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Department Chair, Department of Lymphoma/Myeloma
Division of Cancer Medicine
University of Texas MD Anderson Cancer Center
Christopher R. Flowers, MD, MS, has disclosed that he has received consulting fees from AbbVie, Bayer, BeiGene, Celgene, Denovo Biopharma, Genentech/Roche, Gilead Sciences, Karyopharm, MEI Pharmaceuticals, Pharmacyclics/Janssen, and Spectrum; has received funds for research support from AbbVie, Acerta, Celgene, Gilead Sciences, Genentech/Roche, CPRIT, Janssen, Millennium/Takeda, Pharmacyclics, Therapeutics, Burroughs Welcome Fund, ECOG, NCI, and V Foundation.
In 2018, 4 colleagues and I developed an online interactive treatment decision tool for frontline management of follicular lymphoma (FL) to help guide healthcare professionals in rational treatment selection for various patient case scenarios in the setting of newly diagnosed disease. In 2019, we followed with a tool for navigating treatment decisions in the relapsed/refractory (R/R) setting. To address the continuing evolution in the treatment of patients with FL, my colleagues and I incorporated new findings into a combined treatment decision support tool for both newly diagnosed and R/R FL and the updated version was recently launched.
Considerations in the Clinical Management of FL
The clinical management of FL is becoming increasingly complex. When planning a treatment course for newly diagnosed patients, one must consider disease stage and grade, tumor burden or bulk, presence of symptoms, and age and fitness. The first-line treatment plan may also take into consideration potential options for therapy at relapse. Management of R/R FL requires additional considerations, including previous therapies, duration of response to previous therapies, presence of histologic transformation, and now specific molecular characteristics, such as the presence of an EZH2 mutation. Individualized treatment plans should also take patient goals and preferences into consideration.
Management options for FL, whether newly diagnosed or R/R, range from watchful waiting to systemic treatment with chemoimmunotherapy incorporating an anti-CD20 antibody (rituximab or obinutuzumab). In the setting of R/R FL, clinicians may also need to consider using newer agents with mechanisms of action distinct from that of previous therapies on which the disease has already progressed. For example, approval of the PI3K inhibitors idelalisib, duvelisib, and copanlisib for the treatment of R/R FL after 2 previous therapies and umbralisib for the treatment of R/R FL after 3 previous therapies provides clinicians the opportunity to circumvent resistance to chemotherapy or rituximab by aiming at a distinct target in disease pathogenesis. Similarly, approval of tazemetostat, a first-in-class EZH2 inhibitor, provides another option for patients with R/R FL and an EZH2 mutation who have received at least 2 previous therapies and for patients with R/R FL who have no satisfactory alternative treatment options. However, prospective data regarding outcomes associated with sequencing of therapy in the R/R setting remains an unmet need, and we believe that health care professionals can benefit from additional guidance on developing treatment plans from this tool.
Navigating the Updated Treatment Decision Tool for FL
The updated FL treatment decision support tool provides treatment consultation and recommendations from 5 lymphoma experts for 264 defined patient case scenarios in both the newly diagnosed and R/R settings. As a user of the tool, you are able to enter key patient and disease characteristics to define the different patient scenarios for which you are interested (Figure 1).
Figure 1. Entering patient and disease characteristics into the tool.
Once the information for your particular patient scenario has been defined, you are able to indicate your intended treatment choice. After entering your treatment choice, you will be shown the individualized treatment recommendations from all 5 of the experts for that combination of patient and disease characteristics, allowing you to compare them with your intended therapy (Figure 2).
Figure 2. Expert treatment recommendations.
Through this approach, users of the tool can identify clinical scenarios where experts agree on the best treatment options and other scenarios where the available supporting evidence does not clearly favor one treatment over others, and consequently, there is more diversity in expert recommendations.
We hope that you will try this tool and find it useful in the care of your patients with FL.
The goal is to routinely update this online tool so that our recommendations continue to include consideration of emerging data and newly available agents. For example, CAR T-cell therapy was recently approved for FL in March 2021 and bispecific antibody therapies are currently being investigated in early-phase clinical trials for patients with R/R indolent non-Hodgkin lymphoma, including FL. We expect that these and other therapies will join our current armamentarium outside of clinical trial enrollment.
If you have any suggestions regarding this online tool, please be sure to leave a comment below.