Dr Joseph Tuscano, Professor of Medicine at UC Davis, explains how this immunotherapy combination has been shown to increase immune-mediated killing via ADCC and increase direct tumor apoptosis in follicular lymphoma and marginal zone lymphoma cells in vitro.
[Non KOL Voiceover talent]
REVLIMID (lenalidomide) in combination with a rituximab product is indicated for the treatment of adult patients with previously treated follicular lymphoma or marginal zone lymphoma.
REVLIMID is not indicated and is not recommended for the treatment of patients with chronic lymphocytic leukemia (CLL) outside of controlled clinical trials.
REVLIMID is only available through a restricted distribution program, Lenalidomide REMS.
REVLIMID has a Boxed Warning for embryo-fetal toxicity, hematologic toxicity, and venous and arterial thromboembolism.
Please see additional Important Safety Information, including Box WARNING for REVLIMID at the end of this video.
Hello, I’m Dr Joseph Tuscano. I’m a Professor of Medicine at UC Davis. I have been treating patients with follicular lymphoma for over 25 years, and I was one of the first investigators to participate in R2 clinical trials.
In follicular lymphoma, malignant B cells create a microenvironment that is more conducive to cancer cell growth by suppressing the function of the innate and adaptive immune response. Once impaired, this allows the malignancy to develop and progress, creating an environment that is conducive to the growth and proliferation of follicular lymphoma cells.
Follicular lymphoma is a chronic, incurable cancer that is linked to underlying immune dysfunction. Most patients will face multiple relapses during their journey with the disease.
While outcomes continue to improve and ten-year overall survival is greater than 75 percent for patients with follicular lymphoma, the most common cause of death in patients with follicular lymphoma is still the lymphoma itself.
This emphasizes the need for additional treatment options in the relapsed/refractory setting, where delaying disease progression is such an important goal.
R2: COMPLEMENTARY MECHANISMS
R2 is a combination immunotherapy that was approved in 2019 for patients with follicular or marginal zone lymphoma who have been previously treated.
In vitro studies in follicular and marginal zone lymphoma have demonstrated that the combination of REVLIMID plus rituximab increases the activity of NK and T cells through ADCC, enhancing B malignant cell killing.
REVLIMID plus rituximab has been shown to work through complementary mechanisms to modulate these cells in the immune system.
R2 DELAYS DISEASE PROGRESSION
The approval of R2 as a treatment option was supported by the Phase III AUGMENT trial. A total of 358 patients with previously treated follicular or marginal zone lymphoma were randomized 1 to 1 to R2 or rituximab plus placebo for a total of 12 treatment cycles.
The dosing information for REVLIMID and rituximab is shown on your screen.
Highlights of the baseline patient characteristics are presented here. Patients had received at least 2 prior doses of rituximab, but none of the patients were rituximab refractory.
The primary endpoint of the trial was progression-free survival. R2 was studied in a broad range of patients in this trial.
In the Phase III AUGMENT trial, R2 showed a median progression-free survival of 39.4 months compared to 14.1 with rituximab alone, that’s more than two times longer.
There were exploratory endpoints in the study that included progression-free survival through subsequent treatment, also known as PFS2, and time to next anti-lymphoma treatment.
PFS is an important endpoint, but PFS2 and time to next anti-lymphoma treatment may also be important endpoints for patients with follicular lymphoma.
Keep in mind that these follicular lymphoma subgroup data were analyzed for exploratory purposes and should be interpreted with caution.
When considering a long-term treatment strategy for follicular lymphoma, it’s also important to consider potential adverse reactions.
In AUGMENT, neutropenia was the most commonly reported adverse reaction with R2 and was observed in 58% of patients, including 50% who had Grade 3 or 4 reactions. Incidences of Grade 3 or 4 neutropenia resolved in a median of 9 days.
3 percent of patients who received R2 vs less than 1 percent of patients who received rituximab experienced febrile neutropenia.
Other commonly reported adverse reactions were diarrhea, constipation, cough, fatigue, rash, pyrexia, leukopenia, and pruritus.
I hope you found this information useful when considering this treatment for your previously treated follicular lymphoma patients. Here’s some Important Safety Information you should be aware of when considering this treatment.
