Treating Relapsed/Refractory Follicular Lymphoma

If your follicular lymphoma has relapsed, it means the cancer returned after remission, a period when it disappeared or was reduced. Your doctor will call your cancer "refractory" if it doesn't respond to treatment.

Whether your follicular lymphoma is relapsed or refractory, you still have treatment options.

Choosing a Treatment

If your doctor thinks your cancer has returned, you may get tests like imaging scans or blood tests. Your treatment options will depend on the results of these tests as well as:

• Your age
• Overall health
• Which treatments you had before
• How well medications worked
• How many times your cancer has come back

You may get different medications than you had before. Your doctor might suggest you take a combination of drugs to help them work better.

Some drugs that doctors commonly recommend are:

Chemotherapy. Also called "chemo," this treatment uses strong medicine to kill cancer cells. Chemo works throughout your body. You may get chemotherapy alone or combined with monoclonal antibodies or other treatments.

These medicines include:

• Bendamustine (Treanda)
• Fludarabine (Fludara)

Some common side effects from these drugs are:

• Hair loss
• Nausea and vomiting
• Mouth sores
• Diarrhea or constipation
• Greater chance of infection
• Bleeding or bruising
• Shortness of breath

Targeted drugs. These medications block certain parts of cancer cells, such as proteins or genes, that help the cancer grow and divide. Drugs that treat follicular lymphoma target the proteins PI3K and EZH2.

Targeted drugs include:

• Copanlisib (Aliqopa)
• Duvelisib (Copiktra)
• Idelalisib (Zydelig)
• Tazemetostat (Tazverik)
• Umbralisib (Ukoniq)

Some common side effects that you might have from these drugs are:

• Nausea
• Diarrhea
• Weakness
• Fatigue
• Low blood cell counts
• Joint, bone, or muscle pain

Monoclonal antibodies. Antibodies are special proteins your body uses to fight infections. Monoclonal antibodies are a specific type of antibody, made in a lab, to find and destroy cancer.

Rituximab (Rituxan) targets the antibody CD20 on the surface of follicular lymphoma cells. Your doctor may prescribe it together with a chemo drug like bendamustine or fludarabine.

A few treatment programs combine rituximab with three or four chemotherapy drugs:

• R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
• R- CVP (rituximab, cyclophosphamide, vincristine, prednisone)
• R-FND (rituximab, fludarabine, mitoxantrone, dexamethasone)

You might get side effects such as:

• Infections
• Bruising or bleeding
• Nausea and vomiting
• Hair loss
• Rash or itching
• Fever and chills

Rituximab can also be prescribed with the immunomodulatory drug lenalidomide (Revlimid) that stimulates the immune system to help kill cancer cells.

CAR T-cell therapy. This treatment reengineers your own immune cells to make them better cancer fighters. Your doctor takes a type of white blood cell from your body. A lab adds a protein so the cells can find your cancer more easily. Then the lab multiplies the cells into the billions. Those cancer-seeking cells then go back into your body.

The FDA has approved two CAR T-cell therapies for follicular lymphoma:

• Axicabtagene ciloleucel (Yescarta)
• Lisocabtagene maraleucel (Breyanzi)

Because CAR T-cell therapy affects your immune system, it can cause side effects. When the CAR T cells multiply in your body, they release large amounts of chemicals called cytokines into your blood.

Cytokine release syndrome can feel like a bad case of the flu, with symptoms like:

• High fever and chills
• Nausea, vomiting, or diarrhea
• Dizziness
• Headaches
• Trouble breathing

This treatment can also cause problems with your brain and nervous system, with symptoms like:

• Headaches
• Confusion
• Seizures
• Shaking

Radiation. This treatment uses high-energy waves to kill cancer cells. Your doctor may recommend radiation, alone or with chemotherapy, if you have a large tumor or a lot of symptoms.

Some common radiation side effects are:

• Blistered or peeling skin in the treated area
• Tiredness
• Nausea
• Diarrhea

Stem cell transplant. High-dose chemotherapy kills cancer cells, but it also damages the stem cells in your bone marrow that grow into new blood cells. A stem cell transplant replaces those damaged blood cells with healthy new ones taken from your own body or from a donor.

Clinical trials. These studies give you a chance to try treatments that aren't available to the public. Your doctor can help you find a clinical trial that's a good fit for you.

What if I Relapse Again?

Follicular lymphoma is hard to cure and you may have more than one relapse. Though you can't prevent relapses, you can watch for any new symptoms and tell your doctor about them.

If you do relapse, your doctor can try a different drug or combination of medications. New treatments coming out are leading to longer remissions and a better quality of life.

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