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These factors can then be utilized to evaluate cohort comparability and perform covariate adjustments, such as in propensity score models. A systematic literature review (SLR)-based identification of prognostic factors, coupled with expert clinical review, offers a comprehensive approach to evaluating and ranking the level of evidence, while also assisting in selection of prognostic factors to assess imbalances between cohorts in single-arm trials and real-world data studies. We performed an SLR followed by a clinical review and ranking by subject-matter experts to identify prognostic factors and EMMs in patients with relapsed or refractory (r\/r) follicular lymphoma (FL) who failed at least two lines of therapy (LoTs). Across 13 included studies, the SLR identified 28 prognostic factors that were significantly associated with clinical outcomes, including overall survival, progression-free survival, and objective response rate. Notably, our review did not identify any statistically significant EMMs. Based on expert ranking of the SLR-derived list, the 5 most important prognostic variables in descending order are: progression of disease within 24 months of first LoT (POD24), chemo-immunorefractory\/chemoresistant, refractory to last LoT, number of prior LoTs, and serum lactate dehydrogenase. This comprehensive SLR and expert review highlight critical prognostic factors in r\/r FL. The identified prognostic variables can inform future research, emphasizing the need for continued investigation into factors affecting outcomes in this challenging and heterogeneous patient population.<\/jats:p>","DOI":"10.1007\/s00277-025-06575-9","type":"journal-article","created":{"date-parts":[[2025,9,2]],"date-time":"2025-09-02T04:43:04Z","timestamp":1756788184000},"page":"4357-4367","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Prognostic factors and effect modifiers in patients with relapsed or refractory follicular lymphoma who failed at least two lines of therapy: a systematic literature and expert clinical review"],"prefix":"10.1007","volume":"104","author":[{"given":"Pau","family":"Abrisqueta","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Jim\u00e9nez-Ubieto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"\u00c1ngel","family":"Serna","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Irene","family":"Zamanillo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuting","family":"Kuang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"Uyei","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohsin","family":"Shah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Walsh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eileen","family":"Thorley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krystal","family":"Cantos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emaan","family":"Rashidi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qiufei","family":"Ma","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica J.","family":"Jalbert","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexi N.","family":"Archambault","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yingxin","family":"Xu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shivani","family":"Aggarwal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Srikanth","family":"Ambati","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hesham","family":"Mohamed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Hampp","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bastian","family":"von Tresckow","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,9,2]]},"reference":[{"issue":"5","key":"6575_CR1","doi-asserted-by":"publisher","first-page":"484","DOI":"10.6004\/jnccn.2011.0046","volume":"9","author":"AD Zelenetz","year":"2011","unstructured":"Zelenetz AD, Abramson JS, Advani RH, Andreadis CB, Bartlett N, Bellam N, Byrd JC, Czuczman MS, Fayad LE, Glenn MJ, Gockerman JP, Gordon LI, Harris NL, Hoppe RT, Horwitz SM, Kelsey CR, Kim YH, LaCasce AS, Nademanee A, Porcu P, Press O, Pro B, Reddy N, Sokol L, Swinnen LJ, Tsien C, Vose JM, Wierda WG, Yahalom J, Zafar N (2011) Non-Hodgkin\u2019s lymphomas. 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The information used in this review was reported in published articles and reported in the aggregate.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"P.A. has received honoraria from Janssen, Roche, Genmab, BMS, AbbVie, Incyte, Regeneron Pharmaceuticals, Inc., BeiGene, and AstraZeneca. A.J.U. has received honoraria from Regeneron Pharmaceuticals, Inc., Gilead Kite, Eli Lilly, AbbVie, Janssen, Sandoz, Roche, and Incyte. A.S and I.Z report no conflicts of interest. Y.K., J.U., M.S., L.W., E.T., K.C., and E.R. are employees of IQVIA, Inc. Q.M., J.J.J., A.N.A., Y.X., Sh.A., Sr.A., H.M., and C.H. are employees of Regeneron Pharmaceuticals, Inc. M.S. was supported by the National Institutes of General Medical Sciences (NIGMS) grant T32GM-075766 from 2019 to 2022 while at the University of Pennsylvania Perelman School of Medicine and received an International Society for Pharmacoepidemiology (ISPE) grant scholarship in 2022. These funding bodies had no role in the design and conduct of this study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the abstract; or the decision to submit for publication. B.v.T is an advisor or consultant for Allogene, Amgen, Bristol Myers Squibb\/Celgene, Cerus, Gilead Kite, Incyte, IQVIA, Lilly, Merck Sharp & Dohme, Miltenyi, Novartis, Noscendo, PentixaPharm, Pfizer, Pierre Fabre, QualWorld, Roche, Sobi, and Takeda; has received honoraria from AbbVie, AstraZeneca, Bristol Myers Squibb\/Celgene, Gilead Kite, Incyte, Lilly, Merck Sharp & Dohme, Novartis, Roche Pharma AG, and Takeda; reports research funding to institution from Esteve, Merck Sharp & Dohme, Novartis, and Takeda; and reports travel support from AbbVie, AstraZeneca, Gilead Kite, Lilly, Merck Sharp & Dohme, Novartis, Pierre Fabre, Roche, and Takeda.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}