The American Society of Hematology (ASH) meeting in December is the largest gathering of lymphoma experts worldwide. In January, UK experts met in London to talk about the latest developments presented at ASH and their implications for clinical practice in the UK.
Research is continuing to answer questions about the role of maintenance treatment in keeping follicular lymphoma under control. It remains routine practice to have rituximab every 2 months for 2 years after successful treatment but does everyone need it? Is rituximab the best treatment for maintenance? How long should it be given for? And, is there a benefit to maintenance when it is given with newer regimens (combinations of drugs), such as rituximab and bendamustine?
The main study that showed that maintenance kept follicular under control for longer than active monitoring (‘watch and wait’) alone continues to provide evidence for the long-term benefits of this approach. After 10 years, around half of the people treated with maintenance in the PRIMA trial are still in remission(lymphoma has not got worse) compared with around a third of people who did not have maintenance. The MAINTAIN trial showed that maintenance still benefits people who were treated with rituximab and bendamustine. However, there is no clear evidence that longer maintenance is beneficial. As maintenance carries a risk of infection and other side effects, 2 years’ maintenance remains standard care.
For now, rituximab remains the most widely used treatment for maintenance in low-grade non-Hodgkin lymphoma. The GALLIUM trial showed that the newer antibody obinutuzumab could improve outcomes further. However, there may be a greater risk of side effects with obinutuzumab. Long-term follow-up of this study continues. Adding a newer drug, lenalidomide, to rituximab maintenance didn’t have any benefit and caused more side effects than rituximab alone.
Maintenance increases the time people live without needing more treatment but doesn’t seem to increase the time people live overall. Research is still needed as it is not clear why people don’t live longer. It may be that some people do not benefit from maintenance and could avoid the side effects associated with it.
Coming next: New approaches show promise for high-grade non-Hodgkin lymphoma.