What is the best current treatment for non-hodgkins lymphoma?

Answer 1

Although non-Hodgkin’s lymphoma is a serious disease, it can be treated and, in some cases, cured. Care should be provided by a team of health care professionals who are experienced in treating non-Hodgkin’s lymphoma. This team may include a surgeon, medical oncologist, radiation oncologist, pathologist, oncology nurse, radiologist, and social worker often along with your primary care doctor.

The treatment options depend on the type of lymphoma and its stage, as well as the prognostic index. Of course, no 2 patients are exactly alike, and standard treatment options are often tailored to each patient’s unique situation.

It is important to know and understand all treatment options. It is often a good idea to seek a second opinion. This can give you more information and help you feel more confident about the treatment plan that is chosen.

Surgery
Surgery is often used to get a tissue sample to diagnose and classify lymphoma, but it is very rarely used as treatment because lymphoma is considered a systemic disease, involving the lymphatic system that circulates lymphatic fluid throughout the body. However, surgery is sometimes used to treat lymphomas that start in certain extranodal organs, such as the thyroid or stomach, and have not spread beyond these organs.

Radiation Therapy
Radiation therapy uses high-energy rays to kill cancer cells. Radiation focused on a cancer from a source outside the body is called external beam radiation. This is the type of radiation therapy most often used to treat non-Hodgkin’s lymphoma. Radiation might be used as the main (primary) treatment of early (stage I or II) non-Hodgkin’s lymphomas. More often, it is used along with chemotherapy. Radiation therapy can also be used to ease (palliate) symptoms caused by lymphoma when it affects internal organs, such as the brain or spinal cord, or causes pain by pressing on nerves.

Side effects of radiation therapy may include mild skin problems or fatigue. Radiation of the abdomen may cause upset stomach and diarrhea. These usually go away after radiation is finished. Chest radiation therapy may damage the lungs and lead to trouble breathing. Side effects of brain radiation therapy usually become most serious 1 or 2 years after treatment and may include headaches and difficulty thinking. Radiation may also make the side effects of chemotherapy worse.

Chemotherapy
Chemotherapy uses drugs that are injected into a vein or a muscle or taken by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment very useful for lymphoma. Depending on the type and the stage of the lymphoma, chemotherapy may be used alone or in combination with radiation therapy. In some cases, chemotherapy is given by injection into the spinal fluid (intrathecal injection) to kill lymphoma cells on the surface of the brain and spinal cord.

Many drugs are useful in the treatment of patients with lymphoma. Usually, several drugs are combined. (See Table 2 for examples of combination chemotherapy treatments for lymphoma.) The treatments all have different schedules, but they are usually repeated several times in cycles given 3 or 4 weeks apart. Sometimes a patient may take one chemotherapy combination for several cycles and later switch to a different one if the first combination does not seem to
Chemotherapy drugs kill lymphoma cells, but they can also damage normal cells. For this reason, some side effects occur. These depend on the type of drugs, the amount taken, and the length of treatment. Temporary side effects might include nausea and vomiting, loss of appetite, loss of hair, and mouth sores. Because chemotherapy can damage the blood-producing cells of the bone marrow, patients may have low blood cell counts. This can result in an increased chance of infection (due to low white blood cells), easy bleeding or bruising after minor cuts or injuries (due to low platelet counts), and fatigue (due to low red blood cell counts). There are often ways to lessen these side effects. For example, antinausea drugs can be given to prevent or reduce nausea and vomiting. Drugs known as growth factors (G-CSF or GM-CSF, for example) are sometimes given to keep the white blood cell counts higher and thus reduce the chance of infection. Another type of growth factor, erythropoietin, helps prevent anemia (too few red blood cells).