[Non KOL Voiceover talent]
Important Safety Information
WARNING: EMBRYO-FETAL TOXICITY, HEMATOLOGIC TOXICITY, and VENOUS and ARTERIAL THROMBOEMBOLISM
Do not use REVLIMID during pregnancy. Lenalidomide, a thalidomide analogue, caused limb abnormalities in a developmental monkey study. Thalidomide is a known human teratogen that causes severe life-threatening human birth defects. If lenalidomide is used during pregnancy, it may cause birth defects or embryo-fetal death. In females of reproductive potential, obtain 2 negative pregnancy tests before starting REVLIMID treatment. Females of reproductive potential must use 2 forms of contraception or continuously abstain from heterosexual sex during and for 4 weeks after REVLIMID treatment. To avoid embryo-fetal exposure to lenalidomide, REVLIMID is only available through a restricted distribution program, the Lenalidomide REMS program.
Information about the Lenalidomide REMS program is available at www.lenalidomiderems.com or by calling the manufacturer’s toll-free number 1-888-423-5436.
Hematologic Toxicity (Neutropenia and Thrombocytopenia)
REVLIMID can cause significant neutropenia and thrombocytopenia. Eighty percent of patients with del 5q MDS (myelodysplastic syndromes) had to have a dose delay/reduction during the major study. Thirty-four percent of patients had to have a second dose delay/reduction. Grade 3 or 4 hematologic toxicity was seen in 80% of patients enrolled in the study. Patients on therapy for del 5q MDS should have their complete blood counts monitored weekly for the first 8 weeks of therapy and at least monthly thereafter. Patients may require dose interruption and/or reduction. Patients may require use of blood product support and/or growth factors.
Venous and Arterial Thromboembolism
REVLIMID has demonstrated a significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with MM (multiple myeloma) who were treated with REVLIMID and dexamethasone therapy. Monitor for and advise patients about signs and symptoms of thromboembolism. Advise patients to seek immediate medical care if they develop symptoms such as shortness of breath, chest pain, or arm or leg swelling. Thromboprophylaxis is recommended and the choice of regimen should be based on an assessment of the patient’s underlying risks.
Pregnancy: REVLIMID can cause fetal harm when administered to a pregnant female and is contraindicated in females who are pregnant. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risk to the fetus.
Severe Hypersensitivity Reactions: REVLIMID is contraindicated in patients who have demonstrated severe hypersensitivity (e.g., angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis) to lenalidomide.
WARNINGS AND PRECAUTIONS
Embryo-Fetal Toxicity: See Boxed WARNINGS.
Lenalidomide REMS Program: See Boxed WARNINGS. Prescribers and pharmacies must be certified with the Lenalidomide REMS program by enrolling and complying with the REMS requirements; pharmacies must only dispense to patients who are authorized to receive REVLIMID. Patients must sign a Patient-Physician Agreement Form and comply with REMS requirements; female patients of reproductive potential who are not pregnant must comply with the pregnancy testing and contraception requirements and males must comply with contraception requirements.
Hematologic Toxicity: REVLIMID can cause significant neutropenia and thrombocytopenia. Monitor patients with neutropenia for signs of infection. Advise patients to observe for bleeding or bruising, especially with use of concomitant medications that may increase risk of bleeding. Patients may require a dose interruption and/or dose reduction. FL/MZL: Monitor CBC in patients taking REVLIMID for FL or MZL weekly for the first 3 weeks of Cycle 1 (28 days), every 2 weeks during Cycles 2-4, and then monthly thereafter.
Venous and Arterial Thromboembolism: See Boxed WARNINGS. Venous thromboembolic events (DVT and PE) and arterial thromboses (MI and CVA) are increased in patients treated with REVLIMID. Patients with known risk factors, including prior thrombosis, may be at greater risk and actions should be taken to try to minimize all modifiable factors (e.g., hyperlipidemia, hypertension, smoking). Thromboprophylaxis is recommended and the regimen should be based on the patient’s underlying risks. Erythropoietin-stimulating agents (ESAs) and estrogens may further increase the risk of thrombosis and their use should be based on a benefit-risk decision.
