Watch & Wait in Follicular Lymphoma

Follicular lymphoma is indolent (slow-growing), and (at least for the moment) incurable. For this reason, studies have shown in the past that there is no benefit to beginning immediate treatment per se. The exception is in early, localized disease, when chemotherapy and radiation treatment may be able to effect a cure. Most patients have advanced (Stage III or Stage IV) disease at diagnosis, but have no symptoms (are "asymptomatic") other than swollen lymph nodes.

That doesn't mean "watch & wait" is a comforting strategy for patients, though. Quite the contrary -- "watch & worry," as the less formal title for this strategy goes, can be a time of great stress and anxiety. For this reason, it's important to know the arguments for and against watch and wait, to determine whether this really is beneficial for you and your loved one.

How Watch & Wait (W&W) Works

Nervous patients understandably put the emphasis on the "wait" part. Oncologists tend to put the emphasis on the "watch" part. During watch and wait, patients check in with their physician on an established schedule, such as every three tests. Palpable (feelable) lymph nodes are examined, blood counts are taken, and standard scans (such as CT scans) are ordered, and the results are compared with those of the previous examination. For most patients, follicular lymphoma grows slowly, and these checkups allow the doctor and patient to monitor the progress of the disease. Eventually, usually when symptoms appear (criteria are discussed in further detail below), watch and wait ends and treatment begins.

An End to "Watch & Wait"?

"Watch & Wait" has got to be one of the stupidest phrases in medical history, guaranteed to provoke anxiety as much as any other response. The rationale is the same for all indolent lymphomas, like follicular lymphoma: decades ago, studies demonstrated that chemotherapy would have more or less the same effect whether it was started immediately upon diagnosis, or delayed until a later date when troubling symptoms developed or tumours grew to an unacceptable size. Since then, every new therapy is evaluated as a potential end to the watch and wait era.

Which brings us to Rituxan (rituximab), certainly the most important lymphoma drug of the last decade. One of the most important studies to emerge from the ASH conference in December 2010, judging from the flourish of congratulatory press coverage, is one claiming that rituximab is better with immediate, up-front treatment. So far, I'm just not buying it.