The Role of Maintenance Therapy
in Lymphoma

Arnie Freedman, M.D.
Clinical Director, Dana-Farber/Brigham and Women’s
Cance...
Maintenance
the process of maintaining or
preserving someone or something,
or the state of being maintained.

synonyms: pr...
Maintenance therapy for lymphoma
Use an effective therapy after remission is
attained, to maintain that remission and
hope...
Maintenance therapy
What is the goal ?
maintaining remission
improving survival
What disease ?

What drug to use ?
Maintenance therapy
What are the endpoints and what disease ?
(goals: remission, survival, both)
For aggressive disease, r...
Maintenance therapy
What drug to use ?

has to be effective by itself against
the disease.
benefits have to outweigh the s...
Drug choices
Has anyone taken chlorambucil for long time?

Chemotherapy (chlorambucil)
Pros
effective agent, convenient (o...
Drug choices
Has anyone taken interferon ?

Interferon-a
Pros
“immunotherapy”
Cons:
minimal anti-lymphoma activity, some
i...
Drug choices
Raise your hand if you have had rituximab
maintenance ?
Rituximab
Pros
effective agent, some inconvenience (I...
Maintenance studies (randomized)
Past
CLL, follicular NHL (chemotherapy,
interferon)
Present
DLBCL, follicular NHL, MCL (r...
Maintenance: the past
Chlorambucil maintenance for CLL
No advantage in survival

Myelosuppression
More second malignancies...
Maintenance: the past
Interferon maintenance for follicular NHL

Chemotherapy followed by maintenance
or none.
Longer remi...
Maintenance: the present
Rituximab maintenance for follicular NHL

Longer remissions after chemotherapy,
chemoimmunotherap...
Maintenance: the present
Rituximab maintenance for DLBCL, MCL.

For MCL but not DLBCL, longer
remissions after chemoimmuno...
Maintenance: the future
Should maintenance be pursued?
Generally has not worked well (rituximab is the
exception).
Wrong d...
Maintenance: the future
Enzastaurin (oral kinase inhibitor)
Maintenance for DLBCL
No benefit
Marginally effective drug
Ind...
Maintenance: the future
Brentuximab (antibody drug conjugate)
Maintenance for Hodgkin lymphoma post
autoSCT.

Oral kinase ...
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How Maintenance Therapy Is Used in Lymphoma

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Audio and slides for this presentation are available on YouTube: http://youtu.be/7iFnx9y_cCw

Arnie Freedman, MD, clinical director of the Dana-Farber/Brigham and Women's Cancer Center Adult Lymphoma Program, discusses several options for maintenance therapy of lymphoma, and the pros and cons of each. This presentation was originally given at the Lymphoma Research Foundation's 2013 North American Forum on Sept. 29, 2013. http://www.dana-farber.org | http://www.lymphoma.org

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Transcript of "How Maintenance Therapy Is Used in Lymphoma"

  1. 1. The Role of Maintenance Therapy in Lymphoma Arnie Freedman, M.D. Clinical Director, Dana-Farber/Brigham and Women’s Cancer Center Adult Lymphoma Program
  2. 2. Maintenance the process of maintaining or preserving someone or something, or the state of being maintained. synonyms: preservation, conservation, keeping, prolongation, perpetuation, carry on, continuation.
  3. 3. Maintenance therapy for lymphoma Use an effective therapy after remission is attained, to maintain that remission and hopefully increase survival, without increased toxicity, both early and late.
  4. 4. Maintenance therapy What is the goal ? maintaining remission improving survival What disease ? What drug to use ?
  5. 5. Maintenance therapy What are the endpoints and what disease ? (goals: remission, survival, both) For aggressive disease, remission and survival easier to demonstrate. For indolent disease, survival benefit harder to prove.
  6. 6. Maintenance therapy What drug to use ? has to be effective by itself against the disease. benefits have to outweigh the side effects and risks.
  7. 7. Drug choices Has anyone taken chlorambucil for long time? Chemotherapy (chlorambucil) Pros effective agent, convenient (oral), no hair loss, minimal nausea. Cons: lowers blood counts, toxic to stem cells, risk of malignancy (solid tumor, leukemia).
  8. 8. Drug choices Has anyone taken interferon ? Interferon-a Pros “immunotherapy” Cons: minimal anti-lymphoma activity, some inconvenience (inject), flu like symptoms
  9. 9. Drug choices Raise your hand if you have had rituximab maintenance ? Rituximab Pros effective agent, some inconvenience (I.V.) Cons: infusion reactions, infection risk
  10. 10. Maintenance studies (randomized) Past CLL, follicular NHL (chemotherapy, interferon) Present DLBCL, follicular NHL, MCL (rituximab) Future DLBCL, Hodgkin’s, others (small molecules, antibody-drug conjugates)
  11. 11. Maintenance: the past Chlorambucil maintenance for CLL No advantage in survival Myelosuppression More second malignancies (AML/MDS/solid tumors)
  12. 12. Maintenance: the past Interferon maintenance for follicular NHL Chemotherapy followed by maintenance or none. Longer remissions, no advantage in survival. Poor tolerance, compliance. Never adopted in U.S.A.
  13. 13. Maintenance: the present Rituximab maintenance for follicular NHL Longer remissions after chemotherapy, chemoimmunotherapy, rituximab alone. No increased survival (yet). Reasonably well tolerated, increased viral infections. Well adopted in U.S.A.
  14. 14. Maintenance: the present Rituximab maintenance for DLBCL, MCL. For MCL but not DLBCL, longer remissions after chemoimmunotherapy. Improved survival for MCL. Well tolerated, but maintenance is indefinite (MCL study).
  15. 15. Maintenance: the future Should maintenance be pursued? Generally has not worked well (rituximab is the exception). Wrong drug choice, wrong disease, hard to study (compliance and safety). Will new effective drugs work as maintenance? ADC (brentuximab), oral kinase inhibitors
  16. 16. Maintenance: the future Enzastaurin (oral kinase inhibitor) Maintenance for DLBCL No benefit Marginally effective drug Induction prior to maintenance more effective than in past.
  17. 17. Maintenance: the future Brentuximab (antibody drug conjugate) Maintenance for Hodgkin lymphoma post autoSCT. Oral kinase inhibitors being studied for example, idelalisib for follicular NHL

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