~ 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
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
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
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.