Highlights

The standard of care remains rituximab. I think there has been a lot written about the interpretation of the GALLIUM trial… it didn’t produce the dramatic type of improvement that we are hoping to see, and some criticism has to do with dosing of obinutuzumab versus rituximab. Ultimately, they had very, very similar response rates, and the magnitude of improvement in the primary endpoint people believed to be quite modest. Also, it’s clear that obinutuzumab dosing is higher and the rates of infusion reactions are higher, and rituximab has additional advantages with cheaper biosimilars at this point or a subcutaneously administered version for the branded molecule. So, for me, and I think for most of my colleagues, obinutuzumab is saved for subsequent lines of therapy, and I usually switch unless it’s really someone who had rituximab front line and then stayed off therapy for five/six years. In such an instance, I would sometimes use rituximab again, but in any other situation I would switch to obinutuzumab at second line.

In the first line my most commonly used regimen is BR [bendamustine-rituximab], and that’s followed closely by R2 [lenalidomide-rituximab]. R-CHOP is something I would reserve to really aggressive cases where I would be concerned that we were missing a transformation and have been unable to detect it by biopsy… When it comes to bendamustine-based therapies, very few patients are ineligible. We’re talking maybe about 20% of really older individuals or patients with significant co-morbidity. I think ineligibility is not the primary barrier in administering effective front-line therapy, it’s the patient’s attitude against chemotherapy that frequently drives me to choose something like R2 .