The Benefits of Maintenance (Again)

More research on Maintenance therapy for Follicular Lymphoma.

If I had to guess, I'd say there has been more research on Maintenance in the last 5 years than any other subject related to Follicular Lymphoma. That should tell you how important it is, but also how controversial it is -- if the questions about Maintenance had been settled years ago, we wouldn't have more and more research on it all the time.

For those who need a reminder (or a lesson): Maintenance is the term for extending treatments after an initial successful treatment. The goal is to extend the success. So a patient might have the chemotherapy combination Bendmustine + Rituxan, and do very well with it, and then get more Rituxan every 2 months for another 2 years. Rituxan is less aggressive than traditional chemotherapy, so the side effects usually aren't as harsh (though they certainly exist), but can also "clean up" any cancer cells that remain, or that pop up after treatment.

Maintenance is controversial because its benefits are limited (more on that below), but can also be expensive (treatment goes on for two more years, and someone has to pay for it), and can cause some side effects. Some oncologists like it, and others don't.

The most recent research probably won't change anyone's mind.

"Sustained Progression-Free Survival Benefit of Rituximab Maintenance in Patients With Follicular Lymphoma: Long-Term Results of the PRIMA Study" was published a few weeks ago in the Journal of Clinical Oncology.


The research comes out of the PRIMA rial, which has been around for a very long time (I first wrote about it in in 2011). That's a very good thing -- we can see long-term results of the patients in the study, and that's what this article provides.

The study looked at 1018 patients with Follicular Lymphoma who received one of three immunochemotherapy treatments (R-CHOP, R-CVP, or R-B). For those who had a response, they were then assigned to either receive Maintenance, or to observe and be treated again when necessary. The big results for this article had to do with Progression-Free Survival -- how long it took for the disease to come back or get worse. The patients who had Maintenance had a much longer PFS than those who just observed -- 10.5 years versus 4.1 years. In that way, the Maintenance did its job, extending the time before patients likely needed treatment again.

However, the study also measured Overall Survival -- how long the patients lived. By that measure, Maintenance was not successful. Both groups had a 10 year OS of 80%.

So Maintenance might keep the disease in check longer, but statistically, it won't keep you alive longer than doing nothing after a successful first treatment. Maintenance patients also had a higher incidence of side effects (which makes sense, since they're getting longer treatment).

And that's really what the controversy comes down to -- what are the patient's goals? I'm guessing that no patient would disagree that the big goal is to stay alive as long as possible, so this doesn't really do much for us.

But apart from that, what's the goal? Is it to hold off on chemo for as long as possible? And is the patient willing to spend more money, put up with more possible side effects, and go to the hospital for treatment every two months? If so, then maybe Maintenance is a good choice. If those factors aren't an issue, then maybe not. Maybe treatment every two months, or the higher cost, or the side effects would lower Quality of Life, and the better choice for some patients is to hold off on Maintenance and hope that the initial treatment lasts a good long time, and the next treatment gives a longer remission.

So, no easy answers. That seems to be the way it is with pretty much every question that Follicualr Lymphoma patients face.

But the good news is that we do have options. Not all cancer patients do. So it's important that we keep ourselves educated, and we keep make sure we have doctors who will listen to what we want, and answer our questions. That's the only way all of these great options we have actually become good choices.