Patient benefits of maintenance immunotherapy

Symptoms and toxicity of rituximab maintenance relative to observation following immunochemotherapy in patients with follicular lymphoma

OBJECTIVES

The randomized phase 3 PRIMA trial established that 2 years of rituximab maintenance therapy after attaining disease response to immunochemotherapy as first-line treatment of follicular lymphoma, reduced the risk of disease progression, compared with observation, without adversely affecting patient-reported quality of life (QoL). We now report additional analyses of symptom burden and toxicity.

METHODS

Symptom burden was measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items. The proportion of patients with worsening, no change, or improvement in symptoms from maintenance baseline was compared between rituximab maintenance and observation groups with Pearson χ(2) tests. Improvement in symptoms after 1 and 2 years of maintenance was further analyzed using generalized mixed models. The adverse event (AE) rate was calculated from the toxicity checklist at each visit to explore the frequency and timing of the toxicity AE in each treatment arm. The study protocol was approved by local ethics committees and is registered at ClinicalTrials.gov under NCT00140582.

RESULTS

Being tired, needing to rest, feeling weak, and trouble sleeping were the most frequently reported symptoms at the end of immunochemotherapy. By the end of maintenance, notable improvement was seen for fatigue symptoms, trouble sleeping, shortness of breath, lack of appetite, and nausea, with no significant difference in QoL symptoms between the rituximab maintenance and observation groups. The rate of AEs was low, and hematologic toxicity induced during chemotherapy treatment improved in both rituximab maintenance and observation groups.

DISCUSSION

These results indicated that rituximab maintenance did not negatively impact disease- or treatment-related symptoms.

Rituximab as maintenance therapy for patients with follicular lymphoma

BACKGROUND

Rituximab, a monoclonal anti-CD20 antibody, in combination with chemotherapy improves overall survival compared to chemotherapy alone when used for induction therapy for patients with newly diagnosed or relapsed indolent lymphoma. Randomised controlled trials have demonstrated that maintenance treatment with rituximab prolongs progression-free survival but evidence of effect on overall survival is lacking.

OBJECTIVES

To evaluate the effects of maintenance treatment with rituximab on overall survival in patients with follicular lymphoma.

SEARCH STRATEGY

We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), PubMed (June 2007), EMBASE (June 2007), LILACS (June 2007), databases of ongoing trials, and relevant conference proceedings. References of identified trials were searched and the first author of each included trial was contacted.

SELECTION CRITERIA

Randomised controlled trials that compared rituximab maintenance therapy to observation, treatment at relapse (no maintenance therapy), or other maintenance treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently appraised the quality of each trial and extracted data from included trials. Hazard ratios (HR) and relative risks with 95% confidence intervals (CI) were estimated and pooled using the fixed-effect model.

MAIN RESULTS

Five trials including 1056 adult patients were included in the review. Four trials (895 patients) were included in the analysis of overall survival. Patients treated with rituximab as maintenance therapy had a significantly better overall survival compared to observation alone (HR 0.53, 95% CI 0.38 to 0.73).

AUTHORS' CONCLUSIONS

Rituximab maintenance therapy should be added to standard therapy of patients with relapsed or refractory follicular lymphoma following a successful induction treatment. The drug should be given either as four weekly infusions every six months or as a single infusion every two to three months. Future randomised controlled trials should explore the effect of different protocols of rituximab maintenance therapy on overall survival.

Maintenance therapy in cutaneous T-cell lymphoma: Who, when, what?

The aim of current therapy for cutaneous T-cell lymphoma (CTCL) is to induce clinically meaningful remission, provide symptom relief, improve patient quality of life (QoL) and prolong disease-free and overall survival. A key research question is whether such remissions or minimal disease status can be maintained in the long term. There have been few formal studies of maintenance therapy in CTCL. Some skin-directed therapies such as total-skin electron-beam therapy and high-dose psoralen plus ultraviolet A may not be considered suitable, because of the risk of long-term cumulative toxicities. Other therapies such as nitrogen mustard, interferon (IFN)-alpha and bexarotene have demonstrated positive effects in prolonging remissions in small numbers of patients. Large longitudinal studies are required to investigate the efficacy of maintenance treatments in CTCL and their impact on patients' QoL and overall survival. Of the systemic therapies currently approved for the treatment of CTCL, bexarotene and IFN-alpha are obvious candidates for testing, because they can be self-administered by the patient and provide good long-term tolerability.

Rituximab and its role as maintenance therapy in non-Hodgkin lymphoma

Since rituximab, a chimeric monoclonal anti-CD20 antibody, was introduced into clinical practice in 1997, data regarding its benefit in terms of response rate, quality of response, progression-free survival and overall survival in B-cell lymphoid malignancies continues to expand. Rituximab has proven to be a relatively well-tolerated drug, with its major side effects being infusion related. Rituximab was approved initially by the US FDA and the European Medicines Agency for relapsed or refractory low-grade or follicular CD20+ B-cell non-Hodgkin lymphomas. Subsequently, its use has been extended to include first-line therapy in low-grade lymphoma as well as the treatment of more aggressive histological subtypes such as diffuse large B-cell lymphoma. In this article, we review the landmark trials that have impacted clinical practice in follicular and diffuse large B-cell lymphomas and the emerging data for use of rituximab as maintenance therapy in non-Hodgkin lymphoma.