Episode 35. Bispecific Antibodies in Lymphoma with Dr. Michael Dickinson
Nov 30, 2023
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Dr. Michael Dickinson, a medical professional specializing in lymphomas, discusses the potential of bispecific antibodies in the clinical management of lymphoma, including their mechanism of action and side effects. He explores the challenges of treating relapse after CAR T cell therapy and the advantages of using biospecific antibodies in patients who have not responded to CAR T cell therapy. The podcast also delves into the toxicity management of bispecific antibodies and the complexities of funding and outpatient treatments for refractory lymphoma. Finally, it explores the difficulties in eliminating chemotherapy from lymphoma treatments and the challenges in running trials for chemo ineligible patients.
Bi-specific antibodies show promise in providing effective and durable responses for lymphoma patients.
Patients treated with bi-specific antibodies have shown quick responses and potential for durable remission extending beyond two years.
The use of bi-specific antibodies may vary depending on the lymphoma subtype and individual patient characteristics, and the choice of antibody may depend on administration route and combination therapies.
Deep dives
The efficacy of bi-specific antibodies in treating lymphoma
Bi-specific T cell engaging antibodies, such as glofitomab, epratuzumab, and mocinatumab, have shown promising results in the treatment of lymphoma. These antibodies target CD3 and CD20, leading to T-cell activation and subsequent death of the target B-cells. They have demonstrated overall response rates of around 70% and complete remission rates of approximately 60% in relapsed/refractory diffuse large B-cell lymphoma (DLBCL) patients. Transformed follicular lymphoma and other aggressive subtypes of lymphoma have also shown positive responses to these bi-specific antibodies. Additionally, some early data suggests that mantle cell lymphoma may also benefit from this treatment approach. While there are some differences in efficacy and toxicity profiles among the different bi-specific antibodies, they all hold potential as effective treatment options for lymphoma.
Duration of response and potential for long-term remission
Patients treated with bi-specific antibodies have shown quick responses, with a median time to complete responses of 42 days. The therapy has demonstrated a complete remission (CR) rate of approximately 40% in relapsed/refractory DLBCL and other aggressive lymphomas. The durability of response varies among patients, but data from studies with glofitomab have shown that patients in CR at the end of treatment have an 80% chance of retaining that remission at the 12-month mark. Furthermore, very long-term follow-up data has suggested the potential for patients to achieve durable remission extending beyond two years, indicating the possibility of cure in some cases. While larger studies and longer follow-up are needed to understand the true extent of long-term remission, bi-specific antibodies show promise in providing durable responses for lymphoma patients.
Considerations for treatment and administration
The use of bi-specific antibodies may vary depending on the lymphoma subtype and individual patient characteristics. Patients with CD20-positive B-cell lymphomas, including diffuse large B-cell lymphoma, transformed follicular lymphoma, mantle cell lymphoma, and other aggressive subtypes, are suitable candidates for bi-specific antibody therapy. However, there may be variations in response rates and patient management due to factors such as antigen availability, tumor properties, and previous treatments. Additionally, the choice of bi-specific antibody may depend on the administration route. While glofitomab and mosenatumab are given as fixed-course intravenous treatments, epcoritamab stands out as a subcutaneously administered option. The pairing of bi-specific antibodies with CD20-targeted antibodies like rituximab may also impact treatment outcomes, but further research is needed to determine the significance of this combination approach.
Predictable Timing and Mitigation of Cytokine Release Syndrome
Cytokine release syndrome (CRS) is a known side effect of bispecific antibodies, including glofitomab. However, the timing and characteristics of CRS differ depending on the specific bispecific antibody used. With glofitomab, CRS typically occurs after the first dose, around 10 hours after intravenous infusion. The severity of CRS is dose-related and can be managed with steroids as prophylaxis. The rate of CRS decreases with subsequent doses of glofitomab. Overall, CRS is a manageable side effect that can be anticipated and controlled.
Infection Risks and Infectious Prophylaxis
Bispecific antibodies targeting B-cells, such as glofitomab, increase the risk of infections, although the incidence is lower than in myeloma patients. Factors that affect the risk of infection include the specific target antigen, the patient's disease context, and the cumulative steroid exposure. Prophylactic measures should be taken to prevent infections, such as pneumocystis pneumonia (PCP) and zoster reactivation. Monitoring and managing infections in patients receiving bispecific antibodies is crucial for ensuring patient safety and treatment efficacy.
In this episode, we delve into the weeds of bispecific antibodies across lymphomas with Dr. Michael Dickinson from Peter MacCallum Cancer Center, Melbourne, Australia. Here are the key articles we discussed: