High-risk follicular lymphoma: Treatment options

Follicular lymphoma (FL) is the most common indolent non-Hodgkin lymphoma in the Western hemisphere. The natural history of FL appears to have been favorably impacted by the introduction of rituximab. Randomized clinical trials have demonstrated that the addition of rituximab to standard chemotherapy induction has improved the overall survival. Maintenance rituximab strategies can improve progression-free survival (PFS). Obinutuzumab was superior to rituximab for PFS in the GALLIUM study, although the benefit was small and required more drug. Chemotherapy platforms have changed in the past decade, as bendamustine combined with rituximab has become commonly utilized frontline strategy in North America and parts of Europe, although there is certainly no one standard treatment. However, several unmet needs remain, including a better ability to identify high-risk patients at diagnosis, the development of predictive biomarkers for targeted agents, the development of novel combinations, and strategies to reduce the risk of transformation. A multitude of novel therapies are under investigation in both the frontline and relapsed/refractory settings. It will be critical to identify the most appropriate populations for new agents and to develop validated surrogate endpoints, so that novel agents can be tested (and adopted, if appropriate) efficiently.