~ Dr Willet Whitmore (on prostate cancer)
... Which seems to apply well to the indolent lymphomas and CLL. However, for most types of indolent lymphomas treatment is eventually, but not always, needed. So there are two basic approaches to clinical care and research.
One being to manage it with treatments that have lower toxicity - and only as needed. - With this objective it can be argued that one should treat earlier (when the need to treat is not evident but expected soon) in order to have a better chance for the less aggressive therapies to be effective - but also because milder therapies generally are not as fast-acting and advanced lymphoma can sometimes require a timely response.
The second goal is to treat the indolent lymphoma with intent to induce a durable remission (with a modest or low potential for cure) with more aggressive combination therapy. - Here treatment is generally deferred to when the need for treatment is clearly indicated. However, waiting until the condition becomes too advanced (bulky, causing symptoms) can sometimes limit therapeutic options and lower the odds of achieving the best results.
Which approach is best?
It's sometimes argued that it's better to conserve one's "bullets" to preserve future options. However, it is also noted that having a long remission increases your options - allows you to use even the same therapy again when therapy is needed, and that this might better preserve therapeutic options and lead to less treatment resistance compared to using milder therapies more often.
So this is a big reason why -- for the indolent lymphomas -- there is no standard of care - no easy, one-size-fits-all formulas for how and when to treat.
So informed choice is a process that requires the input of our doctors - to help us to achieve an objective understanding of the clinical context:
1) The natural history - or anticipated clinical course for your type of lymphoma,
2) The potential benefits and risks of the current standards of care,
3) An appreciation of the unique and sometimes changing individual risk factors - such as one's age and performance, the changing behavior of the lymphoma, or responsiveness to prior therapies.
The clinical context can determine how much risk is appropriate to take when treating the lymphoma and also how appropriate it might be to consider clinical trials.
