About Watchful Waiting |
Observation (summary) |
and wait is sometimes called "expectant management."
It has been
"careful observation without initiation of therapy."
See also Monitoring
Comments on the News
* BMC, 2013: Has the time to
come to leave the “watch-and-wait” -
observation strategy in newly diagnosed
asymptomatic follicular lymphoma patients?
encouraging when new data suggests a way to reduce the risk
of a serious and dreaded event in indolent lymphoma - that
However, in general, you can find a study to support most
any point of view on a controversial topic. It's the
rare observational study that changes practice -- rightfully
so, due to either the small size or the limitations in the
design of the study.
Unfortunately, (not necessarily in this case) studies
based on pooled data can suffer substantially from reporting
bias - where only results that meet the study hypothesis are
likely to be published in journals. (THIS IS
A MAJOR ISSUE - holding back progress against disease!)
All that said, some new data is suggesting a potential
benefit for earlier intervention with less toxic agents - in
respect to the risk of transformation.
encouraging signal - what we want to see!
However, and again if the signals of advantages are
supported over time, the benefit part does not come without
potential offsetting risks to the patients.
For example, the risks of Rituxan monotherapy can be serious
even if uncommon and prior exposure to Rituxan (depending on
how much and how recently received) might decrease
the potential to effectively treat a transformed disease.
That is decreasing the incidence of transformation events
might not necessarily improve overall survival.
Treatment naive patients may do better when such events
occur, relative to those exposed to prior treatment.
About Watchful Waiting
When you have an indolent (slow growing)
lymphoma that is not causing symptoms (such as fatigue) or is not
putting you in danger, your doctor might recommend watchful waiting,
when the disease is at an advanced stage.
One reason your
doctor might recommend observation is that the indolent lymphomas can remain
stable for long periods of time, and sometimes
In other words, your quality of
life can be very good when you have an advanced indolent
lymphoma and there is no proven benefit -- in the long term
-- to treating an indolent lymphoma as soon as possible.
Further, 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 1 to 3 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
How much comfort
we have with observation varies
among patients. Some of us refer to it
as "watch and worry"; other find it comforting that
we can live well and long with an indolent lymphoma as a "chronic" disease.
See for a recent patient account:
Story: Barbara on W&W for
physician do with diabetes for example - managing it
with medication over time, but not trying to cure it.)
Indolent lymphomas are
often responsive (sensitive) to standard treatments, but at this time they are not considered
reliably curable* with aggressive approaches. So this is another
reason to monitor the disease and to treat only when
the condition causes symptoms or progresses to a degree that increases
Indications of When to Treat
Indolent Lymphomas |
Indolent lymphomas are very sensitive to many types of treatments, but in the past
the advanced stage (III and IV) lymphomas were rarely cured.
While still controversial (requiring more study and longer follow up), some investigators believe that combination
chemotherapy with immunotherapy may cure a small % of patients with indolent lymphomas. (See Cabinillas'
EARLY STAGE FL:
"In a retrospective analysis from
Stanford University, 43 patients with early-stage follicular
lymphoma were identified who were observed rather than
treated with immediate XRT (radiotherapy).
With a median follow-up of over 7 years,
63% of these patients had not required therapy, and the
estimated survival at 10 years was 85%. ... the authors from
Stanford University concluded that having no initial therapy
was an acceptable approach in selected patients with
early-stage follicular lymphoma.
21. Advani R, Rosenberg SA, Horning SJ: Stage I and II
follicular non-Hodgkin’s lymphoma: Long-term follow-up of no
J Clin Oncol 22:1454-1459, 2004
Hopefully, the indolent lymphoma
you face will 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 to make use of ... and knowledge about how to use
existing treatments in better ways.
Can you watch and wait too long?
The adage of "watch and wait" has
been taken to the extreme to imply a benefit of deferring on
therapy for as long as possible. What it actually is meant to
indicate is that it is important to wait until you identify who
are the progressors from those who are not.
Once someone is
determined to be a progressor, we do not have any data that
holding on treatment carries any benefit.
The way I use this is
to indicate that treatment should be initiated when someone has
indicated that they are a progressor (the classic indications
for treatment) and before they become symptomatic.
We have all
seen others who have deferred on therapy too long and ended up
unable to tolerate therapy because they were too sick.
Suggestion: the CLLer refusing all treatment try to be more open
to hearing what is out there.
~ Furman, MD
How is the Need to Treat defined?
for watchful waiting (close observation)
when there are no symptoms or
indications of progression
Indolent lymphomas can remain
stable for long periods of time, and sometimes
It has been reported that
some patients never require therapy.
Treating at diagnosis could
result in treating sooner than necessary, sometimes by many years.
Therapy can be just as effective if
started when needed -- such as when symptoms begin or there's evidence of advancing disease , instead of immediately at diagnosis.
There is no proven survival benefit from treating at diagnosis.
Treatment has side effects, which can make you feel less well
and could limit future treatment options.
It's feasible that 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 and investigational agents may well improve the management of the disease, which is
typically sensitive to many kinds of treatments. For a detailed discussion on treatment decisions, see
Stage I and II Follicular Non-Hodgkin’s Lymphoma:
Follow-Up of No Initial Therapy
Ranjana Advani, Saul A. Rosenberg, Sandra J. Horning
Ann Intern Med. 1979 Jan;90(1):10-3.
1) No initial therapy for stage III and IV non-Hodgkin's lymphomas of favorable
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:  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  112 previously untreated
patients who have participated in prospectively randomized clinical trials
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