What are the Treatments for Follicular Lymphoma?

What are the treatments for follicular lymphoma, and when can I start treatment? Do my treatment options change based on the stage of the disease? Learn answers to these questions and more below! 

When Do I Start Follicular Lymphoma Treatment? 

Follicular lymphoma is often a slow-growing cancer. The treatment choice for follicular lymphoma frequently depends on its stage. Click here to learn about the stages of follicular lymphoma. 

• If you have stage 1 or 2 follicular lymphoma, involved-site radiation therapy (ISRT) may be recommended to remove lymph nodes that contain cancer cells before the disease spreads to more lymph nodes.
• If you don't meet the GELF criteria, you have what is called low tumor burden follicular lymphoma. Your doctor will likely recommend either observing the disease with no treatment or administering a monoclonal antibody infusion called rituximab. 
• If you meet one of the GELF criteria, you have high tumor burden lymphoma, and treatment is recommended. The standard treatment for high tumor-burden follicular lymphoma is chemotherapy. However, specialists are working on moving away from chemotherapy toward treatments that strengthen your immune system to fight the disease, called immunotherapies. Follicular lymphoma specialists also recommend that younger patients try non-chemotherapy treatments to help save them from the long-term side effects of chemotherapy. 

What are First and Second-Line Follicular Lymphoma Treatments? 

First-line therapy refers to the first treatment you receive. Second-line therapy refers to needing treatment a second time if the cancer comes back. Below, we'll discuss treatments that are FDA-approved for first and second-line therapies. The following section will discuss the types of immunotherapies approved as third-line treatments. 

• Observation/watchful waiting
  • Watchful waiting, also known as active surveillance, may be recommended for people with follicular lymphoma who do not have any symptoms. This approach involves closely monitoring the person's condition without giving treatment until symptoms appear or change. The aim is to avoid unnecessary side effects of treatment for as long as possible. 
• Involved-site radiation therapy (ISRT)
  • Involved-site radiation therapy uses high-energy rays to kill cancer cells. This treatment may be used for follicular lymphoma if the disease is localized to one group of lymph nodes. 
• Monoclonal antibodies (rituximab [Rituxan] or obinutuzumab [Gazyva]) 
  • They attach to a protein called CD20 on the surface of cancerous B-cells, such as follicular lymphoma, tagging them for destruction by the immune system. This helps leave the majority of healthy cells alone. They are administered as an intravenous infusion. You may receive a generic version of rituximab. Obinutuzumab is not given by itself for people with follicular lymphoma but rather alongside chemotherapy.  
• Lenalidomide (Revlimid) 
  • Lenalidomide is a medicine that helps stop cancer cells by interfering with chemicals they need to grow. It targets mainly cancer cells, leaving other healthy cells alone. Lenalidomide also stimulates specialized immune system cells to attack cancer cells. It is often given in combination with rituximab for people with follicular lymphoma. 
• Chemotherapy
  • Chemotherapy is a common treatment for follicular lymphoma. These therapies kill cancer cells or stop them from growing. Chemotherapy works by interfering with the ability of rapidly growing cells, like cancer cells, to divide or multiply. If you are concerned about any side effects of chemotherapy, ask your doctor for supportive resources. The specific types of chemotherapy used for follicular lymphoma may include:
    • Cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with or without obinutuzumab or rituximab
    • Bendamustine with obinutuzumab or rituximab
    • Cyclophosphamide, vincristine, and prednisone (CVP) with obinutuzumab or rituximab

What are Third-Line Follicular Lymphoma Treatments? 

If follicular lymphoma did not respond to two prior treatments, you qualify for third-line treatments. These include:  

• Bispecific antibodies 
  • Bispecific antibodies attach to a surface protein on cancer cells and T-cells, bringing the T-cells close enough to kill cancer cells. Side effects are mild-moderate and manageable. Depending on the brand, they may be administered as an infusion or injection. Brands include: 
    • Epcoritamab (Epkinly) 
    • Mosunetuzumab (Lunsumio) 
• CAR T-cell therapy 
  • A one-time infusion of your T-cells that have been enhanced to kill cancer cells. Before CAR T-cell therapy, side effect education can help you feel prepared and appropriately communicate any concerns with your healthcare team for a safe experience. Brands include: 
    • Axi-cel (Yescarta) 
    • Liso-cel (Breyanzi)
    • Tisa-cel (Kymriah) 
• BTK inhibitors 
  • Bruton tyrosine kinase (BTK) inhibitors are designed to specifically target and eliminate cancerous B cells, the cells driving follicular lymphoma growth. The first FDA-approved BTK inhibitor for follicular lymphoma is zanubrutinib (Brukinsa, BeiGene) when used in combination with the monoclonal antibody obinutuzumab. Click here to learn more about BTK inhibitors for follicular lymphoma. 

What are Clinical Trials for Follicular Lymphoma? 

Clinical trials are studies in which doctors and researchers evaluate medicines to help people with illnesses like follicular lymphoma. They sometimes review new medications, but often, they consider whether current therapies can be improved and patients' side effects can be reduced. To review open clinical trials, click here. You can also contact a follicular lymphoma specialist to talk about clinical trials that may suit you. You are welcome to review HealthTree’s news site, where we often post about clinical trial updates in follicular lymphoma, such as: 

• On the Way to Improved Treatment for Newly Diagnosed Follicular Lymphoma with Acalabrutinib Added to Lenalidomide and Rituximab
• Golcadomide Alone or Combined with Rituximab in Relapsed/Refractory Follicular Lymphoma
• Evorpacept - A Next-Generation CD47 Inhibitor in Phase I Study for Patients With Relapsed-Refractory Lymphoma
• Zanubrutinib (Brukinsa) Receives FDA Approval for Follicular Lymphoma Treatment
• Tazemetostat as a New Therapy for Follicular Lymphoma with the EZH2 Mutation
• Odronextamab for Lymphoma: FDA Delays Approval Decision, Trials Still Enrolling
• Loncastuximab for High-Risk Relapsed/Refractory Follicular Lymphoma
• Promising Results Treating Relapsed and Refractory Follicular Lymphoma with Zanubrutinib & Obinutuzumab
• New Bispecific Antibody AZD0486 for Relapsed/Refractory Lymphoma

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Sources: 

• Predicting time to treatment in follicular lymphoma on watchful waiting using baseline metabolic tumour burden
• Evolution of Radiation Fields from Involved Field to Involved Site—A Summary of the Current Guidelines by the International Lymphoma Radiation Oncology Group
• Treatment for Follicular Lymphoma
• CVP
• Yescarta
• Kymriah