Increased Mortality in Patients With CLL: In a clinical trial in the first-line treatment of patients with CLL, single-agent REVLIMID therapy increased the risk of death as compared to single-agent chlorambucil. Serious adverse cardiovascular reactions, including atrial fibrillation, myocardial infarction, and cardiac failure, occurred more frequently in the REVLIMID arm. REVLIMID is not indicated and not recommended for use in CLL outside of controlled clinical trials.
Second Primary Malignancies (SPM): In clinical trials in patients with MM receiving REVLIMID and in patients with FL or MZL receiving REVLIMID + rituximab therapy, an increase of hematologic plus solid tumor SPM, notably AML, have been observed. In patients with MM, MDS was also observed. Monitor patients for the development of SPM. Take into account both the potential benefit of REVLIMID and risk of SPM when considering treatment.
Increased Mortality With Pembrolizumab: In clinical trials in patients with MM, the addition of pembrolizumab to a thalidomide analogue plus dexamethasone resulted in increased mortality. Treatment of patients with MM with a PD-1 or PD-L1 blocking antibody in combination with a thalidomide analogue plus dexamethasone is not recommended outside of controlled clinical trials.
Hepatotoxicity: Hepatic failure, including fatal cases, has occurred in patients treated with REVLIMID + dexamethasone. Pre-existing viral liver disease, elevated baseline liver enzymes, and concomitant medications may be risk factors. Monitor liver enzymes periodically. Stop REVLIMID upon elevation of liver enzymes. After return to baseline values, treatment at a lower dose may be considered.
Severe Cutaneous Reactions: Severe cutaneous reactions including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) have been reported. These events can be fatal. Patients with a prior history of Grade 4 rash associated with thalidomide treatment should not receive REVLIMID. Consider REVLIMID interruption or discontinuation for Grade 2-3 skin rash. Permanently discontinue REVLIMID for Grade 4 rash, exfoliative or bullous rash, or for other severe cutaneous reactions such as SJS, TEN, or DRESS.
Tumor Lysis Syndrome (TLS): Fatal instances of TLS have been reported during treatment with REVLIMID. The patients at risk of TLS are those with high tumor burden prior to treatment. Closely monitor patients at risk and take appropriate preventive approaches.
Tumor Flare Reaction (TFR): TFR, including fatal reactions, have occurred during investigational use of REVLIMID for CLL and lymphoma. Monitoring and evaluation for TFR is recommended in patients with MCL, FL, or MZL. Tumor flare may mimic the progression of disease (PD). In patients with Grade 3 or 4 TFR, it is recommended to withhold treatment with REVLIMID until TFR resolves to ≤Grade 1. REVLIMID may be continued in patients with Grade 1 and 2 TFR without interruption or modification, at the physician’s discretion.
Impaired Stem Cell Mobilization: A decrease in the number of CD34+ cells collected after treatment (>4 cycles) with REVLIMID has been reported. Consider early referral to transplant center to optimize timing of the stem cell collection.
Thyroid Disorders: Both hypothyroidism and hyperthyroidism have been reported. Measure thyroid function before starting REVLIMID treatment and during therapy.
Early Mortality in Patients With MCL: In another MCL study, there was an increase in early deaths (within 20 weeks); 12.9% in the REVLIMID arm versus 7.1% in the control arm. Risk factors for early deaths include high tumor burden, MIPI score at diagnosis, and high WBC at baseline (≥10 x 109/L).
Hypersensitivity: Hypersensitivity, including angioedema, anaphylaxis, and anaphylactic reactions to REVLIMID has been reported. Permanently discontinue REVLIMID for angioedema and anaphylaxis.
Follicular Lymphoma/Marginal Zone Lymphoma
Periodically monitor digoxin plasma levels due to increased Cmax and AUC with concomitant REVLIMID therapy. Patients taking concomitant therapies such as ESAs or estrogen-containing therapies may have an increased risk of thrombosis. It is not known whether there is an interaction between dexamethasone and warfarin. Close monitoring of PT and INR is recommended in patients with MM taking concomitant warfarin.
USE IN SPECIFIC POPULATIONS
Please see full Prescribing Information, including Boxed WARNINGS, for REVLIMID.
Please see the rituximab full Prescribing Information for Important Safety Information at www.rituxan.com.
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