Hematologic Oncology Update, Issue 3, 2016 (Video Program) - Video 9Sequencing of therapeutic options for relapsed mantle cell lymphoma
3:03 minutes.
TRANSCRIPTION:
DR LOVE: How do you generally sequence the available approved agents — I’m not sure about the approval status in Canada, but lenalidomide and bortezomib are approved in the US and commonly utilized. What’s your usual sequence? DR SEHN: So I think the world’s getting more complicated for mantle cell lymphoma, because we are starting to have more and more options become available. We’re hoping that some of the ongoing clinical trials will help sort out the sequencing question. Ideally, we want to bring in the best drugs earlier and obviously the drugs with the least amount of toxicities. So I think we will see some of these novel compounds like ibrutinib and possibly lenalidomide move into the front-line setting eventually, because they do come with a much lower toxicity profile than our current management strategies for up-front treatment. I think for the time being, chemoimmunotherapy is still the standard up front for patients with mantle cell lymphoma. And for younger patients, as we discussed, the autologous stem cell transplant still is recommended front line, although it’s being questioned as to whether or not with the novel agents we can maybe forego transplants in some patients. Going down the road, I think ibrutinib has proven to be such a highly effective agent, it’s currently what I would use second line in many of these patients. Following ibrutinib, I mean, we still have other options. There are other chemotherapy options. If the patient’s never had bendamustine or bendamustine/rituximab, I think that’s also a very effective treatment for patients with mantle cell. So if they didn’t get it up front, I think that needs to be factored into the mix, possibly third line or shortly after. Lenalidomide or lenalidomide and rituximab I think is also an interesting treatment. Although it’s never been compared head to head to ibrutinib or some of the other targeted agents that are being developed, I think it’s probably not as effective as ibrutinib. And so I would look at it as a down-the-road option. One of the drugs that we’re very excited to see come through development is venetoclax. I think that will challenge some therapies as well, possibly in patients with mantle cell lymphoma, because it’s showing a lot of enticing benefits. So we now have that on the market for CLL. And I think further data will emerge for mantle cell. So I would say there’s no right or wrong sequence in a patient with mantle cell lymphoma. As all patients, you need to look at their clinical condition; not only what their lymphoma is doing but who the patient is. What are the treatment options you have available? What are the toxicities of that treatment? And try and match it up with the patient. So there’s no standard sequence in my mind. All of these options will likely be used, because we know that we still don’t have a curative strategy for patients with mantle cell lymphoma. It’s just a matter in which order you use them in. In my own practice, I’m always trying to pick the agent that I think has the higher — or the highest efficacy next, balanced against the toxicity of that agent in the given patient that I want to treat. |