Follicular Lymphoma - Is Watch & Wait Still An Option?

Is No Treatment a Treatment Option for Advanced Follicular Lymphoma?

What is meant by a wait and watch approach to follicular lymphoma?. Istockphoto.com/Stock Photo©jarenwicklund

Is watch and wait - in other words, no treatment - an option for people with a follicular lymphoma that is advanced and low grade?

Some people with low-grade non-Hodgkin lymphomas (NHL) are offered an option for no initial treatment. This leaves some wondering - how can no treatment be an option for a disease like cancer?  Isn't it better to hit it aggressively?  Why would this be?

Low-Grade Lymphomas are Slow Growers

Unlike the common picture of a fast growing cancer that we have in our minds, low-grade NHLs behave differently.

  They are extremely lazy. They grow slowly, sometimes remain stable over years, and rarely even regress - go away - on their own. This is called 'waxing and waning'. Regardless of treatment, people usually live for a long time. In one study it was found that among asymptomatic people newly diagnosed with stage III and stage IV follicular lymphoma, the risk of dying in the next 10 years was only 13%. Treatment reduces the disease for some time but is often unable to cure it completely. Therefore, for some individuals, immediate aggressive treatment offers no real benefit. 

It may help in understanding this to understand how most chemotherapy works.  It's the same reason it causes side effects like hair loss and stomach upset.  Chemotherapy drugs kill cancer cells (and some good cells) by targeting those cells that are dividing most rapidly.  Since low-grade lymphoma cells divide very slowly, chemotherapy would either be ineffective or do unacceptable damage to good cells in the body.

Avoiding the Unnecessary Toxicity of Chemotherapy

If chemotherapy does not greatly affect the outcome of disease in some people, why go through its toxicity? Most chemotherapy drugs and combination treatments have significant side effects. Doctors feel that these can be avoided initially in some patients by withholding chemotherapy till it is really required.

Who is Offered 'No Initial Treatment'?

'No immediate treatment' is a valid option to consider for those individuals who

  • Are otherwise well.
  • Don't have B-symptoms (fever, weight loss of 10% of body weight over 6 months or drenching night sweats.)
  • Have relatively small lymph nodes.
  • Have stable blood tests.
  • Have disease that is unlikely to affect the functioning of vital organs in the body (such as the heart, lungs, and kidneys.)

About 40% of people with disseminated low-grade lymphomas can be potentially offered a 'wait and watch' approach.

Close Observation is Essential

All patients who choose to not undergo any treatment initially must be in touch with their doctor regularly, often every 3 to 6 months at a minimum. They will be scheduled for regular check-ups, blood work, and periodic scans in some cases. This will help the doctor keep track of how the disease is behaving. If the disease shows signs of increasing or spreading, treatment can be started.

'No Initial treatment' is Not 'No Treatment Ever Required'

Most people who are kept on observation alone will require treatment in the future.

It's just that immediate treatment or delayed treatment does not differ much in the outcomes - how long an individual survives. It has been seen that on an average, treatment may be deferred by 1 - 2 years by the wait and watch approach, without compromising the ultimate outcome of the disease. 

Watch and Wait in the Era of Rituxan (Rituximab)

Until the monoclonal antibody treatment Rituxan (rituximab) was available, watch and wait was the "treatment of choice" for many people with asymptomatic advanced low-grade follicular lymphoma.  Studies now suggest that treatment with Rituxan may improve the time to progression of the disease for some people, and do so in a cost-effective way as well. Talk to your oncologist about current thought, as this area is rapidly changing.

Support

If you decide to choose the treatment of 'no treatment' it can be helpful to talk to an oncology social worker or become involved in social media with others facing the same disease. Not only do you need to accept that the best treatment is no treatment, but you'll be faced with friends and loved ones asking questions and offering opinions. It seems once you have cancer, everyone has an opinion on what your treatment plan should be. It's important to decide what is right for you, and that choice may differ from what a friend or loved one would choose to do themselves if faced with the same choices. Medicine is changing, and recent advances in treating cancer offer hope that new and better treatments with fewer side effects will be available in the near future.

Sources:

Ardeshna, K., Qian, W., Smith, P. et al. Ritiximab versus a watch-and-wait approach in patients with advanced-stage, asymptomatic, non-bulky follicular lymphoma: an open-label randomized phase 3 trial. Lancet Oncology. 2014. 15(4):424-35.

El-Galaly, T., Bilgrau, A., de Nully Brown, P. et al. A population-based study of prognosis in advanced stage follicular lymphoma managed by watch and wait. British Journal of Haematology. 2015. 169(3):435-44.

Hiddemann, W., and B. Cheson. How we manage follicular lymphoma. Leukemia. 2014. 28(7):1388-95.

Prica, A., Chan, K., and M. Cheung. Frontline rituximab monotherapy induction versus a watch and wait approach for asymptomatic advanced-stage follicular lymphoma: A cost-effectiveness analysis. Cancer. 2015. 121(15):2637-45.

Solal-Celigny, P., Bellei, M., Marcheselli, L. et al. Watchful waiting in low-tumor burden follicular lymphoma in the rituximab era: results of an F2-study database. Journal of Clinical Oncology. 2012. 30(31):3848-53.

Continue Reading