Tuesday, March 25, 2014

Rituxan vs. Watching and Waiting in Follicular Lymphoma

The Lancet, a major British medical journal, offers the latest (though probably not the last) in the debate over Watching and Waiting versus Rituxan. This round goes to...Rituxan.

Researchers looked at 379 patients from Britain, Australia, New Zealand, Turkey, and Poland from 2004 to 2009. Patients were assigned to one of three groups: Watching and Wait; straight Rituxan as a first treatment; or Rituxan plus Rituxan Maintenance for 2 years.

Ritxuan Maintenance won  pretty handily.

Three years after being placed into the study, 46% of W&Wers did not need treatment. However, that's not great compared to the Rituxan group (78%) and the R-Maintenance group (88%).

Furthermore, they looked at Quality of Life, and found that, after 7 months, the R-Maintenance group beat both of the other two in "Mental Adjustment to Cancer" and "Illness Coping Style." (I'm not sure how those things are measured, though the names seem pretty self-explanatory.)

So the conclusion here is that Rituxan Maintenance might be the best option for newly diagnosed patients who are without symptoms and have low tumor burden, whether the measure is time to treatment or quality of life. The quality of life issue makes sense; there are probably lots of people who feel less anxiety when they are getting a treatment every two months. They must feel like they are taking some kind of action, which can be very comforting. I would still maintain that W & W is a choice, and not the best choice for some, and the quality of life issue would explain that. I was OK with not treating right away, and I know that's not emotionally possible for everyone. I'm not sure that part of the study really matters.

The time to treatment, however, is something to pay attention to. Again, using my own (very limited) experience, I would fall right within the W & W group, having taken two years to need treatment.

Would it have been different if I had done Rituxan Maintenance right away? We'll never know. However, if we step back and look at a bigger picture, I'm 6+ years since diagnosis and have only needed one course of treatment. If we looked at long-term follow-up of all of the patients in this study, will we find such a big difference six years out?

I'll admit that I want Watch and Wait to come out better in this debate, since that would validate my own choice.

That said, I think this study tilts things toward R-Maintenance a little, but it's still probably not enough to ditch Watch and Wait. Still too many proponents making good arguments based on available data (like Dr. Bruce Cheson) for this to be a real game changer.

But it certainly does give more fuel to the debate, and at the very least, should help validate the choice of R-Maintenance for those who make it.

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