6.2 Managing relapsed or progressive disease

6.2 Managing relapsed or progressive disease

Managing residual or relapsed disease is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate. From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A, B and C should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.

Survivorship care should be considered and offered at an early stage. Many people live with advanced cancer for many months or years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.

In a suspected relapse, consider conducting a biopsy to confirm the relapse. Also consider whether there are clinical features to suggest transformation to high-grade lymphoma or involvement by a different lymphoma or neoplasm. In the event of a re-biopsy, the appropriate tissue diagnostic and prognostic investigations can be undertaken again as necessary. Molecular tests may in the near future be able to guide use of novel therapies (e.g. EZH2 mutation in FL).

Re-staging of relapsed or refractory disease should be performed with CT-PET scan, or if indolent disease was previously PET-negative, with CT scan. Consider a repeat bone marrow biopsy to evaluate the cause of cytopenias.

In managing people with low-grade lymphomas, treatment may include these options according to the British Society of Haematology (2020) and ESMO guidelines general concepts:

  • first: assess performance status and comorbidities
  • options:
    • asymptomatic relapse – watch and wait
    • localised relapse – consider radiation therapy
    • widespread and systemic recurrence – consider systemic therapy +/− autologous transplantation
  • pre-screen patient for any currently recruiting or imminent clinical trial
  • consider palliation
  • treatment decision: collaboration between patient and specialist.