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NCCN Guidelines Emphasize Patient Preference as Key to Selection of Maintenance Therapy in Follicular Lymphoma


Despite a long natural history and high response to therapy, relapse is to be expected in patients with follicular lymphoma. Maintenance therapies indicate improvement in disease-free survival, but have yet to show significant improvement in overall survival. Recommendations from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) regarding post-remission therapy for follicular lymphoma were the focus of a presentation given at the recent National Comprehensive Cancer Network® (NCCN®) 6th Annual Congress: Hematologic Malignancies™.


FORT WASHINGTON, PA — While therapeutic advances have improved survival of patients with follicular lymphoma (FL), it remains an incurable disease with inevitable relapse. This underscores the need for therapies and strategies to extend the duration of remission without significantly increasing toxicity and while maintaining quality of life. The role of maintenance therapies in FL was discussed in detail by Andrew D. Zelenetz, MD, PhD, of Memorial Sloan-Kettering Cancer Center and chair of the NCCN Guidelines Panel for Non-Hodgkin`s Lymphomas during the NCCN 6th Annual Congress: Hematologic Malignancies™.

Since follicular lymphoma responds well to therapy and is slow-growing, it is often thought of as a chronic disease. In the absence of symptoms, the disease has the potential to be managed through observation, said Dr. Zelenetz.
However, some patients are uncomfortable knowing that they have an active lymphoma that is not being addressed with therapy.

There are several approaches to post-remission therapy. Patients with FL who have responded to first-line therapy have the option of being observed or treated with consolidation therapy. Phase III studies have demonstrated that consolidation with radioimmunotherapy (FIT trial) or rituximab (Rituxan®, Genentech BioOncology and Biogen Idec) maintenance (PRIMA trial) are both effective and improve progression-free survival (PFS).

Studies indicate that prolonged administration of rituximab significantly improves event-free survival in chemotherapy-naïve patients responding to rituximab-containing induction, said Dr. Zelenetz.

Event-free survival is defined as the time from first induction infusion to progression, relapse, second tumor, or death from any cause.

Rituximab has also been shown to be effective when given for a second time at the time of relapse, after patients had previously responded to rituximab. Whether rituximab maintenance treatment is superior to rituximab re-treatment (at the time of disease progression) has not yet been established.

Past trials have shown significantly improved progression-free survival with rituximab maintenance, however no significant difference was seen in overall survival between the maintenance and re-treatment group, noted Dr. Zelenetz. Ongoing research will continue to evaluate this approach.

Dr. Zelenetz emphasized that effect on overall survival (OS) is one of the most influential factors when weighing treatment decisions. However, phase III studies to-date have not demonstrated an OS benefit in patients with FL receiving post-remission therapy.

The NCCN Guidelines include post-remission therapy (radioimmunotherapy consolidation or maintenance rituximab) as an option for patients responding to first-line chemoimmunotherapy, said Dr. Zelenetz. Given the absence of an overall survival benefit, the NHL Guidelines Panel felt the decision to use post-remission therapy has to be made on an individualized basis after discussing the pros and cons with the patient.

About the National Comprehensive Cancer Network

The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 25 of the world's leading cancer centers, is dedicated to improving the quality and effectiveness of care provided to patients with cancer. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers. The primary goal of all NCCN initiatives is to improve the quality, effectiveness, and efficiency of oncology practice so patients can live better lives. For more information, visit NCCN.org.

The NCCN Member Institutions are:

  • Fred & Pamela Buffett Cancer Center at The Nebraska Medical Center
  • City of Hope Comprehensive Cancer Center
  • Dana-Farber/Brigham and Women's Cancer Center
    Massachusetts General Hospital Cancer Center
  • Duke Cancer Institute
  • Fox Chase Cancer Center
  • Huntsman Cancer Institute at the University of Utah
  • Fred Hutchinson Cancer Research Center / Seattle Cancer Care Alliance
  • The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
  • Robert H. Lurie Comprehensive Cancer Center of Northwestern University
  • Mayo Clinic Cancer Center
  • Memorial Sloan-Kettering Cancer Center
  • Moffitt Cancer Center
  • The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
  • Roswell Park Cancer Institute
  • Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
  • St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
  • Stanford Cancer Institute
  • University of Alabama at Birmingham Comprehensive Cancer Center
  • UC San Diego Moores Cancer Center
  • UCSF Helen Diller Family Comprehensive Cancer Center
  • University of Colorado Cancer Center
  • University of Michigan Comprehensive Cancer Center
  • The University of Texas MD Anderson Cancer Center
  • Vanderbilt-Ingram Cancer Center
  • Yale Cancer Center/Smilow Cancer Hospital