EHA 2022 | How the treatment of DLBCL and FL are changing in the UK

So much is changing in lymphoma treatment at the moment. I guess what I would focus on is diffuse large B-cell lymphoma and also follicular lymphoma. In diffuse large B-cell lymphoma, what we are eagerly awaiting is whether we’ll be able to use CAR T-cells in the second-line treatment space. At the moment, they’re only available for third-line. That’s particularly frustrating for the patients who we don’t want to autograft. In other words, they fail their R-CHOP. We want to give them something potentially curative and that’s CAR-T, but we can’t do that until they’ve failed another line of treatment. We sort of have to give them another line of treatment, which we know isn’t going to work very well, only so that they will then be eligible for CAR-T. It would be wonderful to cut out that second-line chemo and go straight for CAR-T. But even for those patients who are autograft fit, the data from ZUMA-7 suggests that actually, event-free survival is strikingly positive. If you compare second-line CAR-T with a chemo versus autograpft approach. Although the overall survival curves didn’t quite reach significance, they were very nearly there. If I had relapsed diffuse large B, I would be wanting CAR-T as second-line. Now, this is going through NICE, as we speak. We will hear, hopefully towards the end of the year, maybe early next year, about whether that approach will be reimbursed.

I think that’s the main way that our pathway for diffuse large B may be affected in the relapsed space. And then again, we’ll be eagerly awaiting what NICE makes of polatuzumab-R-CHP, to see if we will be able to use that and in what patients. Will they restrict it to higher IPI subgroups or all comers based on the trial eligibility criteria? Then the other sort of rapidly changing area, which I think will be affected in the UK quite soon is relapsed follicular lymphoma. So at the moment, the follicular lymphoma pathway is relatively standardized. It’s R-chemo first-line, R-chemo second-line, although sometimes R squared, so rituximab-lenalidomide. Third-line, if you haven’t had R squared, that’s where you would use it. But then fourth-line, there’s sort of nothing. These are patients who are not curative. We need things for subsequent lines of treatment. We have two very exciting new agents. We have again, CAR-T and that’s going to go through NICE for fourth-line treatment. Yeah, it would be great if we could have a more standard of care, effective approach for fourth-line patients. Then the other exciting agents are bispecific antibodies and mosunetuzumab is the one that’s sort of ahead of the game in terms of timelines. And that will be, we hope, NICE assessed quite soon as well. I think how that might change the landscape is it’ll still be R-chemo frontline. It may be R-chemo or R-squared second-line, but then hopefully we’ll be able to use bispecifics, and then hopefully we’ll be able to use CAR-T cells. And that’s a radical change of the follicular lymphoma pathway.