How to treat older patients with follicular lymphoma in the first‑line setting

During the Lymphoma Hub Steering Committee meeting, Gilles Salles, Memorial Sloan Kettering Cancer Center, New York, US, chaired a discussion on, How to treat older patients with follicular lymphoma in the first-line setting. This discussion also featured Francesc Bosch, Grzegorz Nowakowski, Martin Dreyling, Marek Trněný, Michael Dickinson, and Stefano Luminari.

The panel acknowledged the complexity of defining “older patients”, emphasizing that age, frailty, and comorbidities significantly influence treatment decisions. While most agreed that the standard of care is feasible for patients under 75 years with good performance status, they noted that frail patients require tailored approaches. For healthy individuals over 70–75 years, treatments are often similar to those given to younger patients, with only minimal modifications. In contrast, frail patients benefit from reduced-intensity therapies such as bendamustine (administered with dose adjustments of 50–70 mg/m² over 2–4 cycles, alongside growth factor support to manage immunosuppression) or cyclophosphamide, vincristine, prednisone (CVP), which is considered a better-tolerated alternative when combined with anti-CD20 antibodies for improved efficacy.

The steering committee members also explored newer therapies, such as bispecific antibodies, though their application in frail populations is still limited. Radiation therapy was suggested as a viable option for managing localized symptoms in very elderly or high-risk patients who are unable to tolerate chemotherapy. The overarching goals of therapy were described as focusing on achieving a “functional cure” rather than aggressive disease eradication, with an emphasis on prolonging progression-free survival and maintaining quality of life, allowing patients to reach their natural life expectancy.

The panel shared regional practices, including the US preference for rituximab monotherapy as a safe yet less durable option for frail patients and the Australian concern over the infection risks associated with prolonged use of bendamustine. The importance of personalized therapy was a recurring theme, highlighting the need to tailor treatments based on performance status, frailty, and comorbidities, with careful adjustments to dosage and regimens to balance efficacy and safety. 

The session concluded by recognizing the diversity of available treatments and stressing the importance of adapting approaches to individual patient needs, while remaining open to integrating newer therapies as evidence validates their use.