What is the best initial therapy for a patient with symptomatic low-grade follicular lymphoma?

Follicular lymphoma is a diverse disease, both biologically and clinically. Patients may present with symptomatic or asymptomatic disease and with high or low tumor burden. Decisions to treat in the frontline are made based on histology, presence or absence of symptoms, disease burden, comorbidities, patient age, and patient preferences. As most patients with follicular lymphoma will eventually have a relapse, preservation of downstream treatment options also warrants consideration. One must be cognizant of toxicities and how these toxicities may influence later treatments. Given the number of variables, the decision making is often complex, and a certain amount of individualization is required. The goals of this review were to provide a framework for decision making and review the literature supporting the various options.