Despite Advances, Many Questions Remain in Mantle Cell Lymphoma Treatment

Izidore S. Lossos, M.D., discussed how questions remain on how to find the least toxic therapies that will prolong survival in both young and elderly patients with mantle cell lymphoma.
BY Kristie L. Kahl
PUBLISHED April 09, 2019
While significant advances have been made in the treatment of mantle cell lymphoma (MCL), certain questions still remain among certain subgroups of patients, according to Izidore S. Lossos, M.D.

In particular, many still question which treatment regimens should be used in the elderly versus younger patients with MCL. “When it comes to MCL, we divide therapy according to the age and the fitness of the patient,” explained Lossos, professor and director of the Lymphoma Program and head of the Hematological Malignancies Site Disease Group at the Sylvester Comprehensive Cancer Center at the University of Miami Health System.

In young, fit patients, there are two approaches: cytarabine-based chemotherapy followed by transplant or trying to avoid a transplant and use aggressive chemotherapy. Lassos mentioned that one randomized trial – presented by the European-MCL Network – showed that transplant may induce an improvement in progression-free (the time from treatment to disease worsening or progression) and overall survival compared with not using it in these patients. However, the specific regimen that was used in that protocol may not be the optimal regimen, he added.

In addition, researchers from The University of Texas MD Anderson Cancer Center in Houston are currently performing an ongoing study combining hyper-CVAD (cyclophosphamide, vincristine sulfate and Adriamycin [doxorubicin hydrochloride])with Imbruvica (ibrutinib) to try to improve outcomes without transplant.

“Other regimens that are more aggressive may eliminate the need for transplant. This question still needs to be addressed,” Lassos said.

For elderly patients, oncologists appear to moving toward nonchemotherapy-based regimens. For example, the combination use of Revlimid (lenalidomide) and Rituxan (rituximab) as induction therapy has demonstrated estimated progression-free and overall survival rates of 64% and 77%, respectively, in a phase 2 trial.

“In the elderly population, I would not use transplant,” Lassos said. “We’re trying to give treatment without chemotherapy. Follow-up data were presented on the use of (Revlimid and Rituxan) and showed that you can achieve long-term responses and remissions that are very similar to what you would achieve with a chemotherapy-based regimen.”

In patients with relapsed MCL, the addition of Venclexta (venetoclax) to a BTK inhibitor has shown promise as well. “Overall, we’re trying to move toward the use of nonchemotherapy approaches in elderly patients,” Lassos added, saying that researchers need to find the least toxic therapies that will prolong survival for these patients.

“The median survival of this disease 10 to 15 years ago was three to five years. Currently, it's seven years, and we're trying to improve upon that,” he explained. “There are new approaches with cyclin dependent kinase inhibitors, but the data are quite preliminary.”

This article was adapted from an article originally published by OncLive, titled “Despite Progress in Follicular Lymphoma and MCL, Critical Questions Remain.”
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