If a patient’s white blood cell counts are very low, the risk of infection can be reduced by:

avoiding exposure to people with known or suspected bacteria, fungi, or virus infections
paying special attention to washing hands
wearing a surgical mask or having visitors wear a mask, a gown, and surgical gloves
not eating fresh, uncooked fruit and other foods that might carry germs
avoiding contact with children because they are more likely than adults to carry infections
Another way to protect patients with low white blood cell counts against infection is treatment with powerful antibiotics. These may be given before signs of infection appear but most often are given at the earliest sign of an infection, such as fever. If platelet counts are very low, the patient may receive platelet transfusions to protect against bleeding. Likewise, fatigue caused by very low red blood cell counts is treated with red blood cell transfusions. White blood cell transfusions are not useful because these cells exist in such low numbers in the donor blood.

Tumor lysis syndrome is a side effect of the rapid breakdown of cells during very effective chemotherapy for some bulky (large) lymphomas. When the lymphoma cells are destroyed, they release normal cellular components in large amounts into the bloodstream, which may damage, in particular, the kidneys and heart. This condition can be prevented by giving extra fluids and certain drugs, such as sodium bicarbonate, allopurinol, or rasburicase, which help the body get rid of these substances.

Organs that could be directly damaged by chemotherapy drugs include the kidneys, liver, testes, ovaries, brain, heart, and lungs. Some effects occur during and shortly after treatment while others may not occur until much later. While being treated, patients are watched closely so serious side effects are avoided. If serious side effects occur, the chemotherapy may have to be reduced or stopped, at least for a short time. Careful monitoring and adjustment of drug doses are important to avoid long-term side effects to organs. One of the most serious late complications of successful chemotherapy is the possibility of developing leukemia. This affects a small percentage of lymphoma patients.

Patients who are to receive chemotherapy may be concerned about the effects of the treatment on their ability to have children. The doctor and patients should discuss fertility before treatment begins. Questions that might be asked include:

Will this treatment have any short- or long-term effect on my reproductive system? If so, what is the effect and how long will it last?

Is infertility a possible side effect of treatment (including ovarian failure)?
Is there anything that can be done to prevent infertility before treatment?
Do any of the fertility preservation options interfere with my cancer treatment?
If I become infertile, what are my options for having a family?
Can you refer me to a fertility specialist?
Once I finish treatment, how will I know if I am infertile?
How long is it safe to wait to pursue fertility options before beginning treatment for my cancer?
Is my infertility short term or permanent?
Immunotherapy
Immunotherapies use natural substances produced by the immune system. These substances may kill lymphoma cells, slow their growth, or activate the patient’s immune system to fight the lymphoma more effectively.

Interferon: Interferon is a hormone-like protein naturally produced by white blood cells to help the immune system fight infections. Some studies have suggested that interferon can cause some types of non-Hodgkin’s lymphomas to shrink or delay disease progression. Side effects of this treatment include moderate to severe fatigue, fever, chills, headaches, muscle and joint aches, and mood changes.

Monoclonal antibodies: Antibodies are normally produced by the immune system to help fight infections. Similar antibodies called monoclonal antibodies can be made in the laboratory. Instead of attacking germs as usual antibodies do, some monoclonal antibodies can be designed to attack lymphoma cells. One product is called rituximab. Rituximab recognizes and attaches to a substance called CD20 that is found on the surface of some types of lymphoma cells. This attachment kills the lymphoma cell. Patients usually receive 4 intravenous infusions over a period of about 3 weeks. Common side effects are usually minor and limited to the time of infusion, and may include chills, fever, nausea, rashes, fatigue, and headaches.

Another man-made molecule approved by the FDA is called denileukin diftitox. It is used to treat T-cell skin lymphomas. It is made by combining interleukin-2 (a protein that attaches to some kinds of lymphocytes) and diphtheria toxin, which kills cells.

Alemtuzumab is an antibody that is useful in chronic lymphocytic leukemia (CLL) and even T-cell leukemias of the skin.

Other new monoclonal antibodies are being studied in clinical trials.

