Non-Hodgkin Lymphoma

Biosimilar clinical trials provide participants with immediate access to active biologic therapy at no cost and ultimately contribute to more affordable treatment worldwide

The anti-CD20 monoclonal antibody, rituximab, revolutionized the management of non-Hodgkin lymphoma (NHL) and remains the cornerstone of modern NHL management. The high cost of rituximab currently puts it beyond the reach of many eligible patients – but, as its patent expiry approaches, new manufacturers are able to begin developing less costly versions, known as biosimilars. For regulatory approval, a biosimilar must demonstrate similar safety and efficacy to the originator biologic in a head-to-head clinical trial.

Non-Hodgkin lymphoma – a major global health issue   +

Non-Hodgkin lymphoma (NHL) is the 10th most commonly diagnosed cancer worldwide.1,2 In developed nations it ranks as high as 7th, with the greatest incidence in the United States and Europe.1,2 Of the indolent (slow growing) subtypes of NHL, follicular lymphoma (FL) is the most common – comprising around 20% of all cases of NHL3 – while diffuse large B cell lymphoma (DLBCL) is the most common aggressive form.4,5 Over the past few decades there has been a dramatic rise in the incidence of NHL globally, surpassed only by malignant melanoma and lung cancer in women.2 Research is still ongoing to determine the cause of NHL, as well as the reasons for this increase in incidence, although the aging population is a likely factor.3

The advent of biologics has revolutionized NHL management…   +

The introduction of the anti-CD20 monoclonal antibody rituximab significantly changed the management of NHL. Rituximab was licensed in the US in 1997 as Rituxan® and in the EU in 1998 as MabThera®. Its wide range of indications across both oncology and rheumatology make it unique among biologic drugs. The initial FDA approval of rituximab was based on a pivotal study in which it was given as monotherapy to treat relapsed or refractory low-grade FL.6 Subsequent studies demonstrated improved responses when rituximab was administered in combination with CHOP chemotherapy as first-line treatment, and as maintenance therapy following the induction of remission.7  

Two decades after the first Phase I clinical trials in the mid-1990s, rituximab remains the cornerstone of NHL therapy.8 The prognosis of FL has significantly improved with the incorporation of rituximab into treatment regimens, in both first-line and relapsed settings, with overall survival increasing markedly.3,8,9 Some experts now think the old paradigm that viewed FL as an incurable condition is becoming outdated.8

…but many patients can’t benefit because of the cost   +

Unfortunately, many of the world’s patients with NHL are not able to reap the benefits of rituximab therapy. The reason, of course, is cost. A 2014 study examined access to rituximab within the US, Mexico, Turkey, Russia, and Brazil.10 Overall, 450 hematologists and oncologists completed a survey examining their use of rituximab in patients with NHL and also in those with chronic lymphocytic leukemia (CLL). Less than 40% of physicians considered rituximab easy to access from a cost perspective. Furthermore, many physicians chose not to treat, were unable to treat, or had to modify treatment with rituximab, despite guidelines recommending its use in patients with NHL and CLL. Issues with insurance coverage, reimbursement, and costs to patients were commonly cited as barriers to the use of rituximab.10

“At present, access to existing biopharmaceuticals may be viewed as a greater unmet need than that for more effective treatments.” 7 

“Rituximab is like gold dust.” 11

Patent expiry permits introduction of biosimilars   +

The cost of modern cancer biologics reflects the scientific innovation and the investment required to support biotechnological research and development. But it puts these treatments beyond the reach of many people. Pursuit of innovative new drugs is clearly of great importance, but so is broadening patient access to the treatments we have now. There’s no quick-fix solution – but, as many modern cancer biologics start to approach patent expiry, the opportunity arises for new manufacturers to develop more affordable biosimilars. A biosimilar of rituximab has now been approved in Europe and in South Korea, and other countries are expected to follow soon, with the aim of bringing the benefits of this important biologic drug to many more patients worldwide.

In a position paper published by the European Society for Medical Oncology (ESMO) in early 2017, Professor Fortunato Ciardiello, ESMO’s President stated: “Biosimilars are must-have weaponry in financially sustaining healthcare systems on a global scale as well as significantly improving outcomes for an increasing number of patients throughout Europe and the rest of the world.”

Become a rituximab biosimilar investigator in NHL   +

QuintilesIMS is actively supporting the development of rituximab biosimilars for NHL and we invite you to join us as a clinical investigator. The patients you enroll in these studies will all receive active therapy, either with Rituxan®/MabThera® or with a rituximab biosimilar candidate at no cost to them or to their insurers.

