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Watchful Waiting and Monitoring Indolent Lymphomas

  

 About Lymphoma > Treatment >  
Watchful Waiting & Monitoring Indolent Lymphomas

Last update: 05/06/2007

TOPIC SEARCH: ASCO | ASH | ClinicalTrials.gov | Medscape | PubMed 

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

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.

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:

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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
  

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Better treatment protocols may become available when it is time to treat.
 

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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 

About Monitoring Indolent Lymphomas

How often will I see my oncologist during watch and wait?  

Monitoring might include: 

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A direct examination - palpation (feeling) of lymph nodes; questions about symptoms; review of blood tests 
and imaging reports; discussion of treatment goals and priorities ...
 

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Blood tests - CBC, LDH, Liver panel 
in order to monitor for problems and indications of response, progression, treatment toxicity ...
 

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Imaging - Sonograms, CT scans, MRI, PET 
in order to stage the lymphoma or examine areas of interest.
 

NOTE: Since fluctuations of lymphatic lesions are expected for indolent lymphomas, there may be no 
need to image the entire body in short intervals. Instead the timing might be based on symptom reporting, 
the need to provide a baseline or to determine response to treatment (staging), and so on. 
 

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Your honest and timely reporting of symptoms such as fatigue, bowel and kidney function, fevers, sweats.  
Ask your doctor how he or she wishes to be notified.  By phone, fax, email?

NOTE:  Sometimes your performance level can change gradually and it will be difficult to notice.  Therefore, a regular exercise program that *measures* performance can be a good way to both improve your general health and monitor for changes. As always, get approval from your doctor before starting an exercise program that might exceed your ability or put you at risk. 
 

Once the clinical tempo of your lymphoma is estimated, the interval of examinations or tests can increase or decrease. Some patients report seeing their oncologists every 6 months; others report remote system: The doctor faxing a lab script and if the lab report shows red flags" (such as a significant increase in LDH,  the next direct exam might be put back for an additional month or more .... 

In a nutshell, the monitoring interval varies, and can depend on the behavior of the lymphoma, test results, and reported symptoms. For example, it's prudent to report the appearance of new enlarged lymph nodes, especially if in multiple locations; and to report fever or frequent and drenching night sweats.

NOTE:  The variable clinical course and long survival of patients with indolent lymphomas is both a blessing and a problem. It's a problem because it takes more time and larger numbers of patients to evaluate new  treatments. (Was it the treatment or chance? Does the treatment influence survival?) Similarly, it also makes it easy for patients to wrongly associate cause and effect: "I ate almonds and my tumors regressed. I took this supplement and it progressed" ...  This is not to say that some life style practices cannot provide benefits or risks; but just that anecdotes of this kind are not reliable, particularly for indolent lymphomas.   See for details: Evaluating Medical Claims and Data

Some possible reasons for the variable clinical course of indolent lymphomas are explained in Lymphoma Simplified; possible reasons for spontaneous regressions are posted here.

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

 
Disclaimer:  The information presented on Lymphomation.org is not intended to be a substitute for 
professional medical advice or to replace your relationship with a physician.
For all medical concerns,  you should always consult your doctor. 
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