Follicular lymphoma

Follicular lymphoma is the second most common type of non-Hodgkin lymphoma (NHL). It starts in B cells and is usually indolent (slow-growing). Follicular lymphoma is often spread throughout the lymphatic system at diagnosis. It can also spread to other parts of the body, such as the bones, skin, gastrointestinal (GI) tract and lungs. It often responds well to treatment, but it often comes back.

Sometimes follicular lymphoma can change into an aggressive (fast-growing) type of NHL called diffuse large B-cell lymphoma (DLBCL). If it does, it is treated like DLBCL. If the follicular lymphoma is high-grade, it is also treated like DLBCL. Find out more about treatments for DLBCL.

The Follicular Lymphoma International Prognostic Index (FLIPI) was developed to determine the outcome for people with follicular lymphoma. Your healthcare team will use the FLIPI to help determine if follicular lymphoma is likely to respond well to treatment and if it is likely to come back (relapse) after treatment.

The FLIPI includes the following poor prognostic factors:

• 60 years of age or older
• high lactate dehydrogenase (LDH) levels
• stage 3 or 4
• blood hemoglobin less than 120 g/L
• lymphoma cells are in more than 4 lymph node areas

The poor prognostic factors are used to assign follicular lymphoma to one of the following risk groups:

• low risk (0 or 1 poor prognostic factor)
• intermediate risk (2 poor prognostic factors)
• high risk (3 or more poor prognostic factors)

The FLIPI helps you and your healthcare team make treatment decisions that are right for you. This index is also used in clinical trials testing new drugs to treat follicular lymphoma.

Treatment for follicular lymphoma is based on the stage and the FLIPI. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

If follicular lymphoma is developing slowly and not causing any symptoms, you may be offered watchful waiting. The healthcare team will do tests to carefully monitor the cancer. When symptoms appear or there are signs that the disease is progressing more quickly, they will offer other treatments.

Find out more about watchful waiting.

Radiation therapy uses high-energy rays or particles to destroy cancer cells. It is commonly used to treat follicular lymphoma that is in specific areas of the body, such as an area of affected lymph nodes, the chest or the abdomen.

Find out more about radiation therapy for NHL.

Targeted therapy uses drugs to target specific molecules (such as proteins) on cancer cells or inside them. These molecules help send signals that tell cells to grow or divide. By targeting these molecules, the drugs stop the growth and spread of cancer cells while limiting harm to normal cells. Targeted therapy may also be called molecular targeted therapy.

Rituximab (Rituxan and biosimilars) is used to treat follicular lymphoma that is causing symptoms. It can be used alone or with chemotherapy. It may also be used as maintenance therapy after chemotherapy.

Obinutuzumab (Gazyva) may be combined with chemotherapy and then used alone to treat follicular lymphoma. It can also be used to treat follicular lymphoma that has come back after treatment (relapsed) or didn't respond to treatment (called refractory disease).

Zanubrutinib (Brukinsa) combined with obinutuzumab is used to treat indolent (low-grade) relapsed or refractory follicular lymphoma in people who have already received at least 2 systemic therapies.

Lenalidomide (Revlimid) is sometimes used to treat relapsed or refractory follicular lymphoma.

These targeted therapy drugs may not be covered by all provincial or territorial health plans.

Find out more about targeted therapy for NHL.

Chemotherapy uses drugs to destroy cancer cells. It is often combined with a targeted therapy drug to treat follicular lymphoma that is causing symptoms.

The most common drugs and drug combinations used to treat follicular lymphoma include:

• BR – bendamustine (Treanda, Benvyon, Esamuze) and rituximab
• R-CHOP – rituximab, cyclophosphamide (Procytox), doxorubicin, vincristine and prednisone
• R-CVP – rituximab, cyclophosphamide, vincristine and prednisone
• bendamustine and obinutuzumab
• chlorambucil (Leukeran)
• fludarabine (Fludara)

The most common drugs and drug combinations used to treat relapsed or refractory follicular lymphoma include:

• bendamustine
• chlorambucil
• fludarabine
• etoposide (Vepesid)
• CVP – cyclophosphamide, vincristine and prednisone
• CEPP – cyclophosphamide, etoposide, procarbazine (Matulane) and prednisone
• GDP – gemcitabine, dexamethasone and cisplatin
• CHOP – cyclophosphamide, doxorubicin, vincristine and prednisone

Find out more about chemotherapy for NHL.

Immunotherapy helps to strengthen or restore the immune system's ability to fight cancer. It is sometimes used to treat relapsed or refractory follicular lymphoma. The following immunotherapy drugs may not be covered by all provincial and territorial health plans.

Your healthcare team may offer the immunotherapy called CAR T-cell therapy as a treatment option. The following drugs may be used in CAR T-cell therapy:

• tisagenlecleucel (Kymriah)
• axicabtagene ciloleucel (Yescarta)
• lisocabtagene maraleucel (Breyanzi)

Bispecific antibodies are a new type of immunotherapy. Epcoritamab (Epkinly) may be used to treat grade 3B follicular lymphoma after 2 or more lines of systemic therapy and if you previously had CAR T-cell therapy or if you can't have CAR T-cell therapy.

Find out more about immunotherapy for NHL.

A stem cell transplant replaces stem cells. It may be used to treat relapsed or refractory follicular lymphoma.

Find out more about stem cell transplant for NHL.

Talk to your doctor about clinical trials open to people with NHL in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.