unduly emphasise, the risks of relapse and refractory disease.”

The lead author of the guidelines, Dr Christopher McNamara from the University College London Hospitals, told the limbic that updated guidelines were the result of significant collaboration among specialists from several disciplines.

“We hope that it [the guidelines] convey that people with follicular lymphoma now have access to a wider range of treatments, with the prospect of several new and exciting approaches likely to be available soon.”

“The identification of people at higher risk who require alternatives to the current standard of care is an important and growing need that requires ongoing clinical trial research,” he added.

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