Panel Finds Value in Certain Maintenance Therapies for Patients with Lymphoma

With the evolving landscape of maintenance therapies to treat patients with lymphoma following autologous hematopoietic cell transplantation (auto-HCT), a panel consensus recommended four grade A options for physicians across different subtypes of the disease, according to results published in JAMA Oncology.

In particular, the consensus recommended the following:

• Adcetris (brentuximab vedotin [BV]) maintenance and/or consolidation in Adcetris-naïve, high-risk Hodgkin lymphoma
• Rituxan (rituximab) maintenance in mantle cell lymphoma (MCL) undergoing auto-HCT after first-line therapy
• Rituxan maintenance in Rituxan-naïve follicular lymphoma
• No post auto-HCT maintenance in diffuse large B-cell lymphoma (DLBCL).

“Auto-HCT can provide durable disease control in a subset of patients; (however), disease relapse remains the most common cause of death in patients with lymphoma after undergoing (high-dose therapy), the researchers wrote. “Most relapse events occur within the first one to three years following auto-HCT, providing a rationale for post-HCT maintenance and/or consolidative strategies to mitigate relapse risk.”

While treatments like monoclonal antibodies, targeted agents and immune therapies used for the relapsed or refractory settings are now being evaluated as a first-line treatment option in a variety of studies, this leaves little room for clinical trials on maintenance or consolidation therapy, the researchers wrote.

“This unfortunately means that some trials evaluating post-HCT maintenance strategies in lymphomas enrolled patient populations that are increasingly less relevant to current practice,” they added. “Moreover, the off-label, off-protocol use of approved anti-lymphoma drugs after auto-HCT as maintenance and/or consolidation therapies is an increasingly common practice.”

With these currently grey areas, clinical practice recommendations or consensus statements addressing the contemporary role of maintenance and/ or consolidation therapies after auto-HCT in patients with various types of lymphomas are not available.

Therefore, the American Society for Blood and Marrow Transplantation (ASBMT), the Center for International Blood and Marrow Transplant Research (CIBMTR) and the European Society for Blood and Marrow Transplantation (EBMT) jointly convened an expert panel to formulate consensus recommendations regarding the use of maintenance and/or consolidation therapies after auto-HCT in patients with lymphoma.

The researchers noted the expert panel — which recommended for restricting the histologic categories covered in the project to Hodgkin lymphoma, MCL, DLBCL and follicular lymphoma –included individuals with diverse expertise and geographical representation.

The RAND-modified Delphi method was used to generate 22 consensus statements, where at least 75 percent had to vote in favor of a recommendation to be considered a consensus. The process included three online surveys moderated by an independent methodological expert to ensure anonymity and an in-person meeting.

“In clinical scenarios where data from prospective studies are either scarce or unavailable, or in situations where therapeutic advances or new drug indications make patient populations included in published trials less relevant to contemporary clinical practice, formal consensus recommendations can be an invaluable resource in informing clinical decision making,” the researchers wrote.

“Expert opinions and recommendations in the form of review articles and treatment guidelines, although useful, lack methodological clarity and may be subject to bias,” they added. “In contrast, formulation of expert recommendations using established approaches, such as the RAND-modified Dephi method, provides a formal, reproducible, and systematic process.

In addition, the panel also developed consensus statements for important, real-world clinical scenarios, where randomized data are lacking to guide clinical practice, the researchers noted.