Non-Hodgkin lymphoma medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sowminya Arikapudi, M.B,B.S. [2]
Overview
The predominant therapy for Non-Hodgkin lymphoma is chemotherapy. Adjunctive radiation, immunotherapy, and stem cell transplantation may be required.
Medical Therapy
- Treatment decisions for Non-Hodgkin lymphoma (NHL) are based on::
- Age
- The type of Non-Hodgkin lymphoma
- The stage of Non-Hodgkin lymphoma
- Growth of the tumor, slow growing (indolent) or fast growing (aggressive)
- Prognostic factors
- Other medical conditions that may interfere with treatment
- Previous treatment
| Stage | Watchful waiting | Chemotherapy | Radiotherapy | Biological therapy | Stem cell transplant |
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| Indolent Lymphoma | |||||
| Limited stage |
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| Advanced stage |
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| Recurrent | --------- |
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| Aggressive Lymphoma | |||||
| Limited stage | ---------- |
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| Advanced stage | ---------- |
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Watchful waiting
- May be a treatment option for some people with slow-growing (indolent) non-Hodgkin lymphoma (NHL) who are otherwise healthy and the lymphoma is not causing symptoms or problems with other organs.
- Means person has regular checkups and follow-up with their doctor during this time
- Treatment is given when the signs and symptoms of the lymphoma appear or change or the lymphoma looks like it is progressing
Chemotherapy
- Chemotherapy may be used:
- As the primary treatment, with or without radiation therapy, to destroy cancer cells
- Alone or along with biological therapy or radiation therapy, depending on the type and stage of Non-Hodgkin lymphoma
- Early stage, slow-growing (indolent) lymphomas may be treated with radiation therapy by itself or with chemotherapy (single drugs or a combination of drugs) or biological therapy, if the person has symptoms
- Fast-growing (aggressive) lymphomas are usually treated immediately with combination chemotherapy and biological therapy (with or without radiation therapy). This treatment offers the best chance of success
- In people with a lymphoma that tends to spread to the brain and spinal cord
- In combination with biological therapy or radiation therapy to treat recurrent or relapsed lymphoma
- To relieve pain or to control the symptoms of advanced Non-Hodgkin lymphoma (palliative chemotherapy)
Radiation therapy
Radiation may be used for Non-hodgkin lymphoma:
- As the main treatment for early stage (stage I or sometimes stage II) indolent Non-Hodgkin lymphoma
- Radiation therapy may be used when Non-Hodgkin lymphoma is in 1 or 2 lymph node areas in the same part of the body
- Early stage Non-Hodgkin lymphoma often responds very well to radiation therapy
- With chemotherapy to destroy lymphoma cells
- Radiation therapy is often given with chemotherapy, either after or along with chemotherapy, to help destroy lymphoma cells and to reduce the risk of the cancer recurring
- Radiation therapy to certain areas is usually combined with chemotherapy to treat aggressive lymphomas or for large tumors
- To relieve pain or to control the symptoms of advanced lymphoma (palliative radiation therapy)
- Radiation can be used to shrink tumors that are pressing on or spreading into other organs or structures
- It can also be used to shrink enlarged lymph nodes and relieve symptoms caused by tumors
External beam radiation therapy
- Radiation therapy treatment is usually given each day for 5 days a week, the dose and schedule for the radiation therapy is determined by:
- The type of Non-Hodgkin lymphoma
- The extent of the disease
- Whether the treatment is being given to cure the lymphoma or relieve symptoms (palliate)
Radiation fields
- Radiation treatments are given to different areas of the body when treating Non-Hodgkin lymphoma. The radiation field is the part of the body that receives the radiation. Some of the fields where radiation is given for treating lymphoma are:
- Involved field – most commonly used
- Radiation is given to only 1 or a few lymph node areas known to contain lymphoma and is used for localized, early stage Non-Hodgkin lymphoma. Involved field radiation therapy is also called IFRT. When radiation is given to a larger area to cover nearby or the next level of lymph node sites, this may be called extended field radiation therapy (EFRT).
