Expert Discusses Exploring Alternative Treatments for Large Cell Lymphoma

Patients with activated B-cell-like lymphoma may not respond to standard treatment, so new options are being explored.
Patients with large cell lymphomas who fall under the activated B-cell-like (ABC) subtype are not very likely to respond well to R-CHOP, the standard approach of care.

Alternative treatments for these patients are being investigated, such as the regimen of Rituxan (rituximab), Etopophos (etoposide phosphate), prednisone, Oncovin (vincristine sulfate), cyclophosphamide and doxorubicin hydrochloride (R-EPOCH). Researchers are anticipating phase 3 results comparing R-EPOCH with R-CHOP, explains Loretta J. Nastoupil, M.D.

Combination regimens with R-CHOP are also being explored, including one with Revlmid (lenalidomide) (NCT02285062) and one with Imbruvica (ibrutinib), a BTK inhibitor that has shown promise in chronic lymphocytic leukemia (NCT01855750).

In an interview with CURE, Nastoupil, an assistant professor in the Department of Lymphoma/Myeloma at The University of Texas MD Anderson Cancer Center, discussed these ongoing clinical trials and how practitioners can better identify high- and poor-risk patients with large cell lymphomas.

What are the essential updates in the management of aggressive lymphoma?

In terms of what is exciting or coming out in the next few months to one year in untreated large cell lymphomas, there are a number of randomized studies that are looking at building off of the backbone of R-CHOP. They are, essentially, introducing targeted agents or agents that we think might have higher efficacy in the historically considered poor-risk group, which is the ABC or non-germinal center large-cell lymphoma.

Historically, though somewhat controversial, we think that that might be a group that may not do as well with R-CHOP therapy. This is exciting and very promising that we might have alternative therapies that will enhance the efficacy. I briefly touched upon data looking at R-CHOP plus the addition of Revlmid and R-CHOP with the addition of Imbruvica. We think we are going to be promising options for patients of the non-germinal center subtype.

Going forward in the next five to 10 years in this space, what do you see on the horizon?

That’s a great question. We have struggled over the past 10 years to really improve upon R-CHOP. We still consider that to be the standard of care for the majority of patients.

We are doing a little bit better of a job in terms of identifying high-risk patients who we fear will do poorly with R-CHOP. What we have not clearly established is what the preferred alternative is for those patients. In my opinion, I still think those patients should be considered for clinical trials where they may have access to agents where we think hold promise, but we’re still awaiting the randomized study to see if there’s truly a better option than R-CHOP.

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