Comment
CNRI/Science Photo Library
Follicular lymphoma: watch and wait is watch and worry
Published Online March 4, 2014 http://dx.doi.org/10.1016/ S1470-2045(14)70066-X See Articles page 424
368
The selection of initial treatment for patients with follicular non-Hodgkin lymphoma is not a straightforward decision. Physicians who treat patients with follicular lymphoma will usually have a long conversation with a newly diagnosed patient who has a low burden of disease to decide whether a watch and wait approach is best for the patient, compared with treatment with either monoclonal antibodies or combination chemoimmunotherapy.1–4 Patients often have many questions and the decision to watch and wait versus giving treatment is often complicated and difficult. In The Lancet Oncology, Kirit Ardeshna and colleagues5 report the results of a randomised trial in which patients with follicular lymphoma, who presented with a low burden of disease, were randomly assigned to a watch and wait approach (watchful waiting), treatment with four doses of rituximab followed by observation (rituximab induction), or treatment with four doses of rituximab followed by 12 doses of maintenance rituximab over the next 2 years (maintenance rituximab). During the study, the rituximab induction group was closed early, not because of inferior results, but rather because of decreased recruitment as a result of concerns related to other data that showed a benefit for maintenance rituximab over watchful waiting after rituximab treatment.6 This change limited the statistical power to draw conclusions from this cohort. A primary finding of the study was that qualityof-life measures for patients receiving maintenance rituximab were significantly better when compared with those who were in the watchful waiting group. Patients receiving ongoing scheduled rituximab doses felt more in control of their situation than those receiving watchful waiting (p=0·0004). They were also less anxious about interacting with the medical team (p=0·0012) and less concerned about needing treatment (p=0·0037) than those in the watchful waiting group. These findings suggest that patients felt a treatment plan had been decided on and was being followed, and that patients were more satisfied and comfortable with this approach. Additionally, patients receiving maintenance rituximab felt more in control of their situation than did those who
received only four doses of rituximab followed by observation. This finding suggests that the period of watchful waiting after rituximab treatment resulted in similar anxiety to watchful waiting as an initial strategy. Clearly, the findings from this study show that quality of life of patients receiving treatment with rituximab is better than those who undergo watchful waiting and the results of this study should be borne in mind when decisions regarding initial management of patients with follicular lymphoma are being made. However, much less clear is whether maintenance rituximab should be the standard treatment approach for all patients with follicular lymphoma who have a low burden of disease. The study did find that time to initiation of next treatment and progressionfree survival of patients who received maintenance rituximab was better than those who were managed with a watch and wait approach (both p
CNRI/Science Photo Library
Follicular lymphoma: watch and wait is watch and worry
Published Online March 4, 2014 http://dx.doi.org/10.1016/ S1470-2045(14)70066-X See Articles page 424
368
The selection of initial treatment for patients with follicular non-Hodgkin lymphoma is not a straightforward decision. Physicians who treat patients with follicular lymphoma will usually have a long conversation with a newly diagnosed patient who has a low burden of disease to decide whether a watch and wait approach is best for the patient, compared with treatment with either monoclonal antibodies or combination chemoimmunotherapy.1–4 Patients often have many questions and the decision to watch and wait versus giving treatment is often complicated and difficult. In The Lancet Oncology, Kirit Ardeshna and colleagues5 report the results of a randomised trial in which patients with follicular lymphoma, who presented with a low burden of disease, were randomly assigned to a watch and wait approach (watchful waiting), treatment with four doses of rituximab followed by observation (rituximab induction), or treatment with four doses of rituximab followed by 12 doses of maintenance rituximab over the next 2 years (maintenance rituximab). During the study, the rituximab induction group was closed early, not because of inferior results, but rather because of decreased recruitment as a result of concerns related to other data that showed a benefit for maintenance rituximab over watchful waiting after rituximab treatment.6 This change limited the statistical power to draw conclusions from this cohort. A primary finding of the study was that qualityof-life measures for patients receiving maintenance rituximab were significantly better when compared with those who were in the watchful waiting group. Patients receiving ongoing scheduled rituximab doses felt more in control of their situation than those receiving watchful waiting (p=0·0004). They were also less anxious about interacting with the medical team (p=0·0012) and less concerned about needing treatment (p=0·0037) than those in the watchful waiting group. These findings suggest that patients felt a treatment plan had been decided on and was being followed, and that patients were more satisfied and comfortable with this approach. Additionally, patients receiving maintenance rituximab felt more in control of their situation than did those who
received only four doses of rituximab followed by observation. This finding suggests that the period of watchful waiting after rituximab treatment resulted in similar anxiety to watchful waiting as an initial strategy. Clearly, the findings from this study show that quality of life of patients receiving treatment with rituximab is better than those who undergo watchful waiting and the results of this study should be borne in mind when decisions regarding initial management of patients with follicular lymphoma are being made. However, much less clear is whether maintenance rituximab should be the standard treatment approach for all patients with follicular lymphoma who have a low burden of disease. The study did find that time to initiation of next treatment and progressionfree survival of patients who received maintenance rituximab was better than those who were managed with a watch and wait approach (both p
