For older non-transplant eligible patients’ initial treatment options are VR-CAP (bortezomib, rituximab, cyclophosphamide, adriamycin and prednisolone based on the LYM 3002 phase 3 trial of VR-CAP vs R-CHOP which showed a longer survival for patients treated with VR-CAP; or bendamustine and rituximab followed by rituximab maintenance.
The TRIANGLE study has demonstrated the benefit of adding ibrutinib to initial chemotherapy followed by 2-years if ibrutinib maintenance and this may allow for the omission of autologous stem cell transplantation in first remission.