Decisions and supportFollicular lymphoma

Back to the Follicular lymphoma hub →35 questions · 6 red cards

The decisions you may face, the aids that walk through them, the warnings on record, the first sixty days and the questions to ask.

Decisions and support

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Decisions you may face

9 with more than one option · full decision page →

One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.

Limited stage (I-II)2 Advanced, low burden, asymptomatic2 Advanced, high burden (GELF criteria)4 Relapsed (≥2 lines)7 Stage I and contiguous stage II follicular lymphoma: radiotherapy with curative intent6 Advanced follicular lymphoma with no symptoms: watch and wait, or rituximab alone Advanced follicular lymphoma needing treatment: which induction, and whether to add maintenance7 Progression within two years of first chemotherapy (POD24): biopsy first, then a different class of treatment9 Relapsed follicular lymphoma after two or more lines: bispecific antibodies, CAR-T and R-squared14 Transformation of follicular lymphoma to diffuse large B-cell lymphoma8

Red cards

What to watch for and who to call, from the labels and guidelines behind the standard of care. Your team's thresholds win.

Emergency services now
Cytokine release syndrome
Fever of 38 C or higher, chills, low blood pressure, fast heartbeat or breathlessness, especially after a step-up dose. Boxed warning on teclistamab, epcoritamab, glofitamab, tarlatamab and blinatumomab.
Epcoritamab Glofitamab Mosunetuzumab Odronextamab source
Emergency services now
Bleeding or bruising
Bleeding that does not stop by itself, bleeding from more than one site, or new bruising in several places or one large area.
Bendamustine Cyclophosphamide Vincristine source
Emergency services now
Cytokine release syndrome
Fever of 38 C or higher is grade 1 CRS; fever with low blood pressure, fast heartbeat, breathlessness or low oxygen is grade 2 or higher. The labels carry a boxed warning and say to report fever immediately.
Axicabtagene ciloleucel Lisocabtagene maraleucel Tisagenlecleucel source
Emergency services now
Blood clot (lenalidomide, pomalidomide, thalidomide)
A swollen painful calf, or sudden breathlessness with chest pain; venous and arterial thromboembolism is a boxed warning and blood-thinning prophylaxis is recommended.
Lenalidomide source
Emergency services now
Major bleeding
Blood in stool or urine, vomiting blood, a bleed that will not stop, or a severe headache; fatal bleeding events have occurred and the labels advise considering the risk around surgery and with blood thinners.
Zanubrutinib source
Call the 24-hour line now
Neutropenic fever
Temperature of 38 C or higher, or feeling shivery and unwell even without a fever. Antibody-drug conjugates suppress the bone marrow, and several carry a boxed warning for severe neutropenia.
Polatuzumab vedotin source

See all on the product pages:Axicabtagene ciloleucel Bendamustine Cyclophosphamide Epcoritamab Glofitamab Lenalidomide Lisocabtagene maraleucel Mosunetuzumab Odronextamab Polatuzumab vedotin Tisagenlecleucel Vincristine Zanubrutinib·Printable cards in the navigator

Questions to ask

Bring to your appointment

Questions to ask your oncologist about Follicular lymphoma

Generated from this cancer's standard of care, biomarkers, and pipeline · 35 questions

Newly diagnosed

What is my exact diagnosis, stage, and grade, and which tests established them?
Why: Everything else follows from an accurate stage and subtype.
Which biomarkers have been tested on my tumour (for example t/BCL2, FLIPI / FLIPI2 / m7-FLIPI, PET-CTstaging and end-of-induction response, POD24, EZH2 mutation), and what were the results?
Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
Which subtype is my cancer, and does that change the recommended treatment?
Why: Recognised subtypes for this cancer include Classic FL, Follicular large B-cell lymphoma, FL with unusual cytological features.
Is germline (inherited) genetic testing recommended for me or my family?
Why: Inherited variants can change treatment and matter for relatives.

