Follicular lymphoma is a common type of blood cancer that has a good outlook. Learn the symptoms, treatment options, and outlook.

Follicular lymphoma is a type of cancer that starts in your white blood cells. It develops when abnormal cells gather together in clumps. These clumps resemble healthy clusters of immune cells within your lymph nodes called “follicles,” which is where it gets its name.

Experts classify follicular lymphoma as a non-Hodgkin’s lymphoma (NHL). NHL is a broad category that includes many different types of lymphomas. However, lymphomas in this category behave differently from Hodgkin’s lymphoma and require different treatment.

Follicular lymphoma tends to grow slowly. Many people with this type of cancer live for a long time with a high quality of life. Symptoms are often mild or nonexistent at diagnosis.

Read on to learn more about the symptoms of follicular lymphoma and what treatment options are available.

Follicular lymphoma facts and stats

Follicular lymphoma is one of the most common types of lymphoma, and it generally has a good outlook. Here are some key statistics:

  • About 2.4 out of 100,000 people per year develop follicular lymphoma in the United States.
  • Follicular lymphoma accounts for up to 30% of all lymphomas in the United States. According to a 2024 article, it is also the second most common type of NHL.
  • Follicular lymphoma rarely affects people under age 20. It is typically diagnosed in people ages 65 to 74.

Not everyone experiences symptoms of follicular lymphoma in its early stages. As a slow-growing cancer, it can take a long time before changes in the body are noticeable. Many people don’t experience discomfort until a swollen lymph node presses on surrounding tissues or cancer has spread to other organ systems.

When early symptoms are present, one of the most common signs is painless swelling in one or more lymph nodes, typically in areas such as the:

  • underarms
  • neck
  • groin
  • abdomen

These swollen nodes may fluctuate in size over time, growing and shrinking over months or even years.

Other symptoms of follicular lymphoma can include:

Researchers don’t know exactly why follicular lymphoma develops. It’s likely that a combination of genetic, environmental, and immunologic factors contribute.

Genetic causes of follicular lymphoma

  • People with a relative who had follicular lymphoma are at a slightly increased risk of developing this type of cancer.
  • About 85% of people with follicular lymphoma have a noninherited genetic abnormality called a translocation.
  • In adults with this abnormality, parts of chromosomes 14 and 18 break off and switch. This leads to an overexpression of the BCL2gene, which tells cells when to die.
  • Some people have the same genetic abnormality but don’t develop follicular lymphoma, suggesting that other factors are also involved.
  • More than 25% of people with follicular lymphoma have a mutation in their EZH2 gene.
  • Children with follicular lymphoma do not have the BCL2 abnormality. Reports indicate that children develop follicular lymphoma due to changes in the MAP2K1 and TNFRSF14 genes.

Environmental causes of follicular lymphoma

Environmental causes are external factors around you that can impact the likelihood of developing a medical condition. Certain environmental factors may increase your chances of developing follicular lymphoma, such as:

  • exposure to chemicals like benzene
  • exposure to pesticides, such as glyphophosphates
  • some infections that may weaken your immune system
  • smoking and exposure to secondhand smoke

To diagnose follicular lymphoma, your doctor will:

  • consider your symptoms
  • look at your medical history
  • perform a physical exam

If they suspect cancer, they may perform the following tests:

  • Lymph node biopsy. A lymph node biopsy involves removing a small portion of tissue from a lymph node, or sometimes an entire lymph node. Medical experts examine the tissue under a microscope to determine if it’s cancerous.
  • Blood test. Blood tests can evaluate the number and appearance of your blood cells.
  • Imaging. Your doctor may suggest you have an imaging test in order to see the lymphoma in your body and plan your treatment. A CT scan, a PET scan, or a PET/CT scan that combines both these methods is commonly used.

Doctors have developed the Follicular Lymphoma International Prognostic Index (FLIPI) to help determine the outlook for this type of cancer. This system helps categorize follicular lymphoma into three categories:

  • low risk
  • intermediate risk
  • high risk

Your risk is calculated based on your “prognostic factor.” These are measurable characteristics about you or your diagnosis that help predict the course and outcome of follicular lymphoma. The FLIPI uses five prognostic factors:

Your doctor combines the results of these variables to determine how aggressive your cancer treatment should be, how much monitoring and testing you’ll need, and what your projected outcome is.

Several treatment options are available for people with follicular lymphoma. Your doctor will decide which therapy is right for you based on your type of cancer and how advanced it is.

Watchful waiting

If you’re diagnosed early and have no or only a few symptoms, your doctor might suggest watchful waiting. This means your healthcare professional will keep a watchful eye on your condition, but you won’t receive any treatment yet.

Watchful waiting, also known as “active surveillance,” is used when side effects from treatments for a condition may be more harmful than the condition at its current stage.

People treated with this strategy have a similar outlook to people who start treatment early.

