ASH Preview: Statistics on Watching and Waiting

 As I said in my last post, there are a lot of interesting presentations about Follicular Lymphoma  coming up at ASH, and I hope to cover a lot of them. And as I said, I want to start off with a presentation about Watching and Waiting.

If you've been reading for a while, you probably know that I was diagnosed with stage 3, grade 1/2 FL in January 2008. My disease was slow-growing enough that I was able to watch and wait for exactly two years -- I started Rituxan on my second diagnosiversary. The treatment began because of swelling in my leg, probably caused by nodes that were pushing up against something. 

Watching and waiting made absolutely no sense to me when I was diagnosed. Why would anyone choose to not get treatment? But I learned that watching and waiting made sense for some FL patients whose disease was slow-growing, because it essentially delayed using up a treatment. Back then, there were fewer treatments available, and it was assumed that the disease would come back and need another new treatment. The hope was there would be enough treatments, and enough time between them, to outlast the disease.

For a while, there was lots of research on W & W, trying to find some negatives about it. But there was never really anything discovered that upset what the previous research showed -- that there was no real difference in Overall Survival between patients who were treated right away and those who waited. I remember a researcher arguing that W & W was unnecessary because we had more treatments available, and something like Rituxan could be used a s first-line treatment because it was less aggressive than other options. That got debated for a while and then people stopped talking about that.

[I've been writing this blog for almost 17 years, so I don't remember a lot of details, but if you want to be a Cancer Nerd and search the blog for everything I've written about watching and waiting, you have that option.]

So let's take a look at this ASH presentation -- "4416 Practices and Outcomes during a Watch and Wait Approach for Follicular Lymphoma: A Study from the Australasian Lymphoma Alliance."It looks at 267 patients from Australia who were diagnosed with FL and then watched and waited.

It doesn't necessarily present anything new, but it gives an interesting snapshot about what happens when patients watch and wait. Given that I've had a couple of conversations recently about this, I'm guessing there are a bunch of you who are curious about this. Here are the bits that I found most interesting:

• For the patients in the study, the median Time to Treatment was 4.88 years (meaning half of them waited for over 5 years). About 30% of the patients were able to continue to watch and wait for 10 years. That's a long time. (I'm thinking of reader Chip, who was getting a little antsy after 3 years. It can go on for a while, obviously.
• While they were waiting, they had a median of 8 appointments with their oncologists and 2 CT or PET scans.This is pretty interesting, too. I know when I was first diagnosed, and we agreed to watching and waiting, I expected to see the doctor very frequently, and at first I did. But then we stretched out the every 3 months. In this study, if patients waited for 5 years and had 8 appointments, then they were seeing their doctor every 7.5 months. If you're newly diagnosed, keep that in mind -- patients don't need to be seen very frequently, if that's something you're concerned about. The reason is related to the second bit of information here -- only 2 scans in 5 years. Again, I thought I would get scanned every few months. But we shouldn't be exposed to that much radiation -- a scan every year is probably the most frequent you'd need, and even that is a lot of scans. I remember reading a study that said that most patients notice symptoms themselves and then alert their doctor about it.  The new symptoms (like my swollen leg) aren't found in scans or during a doctor's visit. They are found by patients. Why? Because we know our bodies and we know when something isn't right. Trust yourself. 
•  Just to be clear -- the range of doctor appointments in the study was 1 to 34, and the range of scans was 0 to 14. Don't take the median to be the goal. If your doc wants to meet or scan more or less than that, then ask why and if you're ok with the answer, then meet more or less frequently. But it's OK to ask to meet more frequently, if only for the peace of mind (I meet my doctor way more frequently than I need to, even 16+ years later, because it gives me a little comfort.)
• Complications, including patients having new symptoms, happened to 28% of the patients in the study. About 13% of them had transformed disease, where their slow-growing FL turned into a more aggressive type of lymphoma. About 12% had pain or discomfort,  3% had hydronephrosis (swollen kidneys) and 2% had thrombosis (blood clots). Most, it seems, it not have serious medical complications.
  
•  Here's a big one: There was no mortality associated with a WW approach. No one died because they watched and waited. That's worth mentioning. I know I had the fear that I or the doctor would miss something important. That doesn't happen.
• Back to scans. For those who did get scans, about 20% were for "surveillance," basically to take a look around and see what's going on. The other 80% were triggered by "clinical findings," either discovered or confirmed by a doctor;s examination.
  
• During the 5.5 years of follow up, 138 of the 267 patients started treatment -- just over half. For those who did start treatment, 38% did so because of tumors getting larger, 25% transformed, 17% had organ compromise, 7% was for potential organ compromise (I think this was technically the reason I started treatment), 7% had cytopenia (low blood counts). So for those of you who wonder when to start treatment, there are lots of reasons, and I think it's safe to say that you'll know when something is up.
  
•  This is important too: 1 of the 138 patients who started treatment did so by choice. That is, there weren't any symptoms or complications that made the doctor say "It's time to start." The patient said, "I can't do this anymore. I need to start treatment." And that's OK.  Honestly, I'm surprised it was only one. As I have said many times before, we have a disease that has emotional symptoms as much as it has physical symptoms, and for those who are watching and waiting, there are more emotional than physical symptoms. If a treatment results in too great of a physical toll, we stop doing it. If the choice to watch and wait takes too much of an emotional toll, then ask to stop. that's a legitimate choice.
• And finally, it's the same story as I heard 16+ years ago -- Overall survival was similar for watching and waiting than it was for patients being treated. 

So there you have it -- as up-to-date a picture of watching and waiting as we have. If you're watching and waiting now, and you have questions, I hope this answers them. It's such a strange situation to be in, it's only natural to have questions. At least for now, I hope you have something to compare to, and you can see that watching and waiting can be a good choice -- one that won't results in any special problems, as long as you pay attention to your body and let your doctor know when something is off.

There's another interesting watching and waiting presentation that I may write about. But maybe not  -- this one answers lots of questions, and there is so much more to share with you.

Come back soon.

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One final push for patients and caregivers to take that FLF survey. It closes on November 19, so do it soon if you haven't yet!