The prognosis of elderly patients with mantle-cell lymphoma (MCL) is dismal; most patients relapse following treatment with rituximab-based regimens, such as R-CHOP. This situation prompted Hanneke Kluin-Nelemans and colleagues to address two questions: “firstly, can a new regimen consisting of fludarabine, cyclophosphamide and rituximab (R-FC) induce a higher remission rate than R-CHOP and, secondly, can maintenance therapy with rituximab prolong the remission duration?”

A total of 532 patients were randomized to R-CHOP or R-FC; the 316 responders were then randomized to maintenance therapy with rituximab or interferon-alfa (IFN-α). Although complete remission rates were similar for the two induction regimens, more patients had progressive disease with R-FC therapy. Importantly, overall survival was significantly shorter for R-FC compared with R-CHOP, and haematological toxicity was more frequent for patients treated with R-FC.

Kluin-Nelemans highlights the key results from the second part of the study, “rituximab maintenance significantly improved 4-year overall survival compared with IFN-α in patients responding to R-CHOP. This is the first study to show a survival gain for rituximab maintenance.” This large study with two randomizations inbuilt in its design provides, “a new standard for older patients with MCL: induction therapy with R-CHOP followed by maintenance with rituximab until disease progression.” Kluin-Nelemans suggests that future work should incorporate new drug combinations for induction and additional drugs to rituximab maintenance adapted for older patients—an undertaking that will require an international networking effort.