Practice Pearl 2: Selecting SQ Formulation for a Patient
Factors that inform the decision to stratify patients to subcutaneous formulations.
Adam M. Brufsky, MD, PhD: Are patients aware that there's subcutaneous rituximab?
Matthew J. Matasar, MD: I've never had a patient come to me and specifically say, "Dr Matasar, I heard about this Rituxan Hycela. Can you tell me about that?" That's not come up in clinic with me yet. Typically, they may have heard of the medicine rituximab, because it's well known.
Adam M. Brufsky, MD, PhD: Right.
Matthew J. Matasar, MD: And then you get to have a discussion about, "Well, we have both an intravenous [IV] and a subcutaneous formulation, here are the pros and cons, and this is what I'm thinking."
Adam M. Brufsky, MD, PhD: Right. So patients really don't know, but when you talk to them, do you even tell them? Do they get a choice? Do you say, "Well, I can give it to you intravenously or subcutaneously"? Or do you just say, "You're going to get your rituximab, it's going to be subcutaneous." As we talk to patients, when we sit them down and go through their whole treatment course of what's going to happen to them, do you just tell them they're going to get a subcutaneous formulation and that's it?
Matthew J. Matasar, MD: At Memorial Sloan Kettering Cancer Center, we tend to skew toward using the subcutaneous formulation as I've suggested for more indolent forms of lymphoma and intravenous exclusively for aggressive when treated with curative intent.
For a patient coming to me with follicular lymphoma in whom I'm planning rituximab-based treatment, I'll simply spell out what I think is the approach. You can have you first dose intravenously and assuming that goes well, you'll get subsequent doses as a 5-to-7-minute shot in the belly as part of your treatment. And then only if there's a problem, if there's intolerable local site reactions that we can't get around with conservative management, will I then revert to intravenous treatment.
Adam M. Brufsky, MD, PhD: You haven't had someone say, "Well, I saw in the support group on this Facebook Group that all these people are getting IV, why are you giving me subcutaneous, Dr Matasar?" You don't get that sort of pushback at all?
Matthew J. Matasar, MD: The times when that's come up for me is when patients are being re-treated, when patients back before the availability of subcutaneous formulation received all the rituximab intravenously, and are now being treated for relapsed disease and getting their second experience with Rituxan, and are now getting it quite differently. You simply explain that this is a new formulation that has become available, this is what we know about it, and it makes your treatment easier, and all that time you sat in the chair you won't have to this time. And that's generally met with smiles.
Adam M. Brufsky, MD, PhD: In breast cancer, I'd say it's probably 50/50. I guess the most reasonable analogy in breast is probably metastatic disease. And so about 50/50, they'll get a central line, most of the time a port. How often do they get ports at Memorial Sloan Kettering for lymphoma-like diseases?
Matthew J. Matasar, MD: It depends on the setting. Obviously, lymphomas are a wide variety of diseases, many of which are managed with more or less treatment. For patients who are receiving vesicant-based therapy, I'd say probably about half will require some sort of central venous access and half won't.
Adam M. Brufsky, MD, PhD: They're going to need it anyway, because they're going to get the vesicant chemotherapy, right? And so it's hard to know. I think that one thing people could argue with the subcutaneous formulation is, you don't need a central line for it. But again, with breast it's the same way if you're going to be getting vesicants or your veins just give out because you're on very long-term chronic therapy, which is to some degree with chronic lymphomas... . With metastatic breast cancer, people are going to be on therapy forever, basically. We hope not, but generally we use intravenous therapy. And so at some point just about everyone will have a line. So subcutaneous probably won't help that as much.
Matthew J. Matasar, MD: Even there it can help when you're planning maintenance therapy with rituximab for those patients who need Rituxan monotherapy following completion of their chemoimmunotherapy program, being able to bring them in and just give them a 5-minute shot as opposed to having to put an IV or access their port and give them treatment. I thinkt here's still value for patients in that setting.