- Mantle field
- Radiation is given to the lymph nodes in the neck, chest and underarms
- Upper abdominal field
- Radiation is given to lymph nodes around the heart and aorta (para-aortic area) and possibly the spleen (unless it has been removed)
- Pelvic field
- Radiation is given to lymph nodes in the pelvis and groin
- A large amount of bone marrow is also radiated because the hip bones, which contain the most bone marrow, are in this field
- Inverted (upside down) Y field
- Radiation is given to lymph nodes in the upper abdominal and pelvic fields
Hematopoietic stem cell transplantation
- Stem cell transplants may be considered for people with Non-hodgkin lymphoma in the following cases:
- To treat people with high-grade or aggressive Non-hodgkin lymphoma that has recurred or relapsed, depending on the type of lymphoma
- High-dose chemotherapy and a stem cell transplant may be useful, especially if the lymphoma was sensitive or responded to chemotherapy in the past
- Used in some cases when the person's lymphoma is not responding to other treatments or standard treatment has failed to work (refractory disease)
- Occasionally considered to treat people with Non-Hodgkin lymphoma who are in remission, but have a high risk of the lymphoma recurring
Immunotherapy
Biological therapy (also called immunotherapy) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to lessen the side effects that can be caused by some cancer treatments. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. This approach is under close investigation. Biological therapy is sometimes also called biological response modifier therapy.
- Biological therapy may be used:
- To treat advanced indolent Non-Hodgkin lymphoma or aggressive Non-Hodgkin lymphoma
- To treat recurrent or relapsed Non-Hodgkin lymphoma
- In certain cases when chemotherapy no longer seems to be working
- The most common biological therapy drugs used to treat non-Hodgkin lymphoma are:
- Rituximab
- Ibritumomab
- Alemtuzumab
- Interferon alfa
Measuring response to treatment
After treatment for non-Hodgkin's lymphoma, the response is classified as follows:
- Complete Response (CR). This indicates the disappearance of all detectable disease.
- Partial Response (PR). A reduction in the bulk of disease by at least 50%, but with some remaining disease.
- Stable Disease. Less than a partial remission, but no progression of disease and no new sites of disease.
- Progressive Disease. Growth in bulk of disease by >50%, or the appearance of new sites of disease.
If a complete remission is achieved, the patient is watched closely for any evidence of recurrent disease. Standard guidelines dictate that a patient be monitored for relapse every three months in the first year following a complete remission, every six months in the second year, and finally once annually in the third and later years. Diffuse large b-cell lymphoma is the most common type of lymphoma that is considered curable. Currently, if a patient maintains a complete remission for 3 years, the patient is considered cured. Generally most relapses of diffuse large b-cell lymphoma occur within the first year after a complete remission is obtained. Reoccurences after 3 years are rare but they do occur. The effect of Rituximab on relapse rates for diffuse large b-cell lymphoma is still largely unknown, though initial relapse rates since 2003 have been much lower than expected.
Patients with follicular lymphoma are generally not considered cured. Instead, they are categorized as in ongoing complete remission. Relapses occur steadily over time. Relapse rates are estimated to be 33%, 66%, and 100% for follicular lymphoma's Grades I, II, and III respectively.
Research has indicated that relapse rates can be lowered on patients with follicular lymphoma by giving supplemental radiation therapy, however, it is known that this additional therapy increases the chances of a second malignancy of unknown type later in life.
If the response to treatment falls short of a complete response, more treatment may be administered (using a differentchemotherapy regimen), or watchful waiting may be utilized, depending on the goals of treatment.
Nutrition during treatment
Eating well during cancer treatment means getting enough food energy and protein to help prevent weight loss and regain strength. Good nutrition often helps people feel better and have more energy.
Some people with cancer find it hard to eat a balanced diet because they may lose their appetite. In addition, common side effects of treatment, such as nausea, vomiting, or mouth sores, can make eating difficult. Often, foods may taste or smell different. Also, people being treated for cancer may not feel like eating when they are uncomfortable or tired.
Doctors, nurses, and dietitians can offer advice on how to get enough food energy and protein during cancer treatment. Patients and their families also may want to read the National Cancer Institute (USA) booklet Eating Hints for Cancer Patients, which contains many useful suggestions.[1]
Followup care
People who have had non-Hodgkin's lymphoma should have regular followup examinations after their treatment is over. Followup care is an important part of the overall treatment plan, and people should not hesitate to discuss it with their health care provider. Regular followup care ensures that patients are carefully monitored, any changes in health are discussed, and new or recurrent cancer can be detected and treated as soon as possible. Between followup appointments, people who have had Non Hodgkin's lymphoma should report any health problems as soon as they appear.
References
- ↑ "Eating Hints for Cancer Patients: Before, During, and After Treatment". National Cancer Institute. Retrieved 2007-07-15.