Your treatment options depend on the stage of Non-Hodgkin Lymphoma, your overall health and your preferences about treatment. In all cases, treatment should be individualized for you. Although cancers are classified into particular stages, each person is unique.
You do not have to rush to make a decision, so consider the options carefully. Ask questions if you do not understand any aspect of treatment or the terms your doctors are using. Research shows that cancer survivors of all educational levels and backgrounds can have a hard time communicating with their health care team. One of the best ways to improve communication with your health care team is to prepare your visits so that you can best make use of the time.
A treatment plan is a way to deal with both the short and long term goals of managing your cancer. There are several treatment options for Non-Hodgkin Lymphoma, depending on the cancer stage and the patient’s age and general health. Patients have time for second opinions and to talk through all of their options with their doctors and develop a treatment plan that best fits their needs.
Non-Hodgkin Lymphoma Treatment Options
Bone Marrow or Peripheral Blood Stem Cell Transplantation
Stem cell transplants allow doctors to use higher doses of chemotherapy than would normally be tolerated. High-dose chemotherapy destroys the bone marrow, which prevents new blood cells from being formed. This could lead to life-threatening infections, bleeding, and other problems due to low blood cell counts. Doctors try to prevent this by giving an infusion of blood-forming stem cells after treatment.
Stem cells are very primitive cells that can create new blood cells and are obtained either from the blood (for a Peripheral Blood Stem Cell Transplant, PBSCT) or from the bone marrow (for a Bone Marrow Transplant, BMT.)
Peripheral blood stem cells are obtained from a procedure similar to a blood donation, while bone marrow donation is usually done in an operating room under general anesthesia.
There are two main types of stem cell transplants which differ with regard to the source of the blood-forming stem cells.
Allogeneic Stem Cell Transplant
- In this transplant the stem cells come from someone else. The donor's tissue type (also known as the HLA type) should be almost identical to the patient's tissue type to help prevent the risk of problems with the transplant. Usually the donor is a sibling if they have the same tissue type as the patient. If there are no siblings with a good match, the cells may come from an HLA-matched, unrelated donor.
These stem cells are from one of three sources:
- The stem cells are collected from the donor during several bone marrow aspirations.
Peripheral (circulating) Blood
- The stems cells are taken from the blood during apheresis, a procedure similar to donating blood, but instead of being collected in a bag, the blood goes into a special machine that filters out the stem cells and returns the other parts of the blood to the person's body.
Umbilical Cord Blood
- These stem cells are collected from the umbilical cord attached to the placenta after a baby is born and the umbilical cord is cut. The blood is then frozen and stored until it is needed by someone with the same tissue type.
Allogeneic transplants have limited usefulness in treating lymphoma because it is often hard to find a matched donor. Another drawback is that side effects of this treatment are often too severe for most people over 55 years old.
Autologous Stem Cell Transplant
- In this type of transplant, a patient's own stem cells are removed from his or her bone marrow or peripheral blood and collected on several occasions in the weeks before treatment. The cells are frozen and stored while the person gets treatment (high-dose chemotherapy and/or radiation) they are then are reinfused into the patient's blood.
Some types of lymphoma tend to spread to the bone marrow or blood, so an autologous transplant may not be possible. Even after purging (treating the stem cells in the lab to kill or remove lymphoma cells), it's possible to return some lymphoma cells with the stem cell transplant.
The Transplant Procedure
The patient getting the stem cell transplant may be admitted to the bone marrow transplant (BMT) unit of the hospital or receive treatment as an outpatient depending on a number of factors.
If treated as an inpatient, the patient is usually admitted to the hospital on the day before chemotherapy begins and will usually stay in the hospital until after the chemotherapy and the stem cells have been given, and until the stem cells have started making new blood cells again.
Treatment starts with high-dose chemotherapy and may include high-dose whole body radiation. The chemotherapy and radiation treatments are meant to destroy any remaining cancer cells. Normal cells of the bone marrow and the immune system are also affected. This prevents the stem cell transplant (graft) from being rejected by the body. Once treatment is complete, the stem cells (autologous or allogeneic) are given through a vein, just like a blood transfusion. The stem cells migrate to the bone marrow.
