Treatment Options for Follicular Lymphoma

"A common question I get is, 'Well, I have cancer. Why aren't we treating the cancer? Are we missing something and losing our chance to get on top of it?'" says Dr. Elise Chong, an oncologist/hematologist at Penn Medicine. "But the challenge we have with follicular lymphoma is that we really don't have data showing that instituting treatment early makes people live longer."

Studies show that patients who are managed with watchful waiting have survival outcomes similar to people who are treated soon after diagnosis.  The average survival time with follicular lymphoma, even when it's diagnosed at an advanced stage, is more than twenty years.

Since cancer treatments themselves have side effects, it makes sense not to begin aggressive treatment until the patient is experiencing troublesome symptoms, or when tests show the cancer has changed and started to spread more quickly. "The best approach is to be careful about when to initiate treatment, and then to choose the proper treatment to try and maximize the response rates. . . which tend to be quite good in follicular lymphoma," says Dr. Chong. "But you also want to minimize unnecessary toxicity."

When Treatment Becomes Necessary

Follicular lymphoma responds well to chemotherapy and radiation. In some patients with local disease, radiation alone may lead to a long remission. Often now the recommended treatment, especially in advanced cases, is a monoclonal antibody called rituximab (Rituxan), alone or in combination with chemotherapy. "Rituximab targets a protein called CD20 on the cell surface of the follicular lymphoma cells," explains Dr. Chong. "We've been using this antibody for many years now."

Some common combination treatments for follicular lymphoma that include rituximab include:

• R-Bendamustine (rituximab and bendamustine)
• R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)
• R-CVP (rituximab, cyclophosphamide, vincristine, and prednisone)

The combination prescribed is always specific to the patient. "It really depends upon the individual patient as well as the trajectory of their disease," says Dr. Chong.

Rituximab can also be used in combination with non-chemotherapy agents. One of these combinations is antibody therapy plus lenalidomide (Revlimid), an oral drug. “People refer to this combination as the R-squared regimen," says Dr. Chong. "But it has its own set of side effects.”

Still another possible treatment for follicular lymphoma is radioimmunotherapy (RIT) which uses a radioactive particle attached to an antibody that targets cancer cells.

Dr. Chong explains that, just because something isn't chemotherapy doesn't mean it has no side effects. "And that's something to really talk to your oncologist about so you can weigh the risks and benefits." Fortunately follicular lymphoma responds well to a variety of different treatments. You and your doctor can decide together which is the best one for you.

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