NCCN Guidelines for Patients® | Follicular Lymphoma Grade 1-2

39 NCCN Guidelines for Patients ® : Follicular Lymphoma, Grade 1–2, 2017 4 Treatment guide Typical type Stages III & IV Guide 6 lists options for first-line treatment of stages III and IV. Stage III cancers are on both sides of your diaphragm. Stage IV cancers have widely spread outside the lymphatic system. Your doctor will decide if treatment is needed now. Observation You may not have to start treatment right away. Instead, you may start observation. This wait-and- watch approach may be an option if the following statements describe you: † † There are no clinical trials that you can join. † † The cancer is not causing symptoms. † † The cancer is not limiting organs from working. † † The cancer is not causing low blood cell counts. † † The cancer has not grown large or spread far. † † The cancer has not increased your spleen size. † † There’s been no cancer growth for at least 6 months. Research has shown that starting treatment now does not treat the cancer any better. Your length of life will not be extended. During observation, your doctor will look for signs to start treatment. The care received during observation is the same as for follow- up care. Drug treatment Treatment with cancer drugs is an option. Chemoimmunotherapy is standard care. There is good proof that bendamustine with rituximab, RCHOP, and RCVP work well. Obinutuzumab may also be given with bendamustine, CHOP, and CVP. Other options are rituximab alone and lenalidomide with or without rituximab. Some cancer drugs can be harmful to people who are older or quite sick. In these cases, rituximab may be the preferred option. Another option is chemotherapy that’s not too harmful. Such treatment includes chlorambucil or cyclophosphamide. Rituximab may be added to these drugs. Many people can also withstand ibritumomab tiuxetan, but you must meet certain conditions. These conditions include having enough healthy bone marrow. Guide 6. First-line treatment for stages III & IV What are the options? • Observation • Drug treatment ◦◦ Bendamustine + rituximab ◦◦ Bendamustine + obinutuzumab ◦◦ RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) ◦◦ CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) + obinutuzumab ◦◦ RCVP (rituximab, cyclophosphamide, vincristine, prednisone) ◦◦ CVP (cyclophosphamide, vincristine, prednisone) + obinutuzumab ◦◦ Rituximab ◦◦ Lenalidomide + rituximab ◦◦ Less harsh chemotherapy, (eg, chlorambucil, cyclophosphamide) ± rituximab ◦◦ Ibritumomab tiuxetan • Clinical trial • Local radiation therapy