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Combo Of RT And Chemotherapy: Best For Early FL

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For the management of early-stage follicular lymphoma (FL), a randomized trial shows that the combination of radiotherapy (RT) with chemo immunotherapy gives better clinical outcomes that treatment with radiation alone, and the researchers reporting these results say that they should change clinical practice.

After a median follow-up of 9.6 years, the estimated 10-year progression-free survival (PFS) was 59% for patients who received involved-field RT (IFRT) and systemic therapy and 41% for patients who received IFRT alone.

However, this benefit was apparent only after 5 years; it was at that point that the Kaplan-Meier PFS curves began to separate, not sooner.

The results, from the Trans-Tasman Radiation Oncology Group (TROG), were published online July 5 in the Journal of Clinical Oncology. Radiation oncologist Michael MacManus, MBBCh, MD, from the Peter MacCallum Cancer Center in Melbourne, Australia, was its corresponding author.

“For patients with stage I to II FL who are treated with curative intent, we recommend treatment with IFRT followed by chemoimmunotherapy as a reasonable evidence-based choice for the standard of care,” MacManus and colleagues conclude.

Will Results Change Management of Early FL?

MacManus explained that for early FL, several approaches have been used in its management, but the results of this study should make a difference.

Because of its long natural history, typically slow rate of progression, and initial responsiveness to chemotherapy, there is a perception that initial therapy in localized FL, or even the withholding of therapy, may not influence the natural history of the disease and that it therefore may not matter very much, MacManus noted. “In the absence of properly conducted randomized trials, all of these approaches have been potentially supportable,” he said.

“However, our trial indicates that initial therapy does matter in early-stage FL and that a nihilistic or laissez-faire approach may not be appropriate in patients who would otherwise have a long life expectancy,” MacManus pointed out.

“Our standard approach in the light of our new data is to offer combined-modality therapy to patients with a long life expectancy to give them the best chance of long-term disease-free survival,” he said.

“To our knowledge, this is the first RCT [randomized clinical trial] providing high-level evidence that the long natural history of localized FL can be affected by adding systemic therapy to standard IFRT,” MacManus and colleagues write.

News reached out to Nadia Khan, MD, a lymphoma expert from the Department of Hematology/Oncology at Fox Chase Cancer Center, Philadelphia, Pennsylvania, to weigh in on the significance of this study and its impact on clinical practice.

“While this is a well-designed study, with statistically meaningful results, the conclusions are not clinically impactful because of practice trends in early-stage FL,” Khan said.

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