Follicular lymphoma (FL) is the second most common subtype of non- Hodgkins lymphoma (NHL), with an estimated 14000 cases diagnosed each year in the United States. Considered an indolent NHL, 10-year overall survival ranges from 36-71% depending on associated risk factors. The Follicular Lymphoma International Prognostic Index (FLIPI) was developed in 2004 as a prognostic tool to standardize treatment approaches and interpretation of clinical trials, although its application has been limited due to variations in practice patterns. Friedberg et al established the National LymphoCare study (NLCS) and prospectively collected data on 2728 patients with newly-diagnosed FL seen and treated at 265 different treatment centers in the United States from 2004-2007. Median age was 61 years; 43% had grade 1 histology, and 66% had Stage III-IV disease. Initial management was: observation, 17.7%; radiotherapy alone, 5.5%; rituximab alone, 13.9%; chemotherapy plus rituximab, 51.9%. Only 6.1% were treated on clinical trials. Among patients with Stage I disease, only 23.4% received radiotherapy, despite recommendations from the National Comprehensive Cancer Network and the European Society for Medical Oncology recommending primary radiotherapy for limited stage FL. Management approaches differed geographically and also for academic vs community treatment centers. FLIPI risk groups were distributed equally, although FLIPI could not be calculated in 18% of patients due to missing information. The lack of uniformity in management, the absence of adequate prognostic information (for FLIPI determination) in nearly one-fifth of cases, and the miniscule proportion of FL patients on clinical trials, illustrate the need for a consensus regarding management of FL. - Alfred Ian Lee, M.D, Ph.D., and Ann S. LaCasce, M.D.