Limited stage (I-II)

For my situation (limited stage (i-ii)), which of the standard options do you recommend and why?
Why: Guideline options include: Involved-site radiotherapy 24 Gy (FoRT); rituximab alone or observation in selected cases.
Am I a candidate for Rituximab, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
How do the results of FoRT apply to someone like me?
Why: Trial populations differ from individual patients; ask how closely you match.

Advanced, low burden, asymptomatic

For my situation (advanced, low burden, asymptomatic), which of the standard options do you recommend and why?
Why: Guideline options include: Watch and wait (no survival penalty), or rituximab monotherapy to delay chemotherapy.
Am I a candidate for Rituximab, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Advanced, high burden (GELF criteria)

For my situation (advanced, high burden (gelf criteria)), which of the standard options do you recommend and why?
Why: Guideline options include: Bendamustine-rituximab or bendamustine-obinutuzumab (GALLIUM), R-CHOP, or lenalidomide-rituximab (RELEVANCE); anti-CD20 maintenance 2 years (PRIMA).
Am I a candidate for Rituximab, Obinutuzumab, Bendamustine or related drugs, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
How do the results of GALLIUM and RELEVANCE apply to someone like me?
Why: Trial populations differ from individual patients; ask how closely you match.

Relapsed (≥2 lines)

For my situation (relapsed (≥2 lines)), which of the standard options do you recommend and why?
Why: Guideline options include: Lenalidomide-rituximab (AUGMENT); CD20×CD3 bispecific (mosunetuzumab, epcoritamab); CD19 CAR-T (axi-cel, tisa-cel, liso-cel); zanubrutinib + obinutuzumab; clinical trials.
Am I a candidate for Mosunetuzumab, Epcoritamab, Axicabtagene ciloleucel or related drugs, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Stage I and contiguous stage II follicular lymphoma: radiotherapy with curative intent

For my situation (stage i and contiguous stage ii follicular lymphoma: radiotherapy with curative intent), which of the standard options do you recommend and why?
Why: Guideline options include: Truly localised follicular lymphoma, which means stage I or contiguous stage II confirmed on PET-CT and marrow assessment, is treated with 24 Gy in 12 fractions to an involved-site field and a substantial minority never relapse. PET staging matters: a quarter or more of patients thought to have stage I on CT are upstaged, and those are the ones who relapse outside the field. Adding systemic treatment lengthens remission without proven survival gain. TROG 99.03 randomised 150 patients after 30 Gy involved-field radiotherapy to observation or six cycles of CVP, with rituximab added from 2006: ten-year progression-free survival was 59 per cent with systemic therapy against 41 per cent with radiotherapy alone (hazard ratio 0.57), overall survival was not significantly different (95 against 87 per cent), and the effect was largest in the rituximab-containing subgroup. Four gray in two fractions is not an alternative for cure: FoRT found it clearly inferior to 24 Gy for local control. Observation is a defensible option in an older patient with a small, asymptomatic node, and so is rituximab alone. Doing nothing is not the same as doing nothing wrong.
Am I a candidate for Rituximab, Cyclophosphamide, Vincristine or related drugs, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Advanced follicular lymphoma with no symptoms: watch and wait, or rituximab alone

For my situation (advanced follicular lymphoma with no symptoms: watch and wait, or rituximab alone), which of the standard options do you recommend and why?
Why: Guideline options include: Starting chemotherapy early does not lengthen life in asymptomatic, low-burden disease, and a third of people never need treatment in the first few years. The British-led trial that settled this randomised 379 patients with asymptomatic, non-bulky, advanced disease: at three years, 46 per cent of those watched had not needed treatment against 88 per cent of those given four weekly doses of rituximab and two years of maintenance (hazard ratio 0.21), with no overall survival difference. So rituximab delays the next treatment; it does not extend life, and it costs two years of visits. The GELF criteria are the usual trigger to treat: a mass of 7 cm or more, three or more nodal sites each 3 cm or more, B symptoms, splenomegaly, effusion, cytopenias or a leukaemic phase. Monitoring is clinic review and bloods every three to six months; routine scanning of a well person finds little.
Am I a candidate for Rituximab, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Advanced follicular lymphoma needing treatment: which induction, and whether to add maintenance

