Watching and Waiting in the News

The Journal of Clinical Oncology's latest edition includes an article on the effectiveness of Watching and Waiting as an initial treatment strategy for low-tumor burden Follicular Lymphoma.

(I can't get the link to the article to work, so here's a link to a piece from Doctor's Lounge that reports on the JCO article.)

Basically, the article says that Follicular patients that don't have symptoms, and have more than 4 node clusters affected, are more likely to need treatment sooner than those with fewer affected nodes. The study compared people who watched and waited to those who had treatment right away with Rituxan or Rituxan plus something else. The researcher looked at FFTF rate -- Freedom from Treatment Failure -- how long it took for their initial treatment to stop working. In the study, 79% of Watch-and-Waiters went four-years before Treatment Failure, while 69% of the Rituxan group went four years.

So, more evidence that Watching and Waiting is OK.

Which, frankly, is fine with me. I don't need to know that W&W is better than being treated right away. I've been there already. But I do like hearing (yet again) that it's a valid option. For the right person, W&W can be a good thing.

For the right person. That's key. In the same issue of the JCO, Lymphoma Rock Star Dr. Bruce Cheson writes an editorial called "Waiting is the Hardest Part" (for some reason, I am able to link to this JCO article). Dr. Cheson takes a clinician's view of W&W, pointing out "One of the more challenging conversations to have with a patient is one presenting a new diagnosis of an indolent and treatable type of cancer that is incurable but for which the plan is not to offer treatment but merely follow-up with the patient every few months to see what happens." Challenging because, for some people, W&W is a relief -- we can hold off treatment for a while. For others, it's a burden -- emotional, psychological, spiritual, just waiting for "the crescent blade in Edgar Allen Poe’s 'The Pit and the Pendulum' ... swinging overhead with its ominous descent 'inch by inch, line by line, ... at intervals that seemed like ages'."

(A Poe reference in a medical journal. That's why he's a rock star.)

It's an apt reference, though, as we watch and wait for the bad thing to come, that will be our doom. In the end, says Cheson, watching and waiting is not "intellectually satisfying." I assume he means for the doctor. Once we all get over the emotional part of things, and look at the situation rationally, then W&W makes sense. But "rationally satisfying" isn't "intellectually satisfying." What we need, if we really want to get rid of W&W, is a better option -- one that comes with minimal side effects, and the promise of a cure.

And, as he points out, we are moving in that direction. Combing Rituxan with other "biologic agents" (other variations of monoclonal antibodies that target different surface proteins than Rituxan targets) are showing some good results. So are the various kinase inhibitors that are being developed.

So why choose Watch and Wait? The main reason, says Cheson, is "optimism." The belief that what might come will be better than what we have now, and holding off treatment will mean more options later.

I like that. Even more than I like the Poe reference.