Rituximab in the Treatment of Follicular Lymphoma: the Future of Biosimilars in the Evolving Therapeutic Landscape

Rituximab (Rituxan^®; Genentech, South San Francisco, CA, USA/MabThera^®; Roche, Basel, Switzerland) is a chimeric anti-CD20 monoclonal antibody that binds specifically to CD20.^6,7 In addition to its role in the treatment of diffuse large B-cell lymphoma (DLBCL) in the first-line or relapsed/refractory settings, rituximab is also approved for use in FL as a single agent or in combination with first-line chemotherapy.^6,7 Given the importance of rituximab across the spectrum of FL treatment and the evolving therapeutic landscape with the emergence of novel agents, the role of rituximab in the future management of FL is described. The role of rituximab biosimilars in the future of FL treatment and how the introduction of biosimilars can help to relieve this lack of access are also discussed.

FL: THE ROLE OF RITUXIMAB IN THE CURRENT STANDARD OF CARE

The National Comprehensive Cancer Network (NCCN)⁸ (Table 1) and the European Society for Medical Oncology (ESMO) guidelines⁹ (Figure 1) outline the recommended treatment regimens for patients with FL in the US and Europe, respectively. Owing to its established long-term efficacy, rituximab is an important component of FL treatment.¹⁰

(To view a larger version of Table 1, click here.) 

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Treatment options for patients with limited-stage disease (stage I/II) include radiation,^11–13 “watch-and-wait” approach,¹⁴ or rituximab alone or in combination with chemotherapy (eg, bendamustine plus rituximab [BR]; rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone [R-CHOP]; or rituximab plus cyclophosphamide, vincristine, and prednisone [R-CVP]).¹⁵ Despite the paucity of randomized clinical trials, radiation therapy is the preferred treatment for patients with non-bulky stage I FL. Patients with Grade 3b FL or those undergoing histologic transformation are best treated with chemoimmunotherapy regimens, such as R-CHOP. Patients with stage II FL are appropriate candidates for treatment with either rituximab alone or in combination with chemotherapy, depending on their clinical presentation. In general, the treatment approach for patients with stage II FL includes “watch-and-wait”, single-agent rituximab vs rituximab plus chemotherapy, or radiation for those with contiguous nodal involvement. Patients with bulky disease or those with an adverse prognosis presenting with B symptoms and/or clinically significant tumor load are candidates for treatment with rituximab plus chemotherapy.^8,9