During a recent debate, held at the International Waldenström Macroglobulinemia (WM) Foundation Educational Forum in Philadelphia, Pennsylvania, in June 2019, researchers discussed whether patients with WM, a rare, indolent B-cell lymphoma, should receive rituximab maintenance therapy following achievement of a response to rituximab-based induction therapy. The consensus was that this decision needs to be individualized for each patient.1

A central theme of the argument made by Stephen Ansell, MD, PhD, from the Mayo Clinic in Rochester, Minnesota — who presented a case against rituximab maintenance therapy — was the absence of randomized evidence showing an overall survival (OS) benefit for the use of maintenance rituximab in similar settings. 

In support of this conclusion, Dr Ansell cited the results of 2 previous randomized studies of patients with follicular lymphoma, another typically indolent B-cell lymphoma, which showed a progression-free survival (PFS) benefit or an improvement in the duration of response to treatment for some patients, but no statistically significant improvement in OS, with rituximab maintenance therapy compared with observation.2,3 Specifically, in 1 study, a statistically significant improvement in duration of response to rituximab maintenance therapy was observed for patients with a partial response to induction therapy, but not for those with a complete response to treatment. 

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Dr Ansell also mentioned the potential for adverse effects, such as increased risk of infections, as well as increased costs to patients, associated with rituximab maintenance therapy. 

“Maintenance rituximab benefits you when you don’t have such a great response to initial treatment … but, all told, it doesn’t make you live longer,” he concluded.

A key point made by Morton Coleman, MD, from the Weill Cornell Medical Center in New York, New York — who took the opposing view in favor of rituximab maintenance —  was that WM is associated with many disease-related adverse effects, such as neuropathy, neutropenia, anemia, thrombocytopenia, hyperviscosity, thrombosis, and infection, and that maintenance therapy has the potential to increase patient quality of life by prolonging the time that the patient is free of those symptoms.

In his concluding remarks, Dr Coleman noted that they are “shades of gray” when considering whether to offer maintenance therapy to patients with WM, and conceded that it may be safe to “watch and wait” patients who are “not too symptomatic after treatment.” 

References

  1. Ansell SM, Coleman M. Rituxan maintenance vs no maintenance. Presented at: 2019 International Waldenström’s Macroglobulinemia Foundation Educational Forum; June 7-9, 2019; Philadephia, PA.
  2. Hill BT, Nastoupil L, Winter AM, et al. Maintenance rituximab or observation after frontline treatment with bendamustine-rituximab for follicular lymphoma. Br J Haematol. 2019;184(4):524-535. 
  3. Salles G, Seymour JF, Offner F, et al. Rituximab maintenance for 2 years in patients with high tumour burden follicular lymphoma responding to rituximab plus chemotherapy (PRIMA): a phase 3, randomised controlled trial. Lancet. 2011;377(9759):42-51.