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Patients Against Lymphoma

 

Treatment > When to Treat?

Last update: 04/24/2010

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 advantage.   

"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: 369420

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 begin 
    treating indolent lymphomas?

Important:  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 extra-nodal mass 
     (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) 2
- 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. gela.org/ studydoc/ 1_ETUDE/PRIMA_ Protocol_ Version4. 0_Finalnonsurlig ne.pdf

Q: Is  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 claims.  

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 certain herbs.  

Also see: 

When Lay persons give medical advice  
The Problem with Testimonials 
Spontaneous Regressions   


Articles that relate state-of-disease with outcomes

bullet
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.
bullet
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)
bullet
Anti-CD20 Radioimmunotherapy for Non-Hodgkin's Lymphoma  Medscape

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 100% (14/14), 
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.


 
Disclaimer:  The information 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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