Radiation

Radiation uses high-energy beams to destroy cancer cells. People with stage 1 or 2 follicular lymphoma may receive this. In some cases, radiation alone may be able to provide long-lasting remission for this type of cancer.

You may need radiation along with other therapies if your cancer is more advanced.

Monoclonal antibodies

Monoclonal antibodies are medications that target specific markers on tumors and help your immune cells fight the cancer.

Rituximab (Rituxan) is a monoclonal antibody commonly used to treat follicular lymphoma. It’s typically given as an intravenous (IV) infusion at your doctor’s office, and it’s often used in combination with chemotherapy to treat late stage follicular lymphoma.

Common combinations include:

  • R-bendamustine (rituximab and bendamustine)
  • R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)
  • R-CVP (rituximab, cyclophosphamide, vincristine, and prednisone)
  • obinutuzumab together with chemotherapy for untreated follicular lymphoma stage 2 or higher

Chemotherapy

Chemotherapy uses drugs to kill cancer cells in your body. Sometimes people with follicular lymphoma receive chemotherapy along with other treatments such as monoclonal antibodies or radiation therapy.

Radioimmunotherapy uses a combination of monoclonal antibodies and radiation to destroy cancer. It’s typically given in NHLs when there is a high chance of recurrence or when cancer doesn’t respond to first-line treatments.

Ibritumomab tiuxetan (Zevalin) is an FDA-approved radioimmunotherapy drug. It’s a combination of a monoclonal antibody and a radioisotope (a radioactive particle). The monoclonal antibody acts like a missile that targets cancer cells. Once attached, the radioisotope damages the cell and triggers its destruction.

Stem cell transplant

A stem cell transplant is sometimes used for follicular lymphoma, especially if your cancer comes back. This procedure involves infusing healthy stem cells into your body to replace diseased bone marrow. It’s generally only an option for adults in good overall health.

There are two kinds of stem cell transplants:

  • Autologous transplant. This procedure uses your stem cells to treat your cancer. This is a potential treatment option for follicular lymphoma.
  • Allogeneic transplant. This procedure uses healthy stem cells from a donor but is not a treatment for follicular lymphoma.

New CAR T-cell treatments

CAR T-cell therapy is one of the newest therapies available for follicular lymphoma. It uses engineered molecules called chimeric antigen receptors (CARs) that recognize and destroy antigens on the surface of lymphoma cells.

Several CAR T-cell therapies have been approved by the Food and Drug Administration (FDA) for the treatment of follicular lymphoma that has returned after two or more first-line therapy treatments.

Follicular lymphoma can develop into a faster-growing form known as diffuse large B-cell lymphoma. Transformed lymphoma is usually more aggressive and may require more rigorous treatment.

The development of abnormal white blood cells can crowd out healthy blood cells. This can lead to lower levels of various types of blood cells that you need to keep you healthy. For instance:

The buildup of abnormal blood cells can also cause your spleen to enlarge. If you have an enlarged spleen, you’ll likely need to avoid contact sports to avoid rupture.

Treatments for follicular lymphoma, such as chemotherapy and radiation therapy, can damage healthy cells and cause many side effects, such as:

After successful treatment, many people with follicular lymphoma go into remission. Complete remission is a period when symptoms and signs of cancer have disappeared. It doesn’t mean cancer is gone, but it indicates effective management. Even though this remission can last for years, follicular lymphoma is considered a lifelong condition.

Recovery can be challenging, but many people are able to maintain a high quality of life. You may feel tired in the months after your treatment, so it’s important to understand that it may take some time to regain your previous activity level.

Your doctor can help you understand what to expect and advise on how to make your recovery as smooth as possible.

Treating follicular lymphoma effectively can take time, and you may need to try different therapies. It can be disheartening to learn that your first round of treatment wasn’t successful, but there are many other treatment options. Your doctor can work with you to develop a new treatment plan.

Treatments for follicular lymphoma aim to control the disease rather than cure it, and many people successfully manage the condition for many years.

According to SEER statistics, the 5-year relative survival rate for people with stage I follicular lymphoma (the earliest stage) is about 97%. This means that, on average, people with stage I follicular lymphoma are 97% as likely to be alive 5 years after their diagnosis as people in the general population who do not have the disease.

The 5-year relative survival rate for those with stage II follicular lymphoma is around 91%. At stage IV, it drops to around 83%.

Survival rates can offer useful information, but they’re only estimations and can’t predict what will happen in your situation.

Talk with a doctor about your specific outlook and which treatment plans are right for you.

Follicular lymphoma is a slow-growing cancer that starts in the white blood cells inside your lymph nodes.

Many people are able to live a long time with follicular lymphoma, and sometimes the only treatment that’s needed is watchful waiting. People with an advanced stage of this cancer may receive immunotherapy drugs called monoclonal antibodies, often with radiation or chemotherapy.

Follicular lymphoma generally has a good outlook because it tends to grow slowly. The survival rate is likely to continue rising as treatment options improve.