At a session on follicular lymphoma, one of the presenters at this year’s American Society of Hematology (ASH) approached the topic of watch and wait. Essentially monitoring the disease in asymptomatic patients until symptoms arise or tests show the cancer is turning aggressive.
In addition to follicular lymphoma, chronic lymphocytic leukemia and prostate cancer both have “watch and wait” as a treatment strategy. There are even studies examining whether some types of ductal carcinoma in situ (non-invasive) breast cancer could wait to be treated.
The premise is: why treat a patient with therapy that will give them side effects when they don’t have disease symptoms, especially when starting treatment early doesn’t necessarily change the course of the disease, delay progression or improve survival.
It’s a fine line, especially in follicular lymphoma.
Brad Kahl, MD, with University of Wisconsin, presented “Is there a role for ‘watch and wait’ in follicular lymphoma in the Rituxan era.” Kahl mentioned that there have been few clinical studies that actually have examined when to offer watch and wait. He showed a diagram that took into account tumor burden (low and high) and symptoms (yes or no). Patients who had no symptoms and low tumor burden are frequently offered either Rituxan or watch and wait. It becomes tricky when the patient has symptoms and low tumor burden or no symptoms, but high tumor burden.
He also mentioned that some of his patients become so anxious with the thought of doing nothing to treat their cancer, that he considers prescribing Rituxan to them. It sounded a lot like he was offering them a very expensive placebo effect, which one physician in the audience questioned him on. However, Kahl was quick to point out that it does have its benefits, it’s just not known how great those benefits are yet.
In an international trial that was presented a couple of years ago at ASH, researchers found that when Rituxan was given to asymptomatic patients with advanced follicular lymphoma, the patient was able to delay chemotherapy, which carries its own side effects. Side effects of maintenance Rituxan reported in the trial include an increased risk of infection and neutropenia, but the regimen was otherwise well tolerated. However, the trial wasn’t without controversy, as it only followed patients for a few years and didn’t show a survival advantage.
Kahl said that, regardless, the watch and wait strategy requires a physician and patient to be on the same page. “This will not be a short conversation.”
Are you practicing watchful waiting for your cancer?
I’ll tell you, we were hard-pressed to find a patient with prostate cancer for a recent feature on watchful waiting with the disease. On the other hand, a family member with CLL has been monitoring her disease without treatment for several years, living an active life and it doesn’t appear she’s too worried about receiving chemotherapy any time soon. It all depends on your cancer, your lifestyle and probably even your physician’s strategy of treatment.
If you’re doing watchful waiting, are you anxious about not treating your cancer or are you doing other things to take control of your treatment, such as increasing physical activity, reducing stress or improving your diet?