What is the optimal management of early‐stage low‐grade follicular lymphoma in the modern era?

Abstract

BACKGROUND: Despite international practice guidelines endorsing radiotherapy (RT) as the preferred initial therapy, treatment approaches vary for patients with early-stage follicular lymphoma. The authors engaged the National Cancer Data Base to analyze patterns of care and survival outcomes for patients with early-stage follicular lymphoma in the era of modern therapy. METHODS: A National Cancer Data Base retrospective cohort study was conducted of 35,961 patients with lymph node and extranodal, American Joint Committee on Cancer stage I to II, WHO grade 1 to 2 follicular lymphoma who were diagnosed between 1998 and 2012. Univariate and multivariable analyses were performed to identify sociodemographic, treatment, and tumor characteristics that were predictive of overall survival (OS) and treatment use. Propensity score-adjusted Cox proportional hazards ratios for survival in patients treated for follicular lymphoma were used. RESULTS: Of the 35,961 patients with follicular lymphoma included in the current study, 63% had stage I disease, 79% were without extranodal disease, and 61% were aged >60 years. RT use decreased from 37% in 1999 to 24% in 2012 (P<.0001), with corresponding significant increases in observation and single-agent chemotherapy. Patients who received RT had 5-year and 10-year OS rates of 86% and 68%, respectively, compared with 74% and 54%, respectively, for those who did not receive RT (P<.0001). On multivariable survival analysis, including a propensity score to account for potential uncaptured confounding variables due to a lack of randomization, upfront RT remained independently associated with improved OS (hazard ratio of death, 0.54; 95% confidence interval, 0.47-0.63 [P<.0001]). CONCLUSIONS: RT is an increasingly underused treatment approach in the era of modern therapy for patients with early-stage follicular lymphoma. The use of RT appears to improve OS and should remain standard practice as encouraged by clinical practice guidelines. Cancer 2015;121:3325-34.

Rituximab maintenance therapy of follicular lymphoma in clinical practice

“…In parallel, the use of radiotherapy was remarkably reduced in the current vs the previous first‐line induction therapy. A shift from radiotherapy to early chemotherapy appears to be a global trend …”

Management Trends and Outcomes for Stage I to II Mantle Cell Lymphoma Using the National Cancer Data Base: Ascertaining the Ideal Treatment Paradigm

“…From 2003 to 2011, the use of consolidative RT for Hodgkin lymphoma declined by 14.2% (23). Within a similar period, RT use for low-grade follicular and diffuse large B-cell lymphoma has decreased by 13% and 15%, respectively (24,25). In our analysis of early-stage MCL, an analogous 15.9% decline was seen.…”

Clinical management and outcomes of completely resected stage I follicular lymphoma

“…In the United States, treatment choice has been reported to change depending on age, race, marital status and year of diagnosis, as well as income or health insurance coverage even among patients limited to earlystage disease. 19,20 As such socioeconomic characteristics were not collected in the present study, we cannot rule out the possibility that other factors influenced our results. Thus, it is possible that nodal or extranodal presentation influenced treatment choice.…”

“…In general, the local relapse rate after irradiation for early-stage FL is less than 10%, [22][23][24] demonstrating the effectiveness of irradiation for local control. Furthermore, considering irradiation as the only strategy with benefits in terms of overall survival for early-stage FL, 7,19,20 irradiation is one of the most important treatment strategies, as reflected in several guidelines and review articles for early-stage FL. 5,6,25,26 On the other hand, 7 of 13 patients in the WW group experienced distal relapse shortly after diagnosis in their report (median, 1 year; range, 0.5-5 years).…”