For my situation (advanced follicular lymphoma needing treatment: which induction, and whether to add maintenance), which of the standard options do you recommend and why?
Why: Guideline options include: Chemoimmunotherapy is the usual first treatment, and the choice of chemotherapy backbone is made on toxicity. Bendamustine with rituximab gave median progression-free survival of 69.5 against 31.2 months for R-CHOP in the StiL NHL1 trial of indolent and mantle cell lymphoma (hazard ratio 0.58), with no alopecia, less haematological toxicity, fewer infections and far less neuropathy, and is the commonest first choice; it does deplete T cells for a long time, which matters for anyone who may need CAR-T later. R-CHOP is preferred where transformation is suspected. R-CVP is the gentlest. Obinutuzumab instead of rituximab improves progression-free survival: GALLIUM randomised 1,401 patients and gave three-year progression-free survival of 80.0 against 73.3 per cent (hazard ratio 0.66), at the cost of more grade 3 to 5 adverse events (74.6 against 67.8 per cent) and more infusion reactions. Chemotherapy-free induction is a real alternative. RELEVANCE randomised 1,030 patients to rituximab with lenalidomide or rituximab with the investigator's chemotherapy: complete response at 120 weeks was 48 against 53 per cent and median progression-free survival 120.2 against 123.8 months (hazard ratio 0.92), so R-squared is not superior but is equivalent, with less neutropenia (32 against 50 per cent) and more rash. Maintenance rituximab for two years afterwards lengthens remission substantially and does not lengthen life: in PRIMA median progression-free survival was 10.5 against 4.1 years but ten-year overall survival was about 80 per cent in both arms. It is a choice, not a requirement.
Am I a candidate for Obinutuzumab, Rituximab, Bendamustine or related drugs, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
How do the results of GALLIUM and RELEVANCE apply to someone like me?
Why: Trial populations differ from individual patients; ask how closely you match.

Progression within two years of first chemotherapy (POD24): biopsy first, then a different class of treatment

For my situation (progression within two years of first chemotherapy (pod24): biopsy first, then a different class of treatment), which of the standard options do you recommend and why?
Why: Guideline options include: About one in five people treated with first-line chemoimmunotherapy progress within two years, and their five-year overall survival in the National LymphoCare Study was 50 per cent against 90 per cent for everyone else, a difference that held after adjusting for FLIPI. The first step is a repeat biopsy, because transformation to diffuse large B-cell lymphoma is the commonest explanation and is treated as aggressive lymphoma. If it is still follicular, the plan changes class rather than repeating it: CD19 CAR-T (ZUMA-5 reported an overall response of 92 per cent and complete response 74 per cent; ELARA with tisagenlecleucel reported complete response 69.1 per cent and overall response 86.2 per cent), a CD20 bispecific antibody, or lenalidomide with rituximab. A clinical trial is a reasonable first choice at this point. Autologous transplant still has a role in younger patients with chemosensitive early relapse and is used less than it was.
Am I a candidate for Axicabtagene ciloleucel, Tisagenlecleucel, Mosunetuzumab or related drugs, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
How do the results of ZUMA-5 apply to someone like me?
Why: Trial populations differ from individual patients; ask how closely you match.

