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Watchful Waiting With Non-Hodgkin Lymphoma (NHL)

Updated on December 29, 2021
Medically reviewed by
Todd Gersten, M.D.
Article written by
Annie Keller

  • For many people diagnosed with certain types of non-Hodgkin lymphoma (NHL), it’s recommended to “watch and wait” rather than start treatment right away.
  • People can take an active role during watch and wait by monitoring symptoms, undergoing genetic testing, and learning more about their condition and treatment options.
  • Managing stress and connecting with others living with lymphoma can help those with NHL better cope with the challenges of watchful waiting.

Receiving a diagnosis of non-Hodgkin lymphoma for yourself or a loved one can be frightening. Many people immediately start wondering about treatment options. However, for some people, a doctor may choose a watch-and-wait approach instead of starting treatment right away. Whether someone with NHL needs immediate treatment or not depends on which type of NHL they have.


Indolent Types of Non-Hodgkin Lymphoma

There are more than 60 types of non-Hodgkin lymphoma. About 60 percent of lymphoma cases are classified as aggressive. These are usually treated immediately and will progress quickly without treatment. Most of the other 40 percent of NHL cases are classified as indolent or low-grade lymphomas, which typically grow much more slowly and may not require treatment right away.

There are several types of indolent lymphomas, including:

  • Follicular lymphoma
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma
  • Mantle cell lymphoma
  • Waldenström’s macroglobulinemia
  • Marginal zone lymphoma

Follicular Lymphoma

Follicular lymphoma is the most common type of indolent NHL, making up between 20 percent and 30 percent of all NHL cases. Follicular lymphoma is a slow-growing cancer that forms in a type of white blood cell called B lymphocytes (also known as B cells). While it can cause swollen or enlarged lymph nodes, many people don’t have any symptoms at the time of diagnosis. Due to its slow growth, people may live many years with the disease.

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Chronic lymphocytic leukemia/small lymphocytic lymphoma, also called CLL/SLL, makes up around 6 percent of NHL cases. In 95 percent of people with CLL/SLL, blood stem cells in the bone marrow undergo genetic mutations that cause B cells to develop abnormally. A small percentage of CLL/SLL cases involve T cells, another type of white blood cell, rather than B cells. In chronic forms of leukemia, abnormal cells grow more slowly and generally do not interfere with the production of healthy white blood cells, red blood cells, and platelets. Many people with CLL/SLL go without noticeable symptoms for years.

Mantle Cell Lymphoma

Mantle cell lymphoma also makes up about 6 percent of NHL cases and is caused by cancerous B cells invading part of the lymph node called the mantle zone. While the cancer is typically slow-growing, it is often not discovered until the advanced stages.

Waldenström’s Macroglobulinemia

Waldenström’s macroglobulinemia, also called lymphoplasmacytic lymphoma, also arises from abnormal B cells. Cancer cells can be found in both the blood plasma and the lymph nodes. These cells make a protein called macroglobulin, an antibody that builds up in both the organs and lymph nodes. It is believed that certain DNA changes in lymphocytes lead to Waldenstrom’s macroglobulinemia.

Marginal Zone Lymphoma

Marginal zone lymphomas are a group of low-grade lymphomas, making up about 8 percent of all NHL cases. There are three subtypes of marginal zone lymphomas, all of which involve abnormal B cells, but they develop in different locations.

MALT Lymphoma

The most common type of marginal zone lymphoma is mucosa associated lymphoid tissue (MALT) lymphoma. It begins in the mucosa, a soft, moist tissue that lines many organs and some body parts, like the nose and mouth. MALT lymphoma usually begins in the stomach (gastric) area. However, it can also start in other areas, which is called nongastric MALT lymphoma.

Nodal Marginal Zone Lymphoma

Nodal marginal zone lymphoma makes up about 10 percent of marginal zone lymphoma cases. It affects the lymph nodes directly, usually in the head or neck.

Splenic Marginal Zone Lymphoma

Splenic marginal zone lymphoma makes up 20 percent of marginal zone lymphoma cases. The spleen, bone marrow, and blood are all places where abnormal B cells build up in this type of lymphoma.

“Watch and Wait” or “Watch and Worry”?

Doctors often recommend people with indolent lymphomas delay treatment and enter a period of watchful waiting. Watch and wait, also called active surveillance or active monitoring, may be recommended in cases of indolent non-Hodgkin lymphoma when:

  • There are no active symptoms.
  • Lymph nodes and blood cell counts are still normal or close to normal.

