Lymphoma Survivorship Care: Getting Back to Life After Treatment

With 5-year survival rates for Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) at 86% and 71%, respectively, the number of lymphoma survivors is on the rise, but achieving long-term quality of life after treatment is completed remains an ongoing challenge. According to data presented at the National Comprehensive Cancer Network 12th Annual Congress: Hematologic Malignancies, treatment-related side effects cause metabolic, endocrine, physical, and mental alterations leading to impaired functional capacity, and all of these possible conditions must be monitored by survivorship care providers.

“Survivors carry many lingering physical and emotional effects and often feel somewhat in a fog about what their life should look like after treatment,” said Sharyn L. Kurtz, PA-C, MPAS, MA, Dana-Farber Cancer Institute. “Patients are often told that they should feel victorious and physically strong after treatment, but in reality, many feel anything but.”

As Dr Kurtz reported, although surveillance of lymphoma recurrence with a CT/PET scan is not indicated 24 months posttreatment, surveillance for treatment-related side effects is an integral part of survivorship care. According to Dr Kurtz, long-term side effects associated with treatments for HL and NHL may involve the following organ systems:

• Cognitive dysfunction: Treatment with chemotherapy, radiation of the brain/skull, and preexisting cognitive dysfunction are all risks for posttreatment cognitive dysfunction. Neurocognitive testing administered by neuropsychology departments is recommended to identify deficits
• Thyroid: Curative treatments for lymphoma can put patients at risk for hypothyroidism and thyroid nodules, and thyroid monitoring and thyroid replacement therapy are recommended interventions. For patients who received radiation therapy, thyroid exam and thyroid-stimulating hormone treatment are suggested, and for patients with a palpable thyroid nodule, a thyroid ultrasound should be administered. Referral to endocrinology may also be appropriate
• Cardiac: There are many possible cardiac complications associated with lymphoma treatment, including cardiomyopathy (congestive heart failure), coronary artery disease, arrhythmia, pericardial/valvular damage, and noncoronary vascular disease. A cumulative anthracycline dose of at least 250 mg/m²; mantle, mediastinal, and neck radiation therapy; and use of concomitant therapies are considered risk factors. An echocardiogram is recommended 2 years after treatment and then every 1 to 2 years. Dr Kurtz also recommended an annual lipid panel along with patient education regarding cardiac risk factor modification (hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking). Patients older than 60 years and those with compromised cardiac function before or during treatment are considered higher risk
• Pulmonary: Possible toxicities include pulmonary fibrosis, obstructive lung disease, radiation pneumonitis, and bleomycin toxicity. A baseline pulmonary function test at the time of entry into the survivorship clinic is recommended for any patient who received bleomycin. Based on abnormalities detected, pulmonary referral may be indicated
• Bone/bone marrow: Steroids place patients at risk for osteopenia and osteoporosis. Radiation therapy, alkylating agents, and the chemotherapy regimen BEACOPP (bleomycin, vincristine, cyclophosphamide, doxorubicin, etoposide, procarbazine, and prednisone) can lead to myelodysplastic syndromes and leukemia. Bone density evaluation should be performed to assess the integrity of a patient’s bones. Providers should also consider bisphosphonates, calcium/vitamin D replacement, weight-bearing exercise, and smoking cessation. For myelodysplastic syndromes/leukemia, annual complete blood count monitoring is recommended
• Fatigue: Fatigue is a frequent and persistent symptom among HL and NHL survivors and is strongly associated with depression/anxiety. Interventions include exercise, sleep hygiene, and depression/anxiety screening

Secondary Cancer Screening

Secondary malignancies can also occur as a result of treatment for HL and NHL. According to Dr Kurtz, radiation therapy, especially mantle field radiation, confers risk for breast cancer, and patients receiving radiotherapy at a younger age are at higher risk. Annual breast screening (8-10 years after completion of mantle radiation therapy or after age 40 years) is the recommended intervention. For patients younger than 30 years at the time of mantle radiotherapy, semiannual screening is recommended.

In addition, the risk of lung cancer is significant for patients who received radiation therapy (more than 30 Gy) or alkylating agent–based chemotherapy and for smokers. Smoking cessation should be discussed and encouraged at each visit along with low-dose lung CT screening, said Dr Kurtz. Depending on radiation sites, patients are also at risk for esophageal dysmotility/strictures and increased gastrointestinal cancers (esophagus, stomach, colorectal, pancreas, and liver). Procarbazine chemotherapy can also contribute to gastric cancer, Dr Kurtz reported. Interventions include esophagogastroduodenoscopy and/or colonoscopy prior to entry into the survivorship clinic.

Health Maintenance

To promote patient health, Dr Kurtz suggested up to 150 minutes per week of moderate cardiac intensity exercise or 75 minutes of high intensity. The literature indicates that regular exercise is important, she said, as is maintaining optimal body mass index. Dr Kurtz also recommended annual cholesterol screening and dietary counseling, as well as annual influenza vaccinations. Finally, said Dr Kurtz, supporting the emotional health of survivors is an important part of posttreatment care. At the Lymphoma Survivorship Clinic at Memorial Sloan Kettering Cancer Center, psychosocial assessments are used to screen for depression. If the results are positive, social work and/or psychiatric referral may be needed.