What the NHS in England funds for lymphoma, appraisal by appraisal

Follicular lymphoma. TA243 recommends rituximab with one of several chemotherapy backbones for untreated symptomatic stage III and IV disease, and TA226 recommends rituximab maintenance after a response to first-line rituximab-chemotherapy; TA110 and TA137 are the earlier rituximab appraisals. TA513 covers obinutuzumab for untreated advanced disease and TA472 and TA629 cover it with bendamustine after rituximab. TA627 covers lenalidomide with rituximab in previously treated disease. Two refusals matter: TA892 does not recommend mosunetuzumab after two or more systemic therapies, and TA894 does not recommend axicabtagene ciloleucel after three or more. TA1139 allows epcoritamab after two or more lines with a stopping rule at three years. The tisagenlecleucel follicular appraisal, TA842, was terminated.

Marginal zone lymphoma. TA1001 recommends zanubrutinib after at least one anti-CD20-based treatment.

Mantle cell lymphoma. TA1193 allows the TRIANGLE regimen in England: ibrutinib with R-CHOP alternating with R-DHAP or R-DHAOx, followed by ibrutinib alone, for untreated disease in adults for whom an autologous transplant is suitable. TA1184 allows acalabrutinib with bendamustine and rituximab for untreated disease in people not eligible for an autologous transplant. TA502 covers ibrutinib in relapsed or refractory disease and TA1081 allows zanubrutinib after one line of treatment, with an instruction to use the least expensive of the suitable options. TA677 covers brexucabtagene autoleucel after a BTK inhibitor. TA370 covers bortezomib in untreated disease. The lenalidomide appraisal, TA774, was terminated.

Waldenstrom macroglobulinaemia. TA491 and TA795 cover ibrutinib, and TA833 recommends zanubrutinib after at least one treatment but only where bendamustine with rituximab would also be suitable. The ibrutinib with rituximab appraisal, TA608, was terminated.

Hodgkin lymphoma. TA1059 recommends brentuximab vedotin with doxorubicin, dacarbazine and vinblastine for untreated stage 3 or 4 CD30-positive Hodgkin lymphoma in adults, so A-AVD is funded first line in England; an earlier appraisal of the same question, TA594, had been terminated. There is no NICE appraisal of nivolumab with AVD in untreated disease, which is the largest single difference between England and the United States in this cancer. TA524, the Cancer Drugs Fund review of TA446, carries the current recommendation for brentuximab vedotin in relapsed or refractory CD30-positive Hodgkin lymphoma, for people who have already had an autologous transplant or at least two previous therapies when transplant or multi-agent chemotherapy are unsuitable. TA462 covers nivolumab and TA540, TA772 and TA967 cover pembrolizumab in relapsed or refractory classical Hodgkin lymphoma, TA967 down to the age of 3.

T-cell lymphomas. TA478 covers brentuximab vedotin in relapsed or refractory systemic anaplastic large cell lymphoma and TA641 covers it in combination for untreated disease. TA577 recommends it for CD30-positive cutaneous T-cell lymphoma after at least one systemic therapy, restricted to mycosis fungoides stage 2B or over, primary cutaneous anaplastic large cell lymphoma or Sezary syndrome. TA754 recommends mogamulizumab for Sezary syndrome after at least one systemic treatment and for mycosis fungoides only at stage 2B or above after at least two. TA720 recommends chlormethine gel for early-stage (1A, 1B and 2A) mycosis fungoides-type cutaneous T-cell lymphoma. Pralatrexate, belinostat and romidepsin have no United Kingdom licence for peripheral T-cell lymphoma, which is why the relapsed T-cell lymphoma row differs so much between England and the United States.

The clinical guideline behind all of this is NG52, non-Hodgkin lymphoma: diagnosis and management, with NG47, haematological cancers: improving outcomes, setting out how services should be organised.

CAR-T is commissioned nationally and delivered only at NHS England-designated centres after review by the national CAR-T clinical panel, which is why the practical question is often not whether a treatment is funded but how quickly a person can be referred to a centre that gives it.