During watchful waiting, your condition will be regularly monitored to see if symptoms begin.

Waiting may sound scary ­— if you know that you or someone close to you has a potentially fatal condition, the last thing you may want to do is wait. In reality however, for many cases of indolent NHL there is no benefit to beginning treatment earlier. It is often preferable to keep a close eye on disease progression instead of going through unnecessary therapies and side effects.

Some MyLymphomaTeam members acknowledge that watchful waiting may cause feelings of unease, even when it’s the best choice. “I understand the philosophy of ‘Why treat something when there’s nothing to treat?’ but that doesn’t lessen the apprehension!” wrote one member.

“I'm doing watch and wait. It just doesn't feel right. I feel like I should be doing something,” another member said. Connecting with a support group, either online or in person, may help ease those worries.

Take an Active Role

While you may not be undergoing active treatment for NHL, there are ways to be proactive while watching and waiting.

Learn More About Your Condition

Learning more about the type of lymphoma you or your loved one has can be empowering. There are many trustworthy sources of information about the different types of NHL and their potential symptoms and treatment options. The resources below can provide you with accurate and valuable information:

Your doctor may also be able to recommend other sources of information. If your doctor doesn’t seem to be taking your concerns seriously or cannot answer your questions, you’re always free to get a second opinion.

Get Tested for Genetic Biomarkers

Cancer cells carry specific genetic mutations, or biomarkers, that are indicators of disease. Knowing which genetic biomarkers your lymphoma cells have can tell doctors a lot about how quickly your lymphoma is likely to progress and which treatment options are likely to be effective. Genetic testing can look at gene mutations or abnormal chromosomes, and may be done using blood or bone marrow samples.

Biomarkers for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

For people with CLL/SLL, genetic analysis should screen for the following biomarkers:

  • Partial deletion of chromosome 11 or 17 (sometimes called 11p or 17p) can indicate more aggressive disease and that treatment may be needed sooner.
  • Mutation of IGHV (immunoglobulin heavy chain variable region) in CLL cells suggests a better prognosis.
  • TP53 mutation indicates the disease may be resistant to chemotherapy and may behave more aggressively.

Biomarkers for Mantle Cell Lymphoma

For those diagnosed with mantle cell lymphoma, one genetic mutation has been noted in most cases. It is a translocation, or rearrangement, of chromosomes 11 and 14. If this translocation is detected, mantle cell lymphoma is easier to diagnose. The TP53 mutation mentioned above as a CLL/SLL marker may also be present in mantle cell lymphoma. As in cases of CLL/SLL, the presence of the TP53 mutation may indicate potential treatment resistance.

Biomarkers for Marginal Zone Lymphoma

For those people with marginal zone lymphoma, there are several genetic biomarkers to test for. These include:

  • Trisomy 3 or 18, where cells have three copies of chromosome 3 or 18
  • Partial deletion of chromosome 6
  • Deletions of chromosome 7q in cases of splenic marginal zone lymphoma

Biomarkers for Waldenström’s Macroglobulinemia

Most people with Waldenström’s macroglobulinemia have a particular mutation of a gene called MYD88. About 30 percent of people will have another mutation of the CXCR4 gene.

Track Your Symptoms

The “watching” will be partially your responsibility, as you will need to track any potential symptoms of NHL and report them to your doctor. Symptoms to take note of include enlarged lymph nodes, chills, fatigue, shortness of breath, a swollen belly, frequent infections, and easy bruising.

One particular set of symptoms known as “B symptoms” is important to look out for. B symptoms include:

  • Fever without infection
  • Night sweats
  • Unintentional weight loss (at least 10 percent of your body weight within six months)

It may help to keep a journal detailing any potential symptoms you notice over time. Any changes or new symptoms should be communicated to your doctor. Your doctor will also monitor clinical signs of progression, which vary for each type of NHL, with blood tests.

Many potential symptoms of NHL can also be associated with many other conditions and may not be a sign of lymphoma progression. Your doctor will be able to interpret the source of any symptoms you experience.

When Does Watchful Waiting End?

There are many points when your doctor may recommend beginning treatment. Experiencing the symptoms described above may indicate to your doctor that your non-Hodgkin lymphoma is progressing. The results of blood tests may also tell your doctor that it’s time to start active treatment.