Relapsed follicular lymphoma after two or more lines: bispecific antibodies, CAR-T and R-squared

For my situation (relapsed follicular lymphoma after two or more lines: bispecific antibodies, car-t and r-squared), which of the standard options do you recommend and why?
Why: Guideline options include: Nothing here is curative and all of it can produce long remissions, so the choice is about duration of treatment, side effects and how far a person is willing to travel. Fixed-duration bispecific antibodies. Mosunetuzumab, given intravenously in 21-day cycles with step-up dosing and stopped after eight cycles in complete responders, produced a complete response in 60.0 per cent of 90 patients after two or more lines. Odronextamab in ELM-2 gave an objective response of 80.0 per cent, complete response 73.4 per cent and median progression-free survival 20.7 months in 128 patients, with grade 3 or worse cytokine release syndrome of 1.7 per cent using the split step-up. Epcoritamab is approved in combination with rituximab and lenalidomide. CAR-T. Axicabtagene ciloleucel (ZUMA-5) and tisagenlecleucel (ELARA) both produce high complete response rates with remissions that are lasting in a substantial minority; the trade is a single intensive episode against repeated outpatient treatment. Rituximab with lenalidomide. AUGMENT randomised 358 patients with relapsed follicular or marginal zone lymphoma to lenalidomide with rituximab or rituximab with placebo: median progression-free survival 39.4 against 14.1 months (hazard ratio 0.46), with grade 3 to 4 neutropenia in 50 against 13 per cent. Antibody and inhibitor combinations approved since 2024. Tafasitamab with lenalidomide and rituximab received traditional United States approval on 18 June 2025 on the inMIND trial, with a label note that it is not indicated in relapsed or refractory marginal zone lymphoma outside a trial. Zanubrutinib with obinutuzumab was given accelerated approval on 7 March 2024 on ROSEWOOD. Lisocabtagene maraleucel's follicular approval of 15 May 2024 converted to traditional approval on 20 February 2026, and a separate marginal zone lymphoma approval followed on 4 December 2025. Other options: a different chemoimmunotherapy backbone from the one used before, obinutuzumab with bendamustine in rituximab-refractory disease, tazemetostat for EZH2-mutant disease or where nothing else is suitable, radiotherapy to a single symptomatic site, and radioimmunotherapy where it is still available. The PI3K inhibitors (idelalisib, duvelisib, copanlisib) have largely been withdrawn from this indication on the basis of toxicity and unconfirmed benefit.
Am I a candidate for Mosunetuzumab, Odronextamab, Epcoritamab or related drugs, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
How do the results of AUGMENT and ZUMA-5 apply to someone like me?
Why: Trial populations differ from individual patients; ask how closely you match.

Transformation of follicular lymphoma to diffuse large B-cell lymphoma

For my situation (transformation of follicular lymphoma to diffuse large b-cell lymphoma), which of the standard options do you recommend and why?
Why: Guideline options include: Suspected when a single site grows quickly, LDH rises, B symptoms appear or the PET shows one site far brighter than the rest; confirmed by biopsy of that site, which is why a repeat biopsy rather than a scan is the right first step. It occurs in roughly 2 to 3 per cent of patients a year. Treatment follows the aggressive lymphoma pathway, not the follicular one. In a patient who has had little or no previous chemotherapy, R-CHOP or pola-R-CHP with the intent to cure, often followed by consideration of autologous transplant consolidation. In a patient who has already had several lines, CD19 CAR-T; transformed disease was included in the pivotal CAR-T populations. Bispecific antibodies are active. The outlook is better than it was when transformation was treated with more of the same.
Am I a candidate for Polatuzumab vedotin, Rituximab, Axicabtagene ciloleucel or related drugs, and what side effects should I expect?
Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
How do the results of POLARIX apply to someone like me?
Why: Trial populations differ from individual patients; ask how closely you match.

Any stage

Are there clinical trials I could join, for example of Epcoritamab, Mosunetuzumab, Odronextamab, Golcadomide?
Why: Trials are how the next standard of care is set; asking early keeps options open.
Would a second opinion at a high-volume centre change anything, and can you help arrange it?
Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?
Why: Supportive care improves quality of life and helps patients complete treatment.
I read that “Transformation to DLBCL cannot be predicted or prevented”. How does that affect my plan?
Why: Open problems are where trials and second opinions matter most.
I read that “Sequencing bispecifics vs CAR-T”. How does that affect my plan?
Why: Open problems are where trials and second opinions matter most.

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Cancers·Follicular lymphoma