When to treat?
Watch & wait (observation
until symptomatic) became the standard approach for indolent
lymphomas because studies (circa 1979) indicated that early
interventions with combination therapies did not provide a survival
"Careful observation without initiation of therapy is an
appropriate option in the management of patients with relatively
asymptomatic advanced non-Hodgkin's lymphomas of favorable
histologic types." PMID:
Watchful waiting is still common practice today. Click here
for more detail.
Q: How long
before I need treatment for indolent lymphoma?
The Time to initial
treatment can vary significantly. For follicular lymphoma "a
substantial proportion of patients may never require
treatment." Source: Follicular
lymphoma: a historical overview, Koen Van Besien & Harry
Schouten. Feb 2007
In one study "the
median (middle) time before requiring treatment was 31 months, and
there have been 19 patients who have not yet required therapy for
periods of 3 to 104 months. ...
The median actuarial survival for all 44 patients was 121 months
(~10 years). Source: No
initial therapy for stage III and IV non-Hodgkin's lymphomas of
favorable histologic types, Source: PMID:
369420 Also see related
related PubMed articles PubMed
Q: What are
some of the signs and symptoms that may indicate a need to
treating indolent lymphomas?
Delaying treatment to the last
possible minute will not improve the outcome. It may
make it more challenging to achieve a durable complete response,
which is associated with improved overall survival in many
prognostic reports. It may also narrow the range of options,
by requiring therapy that is faster acting.
NCCN Guidelines: Indications to treat
Symptoms (fatigue, pain, fevers...)
- Threatened end-organ function (enlarged node obstructing bowel)
- Cytopenia secondary to lymphoma (low blood counts)
- Bulky disease - according to the GELF criteria: nodal or
(except spleen) > 7cm in its
greater diameter 2
- Steady progression
- Patient preference
- Elevated serum LDH or B2-microglobulin
- Involvement of multiple nodal sites (each with a diameter greater than 3 cm)
- Symptomatic splenic enlargement 2
- Compressive syndrome 2
- Pleural/peritoneal effusion 2
Sources: www.nccn.org/professionals/physician_gls/PDF/nhl.pdf 1
PRIMA study: 2 http://prima.
indolent lymphoma ever treated early?
Yes. Stage I and II (localized)
indolent lymphoma are typically treated at diagnosis with curative
intent with localized radiotherapy. The cure rate is about 50%
according to some reports.
See for many published studies on this question: www.lymphomation.org
NOTE: You may want to ask your oncologist about use of PET and a
bone marrow biopsy to confirm that the lymphoma is truly localized. "PET may be useful in confirming limited disease in the few
patients with early stage I disease, because these patients may be
treated with local radiation." Source: jnm.snmjournals.org
Also, sometimes the need to treat is
evident or reasonable at diagnosis, but many times a period of
watchful waiting is recommended to determine the clinical behavior
prior to treatment. Indolent lymphomas can sometimes be stable
or even regress spontaneously.
Q: What about managing lymphoma with herbs
and alternative therapies?
It's easy to be seduced by
testimonials made by individuals and groups claiming that natural
life style changes can change the course of the disease, but,
unfortunately, there is no clinical evidence to support these
NOTE: We believe that patients should be skeptical about
observational evidence - personal accounts attributed to alternative
practices. The variable clinical behavior of indolent grade
lymphomas lends itself to making associations that can easily be
coincidental. That is, we would can't know if the patient would
have done as well or better had they not changed their diet or took
When Lay persons give medical advice
The Problem with Testimonials
Prognostic factors for the clinical outcome of
patients with follicular lymphoma
following high-dose therapy and peripheral blood stem cell
transplantation (PBSCT) www.nature.com
As proposed by Romaguera et al,13
patients' characteristics, like male gender and high tumor burden,
indicate a group of patients at high-risk for relapse. This also
relates to patients with relapse or progressive disease.
Accordingly, in our patients the extent of the disease expressed as
number of involved lymph node areas and extra-nodal involvement were
negative prognostic factors.
Bexxar therapy (tositumomab and iodine I 131 tositumomab) has
high response rates in the treatment of bulky low grade (LG)
relapsed or refractory non-Hodgkin's lymphoma (NHL) ASCO
CR rate <5 cm: 26 of 63 (41%) NR (19.9-NR)
CR rate > 7 cm: 6 of 27 (22%) NR (NR-NR)
CR rate very bulky: 5 of 27 (19%) NR (11.2-NR)
Anti-CD20 Radioimmunotherapy for Non-Hodgkin's Lymphoma
The overall response rate to ibritumomab (Zevalin) was 74%,
with CR in 15% of patients with follicular lymphoma.
In patients with 2- to 5-cm masses, the overall response rate was
while response was seen in 69% of 13 patients with 7- to 10-cm
masses and in
50% (5/10) patients with bulky disease of 10 cm or more.