Apart from symptoms and specific genetic biomarkers, there may be other indicators of progression for each type of indolent NHL. These include:

  • For all types of NHL — Increased swelling in the lymph nodes or spleen, or signs that cancer is spreading to other locations
  • For Waldenström’s macroglobulinemia — Hyperviscosity syndrome, wherein the blood thickens

When your doctor recommends you start treatment for NHL, you will begin a conversation about your treatment options. This doctor discussion guide can help you talk to your doctor about your personal values, priorities, and goals for lymphoma treatment.

Read more about oral therapies versus chemotherapy for indolent types of NHL.

Learn More About Clinical Trials

If your condition progresses beyond the watch and wait stage, clinical trials may be an option for treating your non-Hodgkin lymphoma. Clinical trials contribute to medical knowledge about NHL and may provide access to new, effective treatments. Participants in clinical trials are protected by the process of informed consent and can withdraw from a trial at any time.

Ask your doctor for information about clinical trials or visit ClinicalTrials.gov.

Manage Stress

Many MyLymphomaTeam members have described watchful waiting as being stressful. One member was quick to reassure others, “Watch and wait is not necessarily a bad thing! It's different than other types of cancer where you have to do something immediately depending on the staging.” Another added, “It's stressful before scans, but way better than going through treatment.”

Some members have mentioned the support of other MyLymphomaTeam members is a comfort. “This team has helped me so much,” one said.

Talk With Others Who Understand

MyLymphomaTeam is the social network for people with lymphoma and their loved ones. On MyLymphomaTeam, more than 10,000 members come together to ask questions, give advice, and share their stories with others who understand life with lymphoma.

Are you currently going through watchful waiting? Do you need support? Share your experiences in the comments below, or start a conversation by posting on MyLymphomaTeam.

References
  1. NHL Subtypes — Leukemia & Lymphoma Society
  2. Management of Intermediate-Grade Lymphomas — Cancer Network
  3. Leukemia — Chronic Lymphocytic — CLL: Introduction — Cancer.Net
  4. CLL Signs and Symptoms — Leukemia & Lymphoma Society
  5. Mantle Cell Lymphoma — Lymphoma Research Foundation
  6. Mantle Cell Lymphoma — Canadian Cancer Society
  7. Do We Know What Causes Waldenström Macroglobulinemia? — American Cancer Society
  8. Marginal Zone Lymphoma — Lymphoma Research Foundation
  9. Low Grade NHL — Cancer Research UK
  10. MALT Lymphoma — Cancer Research UK
  11. Nodal Marginal Zone Lymphoma — Lymphoma Action
  12. Watch and Wait — Leukemia & Lymphoma Society
  13. Treatment for Indolent NHL Subtypes — Leukemia & Lymphoma Society
  14. CLL: Watch and Wait — Leukemia & Lymphoma Society
  15. Tests for Waldenström Macroglobulinemia — American Cancer Society
  16. Active Monitoring (Watch and Wait) — Lymphoma Action
  17. When To Treat People With Waldenström Macroglobulinemia — American Cancer Society
  18. Plasmapheresis (Plasma Exchange) for Waldenström Macroglobulinemia — American Cancer Society
  19. Amyloidosis — Mayo Clinic
  20. Mantle Cell Lymphoma — Lymphoma Action
  21. Detection of Translocation t(11;14)(q13;q32) in Mantle Cell Lymphoma by Fluorescence in Situ Hybridization — The American Journal of Pathology
  22. Recent Advances in Understanding the Biology of Marginal Zone Lymphoma — F1000 Research
  23. CXCR4 Gene — MedlinePlus
  24. MYD88 Gene — MedlinePlus
  25. Helicobacter Pylori Infection and Gastric Lymphoma — The New England Journal of Medicine
  26. Splenic Marginal Zone Lymphoma (SMZL) — Macmillan Cancer Support
  27. Nodal Marginal Zone Lymphoma — DoveMed
  28. Optimizing Therapy for Nodal Marginal Zone Lymphoma — Blood

All updates must be accompanied by text or a picture.
Todd Gersten, M.D. is a hematologist-oncologist at the Florida Cancer Specialists & Research Institute in Wellington, Florida. Review provided by VeriMed Healthcare Network. Learn more about him here.
Annie Keller specializes in writing about medicine, medical devices, and biotech. Learn more about her here.

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