Our current NHL biosimilar study opportunities are in treatment-naïve patients with indolent, low-tumor-burden follicular lymphoma (FL) who will be randomized to receive induction monotherapy with either branded rituximab or a biosimilar candidate given by intravenous infusion once weekly for 4 weeks. Note: this is not a licensed indication for Rituxan®/MabThera®, which is approved in FL as monotherapy only when patients have relapsed on previous therapy or alternatively as a first-line option in combination with chemotherapy.

In treatment-naïve patients with low-tumor-burden FL, rituximab induction therapy has been shown to achieve longer delays before the next intervention becomes necessary, greater progression-free survival, and improved quality of life compared with watchful waiting, but an overall survival benefit has so far not been demonstrated.3,8 This has meant that some physicians prefer a watch-and-wait strategy for such patients. Even if this is your preferred approach, there are still a number of reasons why you may be interested in participating in a study like this as a clinical investigator:

  • The study population and treatment regimen have in this case been stipulated by regulatory authorities, whom biosimilar sponsors should always consult about their clinical development plans. Regulatory authorities sometimes request the use of a patient population where the originator biologic may not be licensed or fully clinically established, but is nonetheless considered to be best suited for the demonstration of clinical equivalence between the two comparator drugs. A positive outcome in the study will therefore directly meet the needs of regulators if and when a submission is made for approval of the biosimilar candidate. You may therefore be part of an initiative that ultimately succeeds in bringing a more affordable version of rituximab to market.
  • As you may be aware, some patients diagnosed with FL are very uncomfortable with the idea of watch-and-wait, which can have a negative impact on their quality of life.12 Enrolling such patients into a study like this will provide an opportunity for active treatment at no cost to them or to healthcare providers.
  • A cost-effectiveness analysis, published in 2015 by the American Cancer Society in their journal Cancer, has shown that provision of rituximab induction therapy to patients with asymptomatic advanced-stage FL (without subsequent maintenance therapy) is more cost-effective in the long term than watchful waiting.13

Learn more about working with QuintilesIMS 

References   +

1. Ekstrom-Smedby K. Epidemiology and etiology on non-Hodgkin lymphoma – a review. Acta Oncologica (2006) 45:258–271.
2. Muller AM, Ihorst G, Mertelsmann R & Engelhardt M. Epidemiology of non-Hodgkin’s lymphoma (NHL): trends, geographic distribution, and etiology. Ann Hematol (2005) 84:1–12.
3. Ansell SM. Non-Hodgkin lymphoma: diagnosis and treatment. Mayo Clin Proc (2015) 90:1152–1163.
4. National Cancer Institute. What you need to know about non-Hodgkin lymphoma: Diagnosis. Available at: Accessed 4 December 2015.
5. National Cancer Institute. Adult non-Hodgkin lymphoma treatment – for health professionals (PDQ®): Cellular classification of adult non-Hodgkin lymphoma. Available at: Accessed 4 December 2015.
6. McLaughlin P, Grillo-López AJ, Link BK et al. Rituximab chimeric anti-CD20 monoclonal antibody therapy for relapsed indolent lymphoma: half of patients respond to a four-dose treatment program. J Clin Oncol (1998) 16:2825–2833.
7. Vital EM, Kay J & Emery P. Rituximab biosimilars. Expert Opin Biol Ther (2013) 13:1049–1062.
8. Aguiar-Bujanda D, Blanco-Sánchez MJ, Hernández-Sosa M et al. Critical appraisal of rituximab in the maintenance treatment of advanced follicular lymphoma. Cancer Manag Res (2015) 7:319–330.
9. Fisher RI, LeBlanc M, Press OW et al. New treatment options have changed the survival of patients with follicular lymphoma. J Clin Oncol (2005) 23:8447–8452.
10. Baer WH, Maini A & Jacobs I. Barriers to the access and use of rituximab in patients with non-Hodgkin’s lymphoma and chronic lymphocytic leukemia: a physician survey. Pharmaceuticals (2014) 7:530–544.
11. Daily Mail (UK), 3 February 2014. Accessed 4 December 2015.
12. Kahl B. Is there a role for “watch and wait” in follicular lymphoma in the rituximab era? Hematology Am Soc Hematol Educ Program (2012) 2012:433–438.
13. Prica A, Chan K & Cheung M. Frontline rituximab monotherapy induction versus a watch and wait approach for asymptomatic advanced-stage follicular lymphoma: a cost-effectiveness analysis. Cancer (2015) 121:2637–2645