In an allogeneic SCT, the person getting the transplant may be given drugs to keep the new immune system from attacking the body (known as Graft-Versus-Host Disease - please see below.)
For the next several weeks the patient is given as much supportive therapy as needed. This may include antibiotics, red blood cell or platelet transfusions, other medicines, and help with nutrition.
Within weeks after the stem cells have been infused, they normally begin to make new white blood cells, followed by platelet production and, then, several weeks later, by new red blood cell production. Because of the high risk of serious infections right after treatment, patients remain in protective isolation until a measure of their white blood cells rises above 500. They can usually leave the hospital when their ANC nears 1,000.
Patients then typically make regular visits to the outpatient transplant clinic for about 6 months, after which time their care is continued by their regular doctors.
Graft-Versus-Host Disease (GVHD),
is the main problem of a donor stem cell transplant. This occurs when the immune system of the patient is taken over by that of the donor. The donor immune system then starts to attack the patient's other tissues and organs.
Symptoms of GVHD can include severe skin rashes with itching and severe diarrhea. The patient may also become tired and have muscular aches. The disease can be fatal.
Drugs that weaken the immune system may be given to try to control it. And, this disease also causes any remaining lymphoma cells to be killed by the donor immune system. Mild graft-versus-host disease can be a good thing.
Biological or Immunotherapy
Biotherapy (biological therapy or targeted therapy) is a cancer treatment that restores or boosts the body’s own immune system to stop or slow the growth of cancer cells and keep cancer from spreading. Some biotherapies interfere with the tumor’s ability to grow its own blood supply; others interrupt the signaling system within the cancer cell to prevent it from growing and dividing.
Monoclonal antibodies, cancer vaccines, and growth factors are all types of biotherapy. Monoclonal antibodies target and destroy a specific characteristic or process of the cancer cell. Unlike chemotherapy, monoclonal antibodies target only cancer cells, so healthy cells are not damaged and patients may experience fewer side effects. Vaccines help the body fight to keep cancer from coming back. Growth factors control side effects by helping the body manufacture blood cells.
Biotherapy is given in the same way that chemotherapy is given: by mouth, through a vein or as an injection. Biotherapy is often given in combination with chemotherapy; you will want to ask specifically what side effects to expect if you receive a combination of these two treatments.
Although biotherapy does not attack healthy cells, it still may have side effects. Some of the more common side effects are skin rashes and a reaction that feels like the flu – fever, chills and body aches.
Biotherapy is currently the most active area of cancer treatment research. You may want to ask your oncologist if a new biotherapy treatment is available for your type of cancer or if a clinical trial with a biotherapy agent is appropriate for your care.
Chemotherapy is the use of drugs to destroy cancer cells. More than half of all people treated for cancer receive chemotherapy and many different types are available. Each patient has a unique response to chemotherapy.
Chemotherapy is a systemic treatment. This means that it can destroy cancer cells almost anywhere in your body. It is most effective against rapidly dividing cells, like cancer. However, healthy, normal cells can also be damaged by chemotherapy.
Radiation therapy (or radiotherapy) is the use of high-energy rays (ionizing radiation) to kill cancer cells. Radiation works by damaging the genetic material in cells. After radiation treatment ends, cancer cells will keep dying for days or even months.
For some people with cancer, radiation therapy is the only treatment needed. For others, radiation is given before, during or after chemotherapy, biotherapy or surgery. The goal of radiation is to damage as many cancer cells as possible without harming healthy tissue. To minimize damage to healthy cells, radiation doses are calculated very precisely. Treatment areas are carefully defined and treatment is spread-out over time.
Social networking and online support groups are important tools. Reaching out to others who have or have had similar experiences can provide you with valuable insights. Check out Cancer Support Community's The Living Room
for more information on clinically facilitated support online.