What are the Treatments for Follicular Lymphoma?

Follicular lymphoma is an indolent B-cell subtype of non-Hodgkin's lymphoma (NHL). It is the second most commonly diagnosed NHL, after diffuse large B-cell lymphoma. Because of the indolent nature of follicular lymphoma, it is not considered to be a curable disease; rather, it is regarded as a manageable disease, and this informs the available treatments for this subtype.

Treatments for Follicular Lymphoma

The following represents the available treatments for FL. It includes FDA approved treatments as well as one treatment not yet available but nearing approval.

Radiotherapy

Radiotherapy, or specifically involved-field radiation therapy (IFRT), is considered standard treatment for follicular lymphoma that is found while still in the early stages, such as stage I or stage II. Radiotherapy may also be used at other times if the patient is diagnosed with B symptoms, specifically with so-called 'bulky disease', which means the disease has formed something of a tumor. In some cases, radiotherapy is used to shrink the tumor and provide palliative care if the tumor is causing problems.

Combination Chemotherapy

Combination chemotherapy regimens are considered first-line therapy in many cases of follicular lymphoma. These combinations include:

-- R-CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone)
-- R-CVP (this regimen is the same as R-CHOP except it does not include the anthracycline doxorubicin; this regimen is safer for patients with heart problems)
-- R-FND (Rituximab, fludarabine, mitoxantrone, and dexamethasone)
-- Bendamustine + rituximab

Oncologists will determine which combination chemotherapy regimen is best suited to each individual patient.

Single-Agent Immunotherapy and Maintenance Therapy

The immunotherapy rituximab can be used either as a single-agent in the first-line treatment of follicular lymphoma, or in combination with chemotherapy regimens, or it can be used in a maintenance setting, where the patient has received induction treatment and then receives an infusion of rituximab over the course of a couple of years.

Radioimmunotherapy

One of the better innovations to come along for the lymphoma community in recent years is the development and approval of radioimmunotherapy, or RIT. This is most commonly administered as the Zevalin therapeutic regimen. Zevalin is the first RIT to be FDA-approved as a first-line therapy against FL. Zevalin—and Bexxar, a similar regimen—work by attaching radioactive isotopes to the monoclonal antibody rituximab, allowing the antibody to deliver to the cancerous B-cells a deadly radioactive payload. It can be considered something of a targeted radiation treatment in that it only radiates specific lymphocytes.

Stem Cell Transplantation

Autologous or allogeneic stem cell transplantations are not common in follicular lymphoma. Because of the seriousness of this procedure, it is reserved as second-line consolidation therapy and rarely if ever is it used in induction treatment.

Watch and Wait

Watch and Wait is a treatment strategy used typically when a patient is found to have follicular lymphoma, but the disease progresses at a very slow rate and does not cause symptoms. Often times, the best course of action is no action at all. The doctor and patient simply 'watch' and 'wait' for the disease to become one that requires treatment. Although watch and wait can be psychologically difficult for the patient, evidence suggests that patients who are treatment-naïve will respond better to treatment when the time comes, if it ever does. The idea is that one of these treatment modalities may be effective against FL, but only once; after that, a different treatment is required. So remaining treatment-naïve is a good idea if treatment isn't necessary.

Therapeutic Vaccine

A therapeutic vaccine for follicular lymphoma appears to be on the horizon. This vaccine, known as BiovaxID, is made from the patient's own tumor cells. The process involves training the body's own immune system to recognize the cancer. If approved by the FDA, BiovaxID will be the first therapeutic vaccine for follicular lymphoma patients. It does not offer a cure—none of the treatments do—but clinical trials suggest a substantially longer time-to-next-treatment with BiovaxID than current modalities.

For more information on BiovaxiD, click here.