The role of treatment deferral in the management of patients with advanced, indolent non-Hodgkin’s lymphomas

Abstract

The management of patients with stages III and IV indolent non-Hodgkin’s lymphomas remains controversial. As initially reported by Jones et al [1] in 1973, the median survival for patients with ‘favorable’ histology lymphomas (Table 1) was more than 8 years, in contrast to a median survival of less than one year for those with ‘unfavorable’ histologic subtypes.¹ With the use of intensive combination chemotherapy over the intervening decade, there has been dramatic improvement in the prognosis of patients with aggressive lymphomas [4], whereas there has been a virtual standstill in the development of more effective therapy for those with indolent histologies. Although complete remissions can be achieved in the majority of patients with advanced stage lymphomas of either indolent or aggressive histologic subtypes, it is only those with aggressive subtypes who experience prolonged remission durations. And with observations extending well beyond 10 years, confidence is high that such patients may be cured. The impact of this paradox is illustrated in Figs. 1 and 2 [5]. In spite of intensive therapy, patients with advanced indolent histologies experience a pattern of continuous late relapse following induction of complete remission; whereas the disease-free survival curve of complete responders with aggressive histologies reveals few relapses, all occurring within the first two years, and none subsequently. Although median disease-free survival is only 1–2 years for patients with indolent lymphomas, patients continue to live for long periods with active disease.