Radioimmunotherapy: Newer forms of monoclonal antibodies similar to rituximab but with radioactive molecules attached to them have also been developed for use in lymphomas. The first to be approved by the FDA was ibritumomab tiuxetan, which is an antibody that has radioactive yttrium attached to it. It is used in patients with low grade or follicular lymphoma that has returned after treatment, and is also being studied in other types of lymphoma. The second drug approved was tositumomab, which is an antibody with radioactive iodine attached. It is also used against low grade or follicular lymphoma after initial treatments no longer work. Both these drugs are being used for lymphomas that do not respond to other treatments. Their one disadvantage is they cannot be used along with chemotherapy because they lower blood counts.

Stem Cell Transplantation
Stem cell transplants are used to treat lymphoma patients when standard treatment does not work. Although only a small number of patients with NHL receive this treatment, this number is growing. Blood-forming stem cells are the earliest form of bone marrow cells. They can develop into normal blood cells such as red blood cells, white blood cells, and platelets. They are given to patients after they have had high-dose chemotherapy to replenish the bone marrow.

Stem cells can be taken from several bone marrow aspirates, or they can be separated from the circulating (peripheral) blood by a method known as apheresis. Recent studies have shown that there may be an advantage to using stem cells obtained by apheresis instead of bone marrow aspiration. This has become the usual way that doctors get stem cells.

The 2 main kinds of stem cell transplants are allogeneic and autologous. In an allogeneic stem cell transplant, the stem cells come from a donor whose cells are almost identical with those of the patient. The donor is often a brother or sister, or it can be a matched unrelated donor. Allogeneic transplantation is limited, however, because of the need for a matched donor. Also, the side effects of this treatment are too severe for most people over 55 to 60 years old.

In an autologous stem cell transplant, a patient’s own stem cells are removed from his or her bone marrow or bloodstream. With some types of lymphoma that tend to spread to the bone marrow or blood, it may be hard to collect stem cells alone without the presence of lymphoma cells. Even after treating the stem cells in the lab to kill or remove lymphoma cells (purging), some remaining lymphoma cells may be returned with the stem cell transplantation.

Stem cells collected from a donor or the patient are frozen and stored. The patient then receives high-dose chemotherapy, and sometimes whole body radiation treatment as well. This destroys remaining cancer cells, but it also kills all or most normal cells in the bone marrow. After treatment, the frozen stem cells are thawed and returned to the body through an intravenous infusion. They then make their way through the blood system to the bone marrow where they grow and divide to become the patient’s new blood-forming system.

A blood stem cell transplant is a complex treatment that can be life-threatening. If the doctors think the patient may benefit from a transplant, the best place to have it done is at a nationally recognized cancer center where the staff has experience with the procedure and with managing the recovery period. Patients should not hesitate to ask the doctor about the number of times he or she has done this procedure and their results with cases such as theirs. Experience and knowledge are key factors in providing the best care.

A stem cell transplant is very expensive and can require a lengthy hospital stay. Side effects from a stem cell transplant are generally divided into early and long-term effects. The early complications and side effects are basically the same as those caused by any other type of high-dose chemotherapy. They are caused by damage to the bone marrow and other rapidly growing tissues of the body.

Complications and side effects that can last for a long time or not occur until years after the transplant include:

radiation damage to the lungs, causing shortness of breath
graft-versus-host disease, which occurs only in allogeneic (donor) transplants
damage to the ovaries that can cause infertility and loss of menstrual periods
damage to the thyroid gland that can cause problems with metabolism
cataracts (damage to the lens of the eye that can affect vision)
bone damage called aseptic necrosis. If damage is severe, the patient will need to have part of the affected bone and the joint replaced.
development of new cancers, mainly leukemia several years later.
infertility in male patients and early menopause in female patients.
Nonmyeloablative transplants: This is a special kind of transplant that takes advantage of the donor cells’ immune response to kill the lymphoma. Only low doses of chemotherapy (usually a drug called fludarabine, which lowers a patient’s immunity) are given. Then stem cells from a matched donor are given. Over time the donor cells take over the bone marrow and develop an immune response to the lymphoma cells and destroy them. The problem with this procedure is the graft-versus-host disease, which harms the patient. Researchers are looking for ways to stop the graft-versus-host response while keeping the graft-versus-lymphoma effect.

