Should patients with DLBCL refractory to frontline RCHOP (or similar) or relapsing within

New data from ASH-2021 /NEJM ZUMA-7 trial

(transformed FL were included in this study)

Take home messages:

  1. Only 30% of patients who are treated with salvage chemotherapy will attain a complete response.

  2. Patients with a CR who proceed to ASCT do as well as patients on CAR-T upfront with good long term survival (data not provided, but extrapolating from figure S4 likely 80% will maintain remission for at least a year)

  3. Patients without a CR do dismally on the ASCT pathway – seemingly almost no long term remissions. ~55% of these patients will benefit long-term from CAR-T (data not provided, but extrapolating from figure S3 showing overall survival of patients who didn’t attain a satisfactory response on the standard of care arm and crossed over to the CAR-T arm)

My approach – use salvage chemotherapy only in patients who had at least a PR to frontline RCHOP/daEPOCH-R. Then an early response evaluation and only patients with a clear and complete response proceed to ASCT. Not sure that this sequential approach provides any advantage over CAR-T, so might be better to simply use CAR-T alone (which seems to be the way the field is going to).

In the 1st image – duration of response (from the time of first response evaluation) limited only to patients who had responded to either second line chemotherapy (n=90) or CAR-T (n=150).

You can observe in the SOC arm most failures are early likely corresponding to 40% of the group that had a PR (20% of the entire cohort) and to an additional subset of patients who had a CR.

* explicit data were not provided so these are speculative estimates.

In the 2nd image – overall survival after CAR-T comparing patients who ‘failed’ the standard arm and subsequently received CAR-T (n=100) to those who had upfront CAR-T (n=179). Note that though the CAR-T upfront looks better suggesting there is a disadvantage for starting with chemotherapy and then transitioning to CAR-T this comparison is biased as it excludes the subset of patients who did well with standard of care.

* explicit data were not provided so these are speculative estimates.

imgur.com/4qTQ12d

www.nejm.org/doi/full/10.1056/NEJMoa2116133…

LMDA

Comments are for educational purposes only and should not be regarded medical advice

Read more here: Source link