No, But the Apoptosis Pathway Has Been Activated
Follicular lymphoma (FL), the most common indolent type of non-Hodgkin’s lymphoma, presents with a highly variable clinical course and affects the overall survival (OS) of patients. Although observation has been adopted widely by clinicians in the management of patients with FL, the benefits of early treatment must be reviewed in light of the significant progress made in the treatment of symptomatic or higher-tumor-burden FL. When treatment is indicated, a variety of combination chemotherapeutic regimens have proven efficacy and have shown improvements in both progression-free and event-free survival, and the addition of rituximab to these regimens has shown a statistically significant improvement in OS. Additionally, single-agent rituximab has been added to the possible therapeutic options for patients with lowtumor-burden FL. Although a paucity of clinical data exists on the upfront treatment of the low-tumor-burden population, the question of whether early treatment, especially with the newer rituximab-containing chemotherapy regimens, would improve OS is thought-provoking. Furthermore, novel targeted therapies with tolerable side effect profiles are rapidly advancing in the treatment of non-Hodgkin’s lymphoma. The future for patients with low-tumor-burden FL is brighter than ever before.

Still Appropriate
Given the incurable yet indolent nature of follicular lymphoma (FL) and the lack of a survival benefit seen with the early treatment of patients with a low tumor burden, watchful waiting has been the predominant strategy for treating asymptomatic patients with newly diagnosed FL for more than 2 decades. The success and tolerability of rituximab for the treatment of this disease, however, has led to challenges for this treatment paradigm and the consideration of early upfront treatment with rituximab monotherapy, with or without rituximab maintenance. These strategies have resulted in improvements in quality of life with a low incidence of toxicity and have led some to practice changes. However, based on uncertainty about how early treatment affects response to second treatment, the differential cost of treatment, and the lack of a survival benefit, observation remains an appropriate and viable strategy for select patients.