Surveillance until rituximab retreatment at progression among patients with low-tumor burden non-Hodgkin lymphoma was not associated with increased anxiety compared with maintenance rituximab, a new study published in the Journal of Clinical Oncology has shown.1

Non-Hodgkin lymphoma is the sixth most common cancer in the United States, and most patients are treated for the disease as a chronic condition similar to that of hypertension and diabetes. Because patients live with non-Hodgkin lymphoma for many years, patients’ health-related quality of life is an important aspect when caring for the patient. 

Particularly, for those with low tumor burden and a good health-related quality of life, clinicians must determine whether treatment toxicities that decrease health-related quality of life might outweigh potential benefits. Therefore, researchers sought to compare disease-related anxiety among patients receiving maintenance rituximab versus rituximab retreatment.1

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Rituximab is a CD20-directed cytolytic antibody approved for the treatment of patients with non-Hodgkin lymphoma. The immunotherapy is relatively safe; the most common adverse events observed are infusion reactions, fever, lymphopenia, chills, infection, and asthenia.2

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In the study, 253 were randomly assigned to maintenance rituximab (single dose of rituximab 375 mg/m2 every 13 weeks until disease progression) or rituximab retreatment (four weekly doses of rituximab at each disease progression).

The patients completed patient-reported outcome measures at baseline; at 3, 6, 12, 24, 26, and 48 months; and after rituximab failure. Patient-reported outcome measures evaluated illness-related anxiety, coping style, general anxiety, worry and interference with emotional well-being, depression, and health-related quality of life.1

Results showed that illness-related anxiety was similar in both arms at all time points (P>0.05) and regardless of whether patients used active or avoidant coping. In both arms, patients experienced significantly decreased illness-related anxiety and general anxiety over time, but health-related quality of life scores remained mostly stable throughout the study.

In addition, researchers found that patients who used avoidant coping had significantly higher anxiety and decreased health-related quality of life compared with those who used an active coping style (P<0.001).1

Clinicians typically opt to use maintenance treatment strategies in order to delay disease recurrence, thereby potentially decreasing cancer-related symptoms and prolonging survival.

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However, indolent non-Hodgkin lymphoma progression is not typically associated with illness-related symptoms and decreased survival, and yet, rituximab maintenance is widely used for the treatment of patients with indolent non-Hodgkin lymphoma.

The reason for maintenance therapy may be that disease progression would cause more anxiety for patients. This study indicates that that assumption is not the case.1

The findings suggest the relapse is not a cause for increased anxiety as long as the recurrence is quickly addressed with well tolerated therapy like a single dose of rituximab. Therefore, rituximab retreatment can be used in place of rituximab maintenance as it can save resources while achieving comparable clinical and patient-centered outcomes. 

The study also reinforces that patients who use an active coping style have a decreased risk for anxiety, lower health-related quality of life, and illness-related anxiety. Those who use avoidant coping would benefit from cognitive-behavioral interventions in order to reduce anxiety and illness-related distress.1


  1. Wagner LI, Zhao F, Hong F, et al. Anxiety and health-related quality of life among patients with low-tumor burden non-Hodgkin lymphoma randomly assigned to two different rituximab dosing regimens: results from ECOG Trial E4402 (RESORT). J Clin Oncol. January 20, 2015. [Epub ahead of print]
  2. Rituxan (rituximab) [package insert]. South San Francisco, California: Genentech, Inc.