Watch and wait in lymphoma: when the right treatment is none yet

Watch and wait is standard for asymptomatic advanced follicular lymphoma, for asymptomatic splenic and nodal marginal zone lymphoma, for asymptomatic Waldenstrom macroglobulinaemia, and for some cases of low-burden mantle cell lymphoma with a leukaemic non-nodal pattern. It is not appropriate for any aggressive lymphoma.

The randomised evidence comes from a British-led trial of 379 patients with asymptomatic, non-bulky, advanced follicular lymphoma. 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 followed by two years of maintenance (hazard ratio 0.21). Rituximab therefore delays the next treatment, but overall survival was not improved by starting early, and the trial's quality-of-life endpoint did not separate the arms at seven months. So rituximab alone is a reasonable option for someone who finds monitoring hard to live with, and watching is a reasonable option for someone who does not.

The GELF criteria are the usual trigger to treat in follicular lymphoma: a nodal or extranodal mass of 7 cm or more, three or more nodal sites each 3 cm or more, systemic symptoms, splenomegaly, effusion, cytopenias from marrow involvement, or a leukaemic phase. In practice the decision is made on symptoms and on whether an organ is threatened, not on a scan result alone.

What monitoring looks like: clinic review and blood tests every three to six months, examination of nodes, and imaging only when something changes. Repeat scanning of a person with no symptoms finds little and costs a great deal in anxiety and radiation.