Debate on the conservative and aggressive treatment options for the optimal management of indolent non-Hodgkin's lymphoma

Indolent non-Hodgkin's lymphoma (NHL) is currently considered to be an incurable disease, with a median survival of 6-8 years. In the absence of a cure, the variety of therapeutic options available for patients with indolent NHL range from 'watchful waiting' to high-dose therapy (HDT) with autologous stem-cell transplantation (ASCT). There is no current consensus on standard treatment. Conventional chemotherapy is clearly not curative, and many clinicians prefer to delay chemotherapy until the patient develops overt symptoms that require treatment. On the one hand, long-term studies indicate that 'watchful waiting'has no effect on overall survival. On the other hand, aggressive treatment strategies, such as HDT with ASCT, may increase disease-free survival in some patients, particularly when used early in the treatment algorithm, but are also associated with potential toxicity. Thus the selection of therapy for each patient involves balancing the benefit of the treatment with any side effects and detriment to quality of life. The development of innovative therapies for indolent NHL, such as monoclonal antibodies with or without chemotherapy, requires a reassessment of the treatment choices. Good clinical responses and time to progression have so far been achieved in clinical trials of rituximab and other agents including radiolabelled antibodies, but in view of the long median survival of patients with indolent NHL, it will be some years before it can be conclusively demonstrated whether such treatments have an effect on the natural history of the disease or produce a cure. This issue raises an important question: outside the setting of a clinical trial, should patients be treated aggressively with therapies that do not yet have proven curative ability? This article considers the evidence and relative merits for the conservative approach to indolent NHL, where patients are treated according to symptoms in order to maintain a normal quality of life wherever possible, and for the aggressive approach, where the lymphoma is targeted soon after the diagnosis. [(C) 2002 Lippincott Williams Wilkins.].