Supportive Care
Most of this document discusses ways to cure people with non-Hodgkin’s lymphoma or to help them live longer. However, another important goal is to help you feel as well as you can and continue to do the things in life that you want to do. Don’t hesitate to discuss your symptoms or how you are feeling with your cancer care team. There are effective and safe ways to treat symptoms you may be having, as well as most of the side effects caused by treatment for non-Hodgkin’s lymphoma.

Pain is a concern for patients with advanced cancer. Growth of the cancer around certain nerves may cause severe pain. It is important that you tell your doctors if you are having pain. For most patients, treatment with morphine or other so-called opioids (medicines related to opium) will reduce the pain considerably. For more information on the treatment of cancer pain, go to our our online Cancer Pain guideline or contact the ACS or NCCN to request a copy of the Cancer Pain Treatment Guidelines for Patients.

Complementary and Alternative Therapies
If you are considering any alternative or complementary treatments, please discuss this openly with your cancer care team and request information from the ACS or the National Cancer Institute. Some alternative treatments can cause serious side effects.



Other Things to Consider During and After Treatment
During and after treatment, you may be able to hasten your recovery and improve your quality of life by taking an active role. Learn about the benefits and disadvantages of each of your treatment options, and ask questions if there is anything you do not understand. Learn about and look out for side effects of treatment, and report these promptly to your cancer care team so that they can take steps to reduce them or make them go away.

Remember that your body is as unique as your personality and your fingerprints. Although understanding your cancer’s stage and learning about your treatment options can help predict what health problems you may face, no one can say precisely how you will respond to cancer or its treatment.

You may have special strengths such as a history of excellent nutrition and physical activity, a strong family support system, or a deep faith, and these strengths may make a difference in how you respond to cancer. There are also experienced professionals in mental health services, social work services, and pastoral services who may assist you in coping with your illness.

You can also help in your own recovery from cancer by making healthy lifestyle choices. If you use tobacco, stop now. Quitting will improve your overall health, and the full return of the sense of smell may help you enjoy a healthy diet during recovery. If you use alcohol, limit how much you drink. Have no more than 1 or 2 drinks per day. Good nutrition can help you get better after treatment. Eat a nutritious diet, with plenty of fruits, vegetables, and whole grain foods. Ask your cancer care team if you could benefit from a special diet. They may have specific advice for people who have had radiation therapy, chemotherapy, or surgery.

If you are being treated for cancer, be aware of the battle that is going on in your body. Radiation therapy and chemotherapy add to the fatigue caused by the disease itself. To help you with the fatigue, plan your daily activities around when you feel your best. Get plenty of sleep at night. Don’t be afraid to ask others for help. And ask your cancer care team about a daily exercise program to help you feel better.

Surgery, radiation therapy, and chemotherapy may sometimes affect your feelings about your body and may lead to specific physical problems that affect sexuality. Your cancer care team can help with these issues, so don’t hesitate to share your concerns.

A cancer diagnosis and its treatment are major life challenges, affecting you and everyone who cares for you. Before you reach the point of feeling overwhelmed, consider attending a meeting of a local support group. If you need assistance in other ways, contact your hospital’s social service department or the American Cancer Society for help in contacting counselors or other services.

Answer 2

In terms of chemo, it would be CHOP plus Rituxan (CHOP-R or R-CHOP). CHOP stands for: Cytoxan (Cyclophosphamide); Hydroxydaunomycin (Adriamycin or Doxorubicin); Oncovin (Vincristine) and Prednisone. Rituxan is a monoclonal antibody that targets only CD20 cells.

Now, there are many kinds of Non-Hodgkins Lymphoma (NHL). The treatment I described is for an aggressive Lymphoma. I had Aggressive Diffuse Large B-Cell NHL. The above was my treatment. I did a LOT of research on it and I realize that what I got was state of the art. It's been 1 1/2 years since my treatment.

However, other types of NHL may require completely different regimens.

I hope this helps. Good Luck.

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