Ask AI
Back Back
FAQs in Follicular Lymphoma
Expert Perspectives on the Management of Patients With Relapsed/Refractory Follicular Lymphoma: Answers to Frequently Asked Questions

Released: December 26, 2025

Peter Martin
Peter Martin, MD
Gilles Salles
Gilles Salles, MD, PhD
Laurie H. Sehn
Laurie H. Sehn, MD, MPH
Activity Information

Activity

Continue to Activity
Key Takeaways
  • Supportive care strategies including consideration of IVIG supplementation and vaccinations are important considerations with bispecific antibody and CAR T-cell therapies in follicular lymphoma.
  • Both bispecific antibodies and CAR T-cell therapy are approved for patients with previously treated follicular lymphoma and treatment decisions should be individualized accounting for patient preferences.
  • In general, experts prefer bispecific antibodies prior to CAR T-cell therapy use based on lower logistical burden, with the exception of patients with rapidly progressing disease.

In this commentary, Peter Martin, MD, Gilles Salles, MD, PhD, and Laurie H. Sehn, MD, MPH, address key questions posed by the audience during the recent symposium titled, “Beyond Chemotherapy: Patient Voices and Expert Insights on Using Precision Therapies to Enhance Personalized Care of Follicular Lymphoma” held during the 2025 American Society of Hematology annual meeting.

In terms of supportive care strategies, do you recommend that patients receive vaccinations before initiating treatment with bispecific antibodies, and what is the role of IVIG? 

Peter Martin, MD:
I have always been an advocate for vaccinations. Studies looking at serologic response to vaccines during and after treatment for lymphoma demonstrated that although serologic response declined, patients still benefit from vaccines despite having been on or recently received anti-lymphoma therapy. My preference is to complete vaccinations prior to initiating anti-lymphoma therapy. However, even if the patient has started receiving anti-lymphoma therapy without receiving prior vaccinations, I will still recommend that the patient gets vaccinated.

Laurie H. Sehn, MD, MPH:
For patients with follicular lymphoma (FL), there is usually a time window for vaccinations before anti-lymphoma treatment begins. I often discuss vaccinations with my patients and their caregivers and recommend vaccinations with a plan to start anti-lymphoma treatment in the next 2-4 weeks. Typically, there is no urgency to start treatment for FL immediately, so there is usually time to have that discussion and allow patients to get all recommended vaccinations.

Gilles Salles, MD, PhD:
Regarding the use of IVIG, it is a shared decision between the patient and the oncologist, and it is used on an individual patient’s basis and need. The recommendation is to supplement treatment with the use of IVIG to prevent severe infections, particularly if the IgG level is less than 400 mg/dL and repeated infections occur despite the use of antibiotics. For example, I have patients with IgG levels of 200 mg/dL who have never had an infection, and for these patients, I have not recommended IVIG use. Conversely, I have patients with IgG levels of 500 mg/dL to 600 mg/dL who benefit from IVIG use.

Peter Martin, MD:
That has also been my experience. In patients with multiple myeloma, IVIG use is generally recommended when administering BCMA-directed bispecific antibodies. However, these antibodies are far more immunosuppressive because they clear plasma cells. On the other hand, the bispecific antibodies approved for use in FL—mosunetuzumab, epcoritamab, and odronextamab—target CD20 and CD3, and so they may take longer to have a similar immunosuppressive effect. Of note, mosunetuzumab and epcoritamab are approved by both the FDA and EMA, and odronextamab is approved by the EMA. In FL, the need for IVIG has a lot to do with which prior therapies patients have received and the degree of immunosuppression that they are starting the next treatment with.

How do you sequence bispecific antibodies and CAR T-cell therapy for your patients with R/R FL?

Laurie H. Sehn, MD, MPH:
Treatment decisions should be individualized on a patient-specific basis. If I had to make a general statement, I would say that for patients with FL, I still consider bispecific antibodies ahead of CAR T-cell therapy. This is largely because I view CAR T-cell therapy as a more intensive therapy with greater risks. Also, there are complex logistical aspects and high treatment costs associated with CAR T-cell therapies. Based on these factors, I tend to favor starting with a bispecific antibody before moving to CAR T-cell therapy for my patients with FL. Although the efficacy of CAR T-cell therapy for patients with relapsed/refractory FL is very promising, I would like to see longer-term data. Perhaps in the end, with longer-term data, there may be a shift in situations where we need to prioritize CAR T-cell therapy vs bispecific antibodies. At present, however, my sequencing preference is to use a bispecific antibody first before moving to a CAR T-cell therapy.

Peter Martin, MD:
There is also the emotional impact of receiving treatment and having no evidence of disease, which may indicate that the patient is potentially cured. The more exposure I get to administering CAR T-cell therapy in FL, the more I wonder about that aspect. In general, my impression is that the bispecific antibodies are more practical. Most patients with FL do not want to be in the hospital for a couple of weeks receiving treatment, although with lisocabtagene maraleucel, that is not always the case.

It is often difficult to understand from the data how to compare an agent that is administered continuously, potentially until disease progression with one that is a 1-time administration with considerations for the impact of that on the patient’s quality of life. My experience has been that most patients choose bispecific antibodies over CAR T-cell therapy when presented with both options.

Gilles Salles, MD, PhD:
At this time in the third-line setting in general, most of us will offer a bispecific antibody before CAR T-cell therapy. However, I have treated some aggressive cases of FL in which CAR T-cell therapy was used in the third-line setting before a bispecific antibody. For patients with more rapidly progressing disease, CAR T-cell therapy is my preferred option, whereas bispecific antibodies may be preferable for patients with disease relapse with a disease-free interval of more than 1 year. We currently have several treatment options in our armamentarium with many more novel and emerging therapies in the clinical pipeline, so, treatment decisions should be personalized to each patient. Also, a shared treatment decision-making process should be utilized with discussions of the efficacy and safety profile of each potential agent and their respective constraints with the patient and their caregivers. Of note, patient preferences should be reassessed regularly as disease status and life circumstances change.

Are there differences in the available CAR T-cell therapies, and should different CAR T-cell products be selected for different patients?

Peter Martin, MD:
I feel that many patients with FL are biased towards more outpatient management and spending less time in the hospital in an in-patient setting. There is also a bias towards lower rates of toxicity. Lisocabtagene maraleucel and tisagenlecleucel seem to have slightly lower rates of toxicity compared with axicabtagene ciloleucel. Without direct comparisons in a randomized clinical trial, it remains unknown if there are differences in efficacy. If there are differences in efficacy, that would influence my treatment decision.   

Gilles Salles, MD, PhD:
I use and prescribe CAR T-cell therapy in my practice, and do not think I have used axicabtagene autoleucel in patients with FL in the last 2 years given the respective safety profiles of the available products. We try to keep the administration of CAR T-cell therapy ambulatory as much as possible. That does not mean that the patient will not spend 3 days in the hospital because of treatment-associated cytokine release syndrome. In my experience, approximately 40% to 50% of patients do not experience cytokine release syndrome or infections with lisocabtagene maraleucel or tisagenlecleucel, and so, patients who receive these agents are able to remain in the ambulatory setting.

Your Thoughts
What are the challenges that you face with the use of CAR T-cell therapies in the management of your patients with follicular lymphoma?

Continue to Activity

Poll

1.

In your practice, how often do you reassess treatment preferences of your patients during the course of their disease?

Submit