SIDEBAR: Is Watch and Wait the Best Strategy for Indolent NHL in the Rituximab Era?


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For follicular lymphoma, we recommend retreatment upon progression for low–tumor burden disease; we give rituximab weekly times four and we do not give maintenance therapy after rituximab induction therapy.

—Michael E. Williams, MD

Data from the RESORT and its planned subanalysis can guide oncologists in optimizing treatment for indolent non-Hodgkin lymphoma (NHL) with low–tumor burden advanced-stage disease, according to Michael E. Williams, MD, of the University of Virginia Cancer Center in Charlottesville.

The phase III RESORT trial showed no benefit for maintenance rituximab (one dose every 3 months indefinitely) in follicular lymphoma patients with indolent disease who responded to rituximab weekly times four vs a “watch and wait” strategy that re-treats upon progression. However, a recent subanalysis suggests that for nonfollicular subtypes, especially marginal zone lymphoma, maintenance may be beneficial. In the subanalysis, time to treatment failure was extended by more than 2 years with maintenance rituximab.

Guiding Treatment

These findings are guiding Dr. William’s treatment approach. “For follicular lymphoma, we recommend retreatment upon progression for low–tumor burden disease; and we do not give maintenance therapy after rituximab induction therapy. The study showed that many patients go 3, 4, and even 5 years without progressive disease after four doses of rituximab,” he said.

“For nonfollicular indolent disease, responders—mostly those with have marginal zone lymphomas—maintenance rituximab is an acceptable strategy,” he continued, “but the numbers are small and need to be confirmed in additional studies.” Though maintenance was also more beneficial than retreatment in patients with small lymphocytic lymphoma, the initial response rate to rituximab weekly times four is discouraging, he added. “There are other, more promising agents that should be evaluated in these patients.”

Dr. Williams said the promising results with bendamustine have also affected his practice. “For older patients, we increasingly are using bendamustine/rituximab front-line. For follicular patients with high-volume disease who need a quick response, or for patients in whom we suspect or confirm transformed lymphoma, we still use R-CHOP and add 2 years of maintenance therapy for responding patients based on the recent PRIMA trial,” he said. ■


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