Expert Point of View: Brad S. Kahl, MD


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Obinutuzumab may get a front-line indication for follicular lymphoma based on this study.
— Brad S. Kahl, MD

Speaking about the GALLIUM study in the ASH News Daily, Brad S. Kahl, MD, of Washington University School of Medicine, St. Louis, commented, “It is a potentially practice-changing study that clearly shows an 8% absolute improvement in progression-free survival at 2 years for the patients getting obinutuzumab (Gazyva) vs rituximab (Rituxan). Obinutuzumab may get a front-line indication for follicular lymphoma based on this study.”

Little Progress in Survival

John P. Leonard, MD, of Weill Cornell Medicine, who introduced the presentation by Dr. Marcus, was more reserved. “Over several decades, there has been relatively little progress in overall survival for patients with follicular lymphoma. The introduction of rituximab led to a survival benefit when added to CVP (cyclophosphamide, vincristine, prednisone) or CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone). Now bendamustine is widely used as front-line therapy in combination with rituximab,” he explained.

“We now know that maintenance rituximab improves progression-free survival but not overall survival when added to CHOP or CVP. Patients with disease progression within 2 years of initial therapy are at greatest risk of death. Two years is an important milestone,” he said.


The goal of treatment is cure, but unfortunately we don’t cure people with maintenance therapy. Another goal is to make patients feel better. Treatment-related side effects suggest that quality of life may not be improved by maintenance therapy.
— John P. Leonard, MD

“Progression-free survival is an important endpoint, but there is no overall survival benefit, and there has never been a survival benefit for maintenance therapy after chemoimmunotherapy in follicular lymphoma. The study raises the question about the magnitude of benefit with maintenance therapy. Not all patients want 2 more years of therapy after their initial therapy. In the absence of a survival benefit, many patients will prefer an abbreviated program of treatment. You have to take patient preference into account,” he continued.

Individual Decision for Patients

“The goal of treatment is cure, but unfortunately we don’t cure people with maintenance therapy. Another goal is to make patients feel better. Treatment-related side effects suggest that quality of life may not be improved by maintenance therapy. It is the oncologist’s job to explain the pros and cons of treatment, and it is an individual decision for patients. If they prefer maintenance, then the study suggests obinutuzumab has a benefit,” he noted.

“I discuss maintenance therapy with all my patients and tell them it will reduce the risk of relapse, but I also tell them that if they hope to live to 80 or 90, there are no data that show that maintenance will make that more likely to happen,” Dr. Leonard said.

He explained that maintenance therapy allows patients to stay in remission longer, but then they are expected to ultimately relapse.

“If patients opt for single-agent therapy [not chemotherapy] at diagnosis or relapse, I would still use rituximab. We don’t have robust data for obinutuzumab upfront or at relapse,” he stated. ■

Disclosure: Drs. Leonard and Kahl reported no potential conflicts of interest.


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