Therapeutic Approach to Advanced Follicular Lymphoma at Diagnosis: An Argentinian Survey

Different treatment guidelines suggest that advanced follicular lymphoma (AFL) subjects should be treated only when meeting criteria treatment, such as GELF, are present. Conversely, when absent the watch and wait (W&W) approach is recommended. However, in our country, we had the impression that in real life, a high percentage of patients without the above-mentioned criteria were treated. With the purpose of unravelling the medical approach of AFL patients at diagnosis and subsequent evolution, the Lymphoma Subcommittee of the Argentinian Society of Haematology undertook this retrospective survey.

Results: From years 2006 to 2014 305 patients from 23 institutions were included. GELF criteria were encountered in 62% of patients at diagnosis and all of them were treated with immunochemotherapy (ICT). Among the 116 (38%) patients without meeting GELF criteria (GELF negative group), in only 30 (26%) W&W was the approach chosen, while the rest received ICT. The survey questionnaire revealed that own assessment of the treating physician was the main reason for treating the GELF negative group. In the W&W group, 60% required ICT at a mean of 17 months, being 15% of them transformed to DLBCL at time of treatment. The 89% of cases (271/305) received ICT at some time; 66% R-CHOP, 29% R-CVP, and 5% other regimes. Patient median age receiving R-CHOP and R-CVP was 57 and 62 years (p<.01), respectively. Rituximab maintenance (RM) was added to ICT in 64% of cases. For the whole group, with a median follow up of 36 months, the overall survival (OS) was 95% and progression free survival (PFS) 68%. Comparing GELF negative and positive groups, PFS was better for GELF negative group, 87% vs 61% (p <.01). There was no difference in OS. Within the GELF negative group, OS was not different between patients treated at the time of diagnosis vs those in which a W&W approach was chosen.

Conclusion: 1) When comparing with international reports, the percentage (62%) of patients with positive GELF criteria was higher at diagnosis. This fact may be due to delay in access to health care; 2) we found a remarkable discrepancy among guidelines recommendations and real life medical behaviour. Three out of four patients received treatment at diagnosis, when W&W ought to have been the guideline-recommended approach; 3) R-CHOP was the most used ICT scheme, while R-CVP was mostly reserved for the elderly. RM was indicated in the majority of patients, particularly after year 2011; 4) despite acknowledging the methodological limitations of this retrospective analysis, a high tumor mass (GELF positive) picture conferred a worse prognosis in term of PFS, while a W&W approach did not affect the OS for the GELF negative group.