Treatment for indolent non-Hodgkin's lymphoma
Approximately four out of 10 non-Hodgkin's lymphomas are indolent, and most of these are follicular in type, although there many more types of indolent non-Hodgkin's lymphoma. The treatment options for indolent non-Hodgkin's lymphoma depend to a large extent on the stage of the disease and on whether the patient experiences symptoms.
Indolent non-Hodgkin's lymphomas grow slowly and rarely cause symptoms until they are reasonably advanced. Therefore, few indolent non-Hodgkin's lymphomas are diagnosed while they are still in stage I or stage II.
Early-stage indolent non-Hodgkin's lymphomas are almost always treated with radiotherapy to the affected lymph nodes. This achieves a cure in about half of patients. In the other half, non-Hodgkin's lymphoma will relapse at some time, usually in other lymph nodes. At that point, the treatment is generally the same as for patients who have advanced-stage disease (stage III or stage IV).
Approximately four out of 10 non-Hodgkin's lymphomas are classed as indolent, and most of these are follicular in type. Indolent non-Hodgkin's lymphomas are usually diagnosed at an advanced stage (stage III or stage IV).
Patients with advanced-stage non-Hodgkin's lymphoma who have no symptoms often need no treatment at the time of diagnosis, and simply have regular follow-ups. This is known as the 'watch and wait' approach.
Clinical studies have shown that, in suitable patients, the outlook in 'watch and wait' patients is no different from that of patients who start treatment at the time of diagnosis. However, the anxiety and stress that can be caused by the 'watch and wait' approach has to be balanced against possible side effects of immediate treatment. It may be recommended by the doctor not to start treatment until it is needed, in order to reduce the impact on patients' lives. However, research into the benefits and risks of the 'watch and wait' approach is ongoing.
If treatment is necessary, chemotherapy is usually used. This is can involve treatment with just one drug, usually chlorambucil. Other chemotherapy treatments that are used include fludarabine, which can be given either as tablets or as an intravenous injection, either on its own or in combination with other drugs.
However, more than one drug is also commonly used, with combinations including CVP, CHOP and FCM. (For more information, see Chemotherapy) Combinations of chemotherapy drugs (such as CVP for indolent NHL) are often given with the monoclonal antibody rituximab, which increases the effectiveness of the treatment, without adding significantly to the side effects.
Patients who have advanced-stage, indolent non-Hodgkin's lymphoma (stage III or stage IV) lymphoma at diagnosis and who have symptoms are usually given chemotherapy in the first place, with or without monoclonal antibody therapy. Various chemotherapy programmes are used (for example, CVP and CHOP), most of which involve more than one chemotherapy drug, or chemotherapy along with monoclonal antibodies.
If the patient's symptoms are severe, a steroid such as prednisolone may be used to help to bring them under control quickly. This can be very effective in the short term, but it is not suitable as a long-term treatment. However, steroids are part of most combination regimens (CVP, CHOP)
Radiotherapy may be used, together with other treatments such as chemotherapy and monoclonal antibody therapy, to treat bulky masses of lymphoma. If so, the radiotherapy is directed specifically at the masses to be treated.
Other treatments include high-dose chemotherapy followed by a stem cell transplant.
Around 75% of patients with symptomatic, advanced-stage, indolent non-Hodgkin's lymphoma experience a remission after their first course of treatment, which generally lasts for between 1.5 and 4 years. After that, the lymphoma frequently relapses. Further treatment may then be necessary and treatment-free intervals become shorter, and patients typically survive for between seven and 10 years. However, these figures also depend significantly on the age and the general health of the patient.
MALT non-Hodgkin's lymphoma affects certain organs, particularly the salivary glands, the thyroid, the lung and the stomach. MALT non-Hodgkin's lymphoma of the stomach is associated with infection with the bacterium Helicobacter pylori.
Antibiotics that kill the bacteria may cure the disease in the early course of MALT, although some people may also need to have chemotherapy. MALT non-Hodgkin's lymphoma of the stomach that is not cured in this way, and MALT in other organs, is treated in the same way as indolent non-Hodgkin's lymphoma.
Small lymphocytic lymphoma, largely similar to chronic lymphocytic leukaemia, is an indolent form of non-Hodgkin's lymphoma and is characterised by the overproduction of abnormal B cells, which tend to live much longer than normal. Although the disease is sensitive to chemotherapy, patients usually go through cycles of remission followed by relapse.
The table shows the common treatments
for indolent non-Hodgkin's lymphoma by disease stage
with typical outcomes