Last update: 05/11/2009

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Watchful waiting has been described as "careful observation without initiation of therapy." ¹  

We receive many questions from patients with indolent lymphomas who are trying to understand why their oncologist has recommended deferring treatment - what is often called watchful waiting - and related questions on monitoring indolent lymphomas.

The following are lay perspectives on watchful waiting and monitoring indolent lymphomas. It's our best effort to summarize the rationales, based on a review of the literature and our experiences. We invite experts to comment as well. 

Please - as always - do not consider this information to be a substitute for the medical advice of your physician.

About Watchful Waiting

One rationale for for expectant management (watchful waiting) is that indolent lymphomas can remain stable for long periods of time, and sometimes regress spontaneously. There have been case reports of indolent lymphomas remaining stable for as long as twenty years,  but it should be noted that most patients will receive first treatment within one to two years after diagnosis.

"For all 44 "deferred" patients, the median 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." ¹

When you have an indolent (slow growing) lymphoma that is not causing symptoms or does not present an immediate medical danger, watchful waiting is commonly prescribed, even when the disease is diagnosed at an advanced stage. 

Note that the comfort level varies among patients with this approach.  Some patients refer to it as  "watch and worry"; other find it comforting that you can live well and long with indolent lymphoma as a "chronic" disease.

Indolent lymphomas are typically sensitive to treatment, but at this time they are not considered reliably curable* with combination therapies. So the approach that is often recommended is to monitor the disease, and to treat only when the condition causes symptoms or develops to a degree that increases risk.

See also Indications of When to Treat Indolent Lymphomas  | Monitoring Lymphomas

Also see PubMed articles on deferring treatment - PubMed 

* Note:  Indolent lymphomas are very sensitive to many types of treatments, but in the past advanced stage (III and IV) were rarely cured. While still controversial (requiring more study and longer follow up), some investigators believe that combination chemotherapy with immunotherapy (rituxan, bexxar, zevalin) may cure a significant % of patients with indolent lymphomas. (See Cabinillas' presentation  
 
  http://clinicaloptions.com/Oncology/Resources/CME%20Options/NHL.aspx ) 

Hopefully, the indolent lymphoma you face will prove to be "well-behaved" and you won't need to make a decision for many years, and that when the time to treat is at hand there will be even better therapies and knowledge about how to use existing treatments.

In summary:

	Indolent lymphomas can remain stable for long periods of time, and sometimes regress spontaneously.
	Better treatment protocols may become available when it is time to treat.
	Your doctor can use this time to judge the clinical tempo of your lymphoma to help  guide the choice of treatment when it is needed.  The clinical tempo is estimated by comparing  the baseline images with subsequent tests to see the rate of growth or stability.

NOTE: There is no standard approach to treating indolent lymphomas, but new agents have improved the management of the disease, which is typically sensitive to many kinds of treatments. For a detailed discussion on treatment decisions, see treatment-decisions

Related Articles:

Stage I and II Follicular Non-Hodgkin’s Lymphoma: Long-Term Follow-Up of No Initial Therapy

Ranjana Advani, Saul A. Rosenberg, Sandra J. Horning

http://www.jco.org/cgi/content/full/22/8/1454 

==

Ann Intern Med. 1979 Jan;90(1):10-3.

1) No initial therapy for stage III and IV non-Hodgkin's lymphomas of favorable histologic types.

Portlock CS, Rosenberg SA.

The question of whether initial treatment is necessary in relatively asymptomatic patients with stage III and IV non-Hodgkin's lymphomas of favorable histologic types was studied by retrospective analysis. 

Two groups of patients were studied: [1] 44 non-protocol patients, followed since 1963, in whom initial treatment was withheld until required to evaluate the pace of disease and the necessity of treatment; and [2] 112 previously untreated patients who have participated in prospectively randomized clinical trials since 1971. 

For all 44 "deferred" patients, the median 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. At 4 years, the actuarial survival of the 44 patients with deferred treatment is 77.3%, compared with 83.2% for the 112 protocol patients (P = 0.60). 

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: PMID: 369420