Survivorship Care: Managing Long-Term Side Effects of Lymphoma Treatment

San Francisco, CA—With 5-year survival rates for Hodgkin lymphoma 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 has ended remains a challenge. Data presented at the 2017 NCCN Hematologic Malignancies Congress reveal that treatment-related side effects cause long-term metabolic, endocrine, physical, and mental alterations that impair functional capacity.

These conditions must be monitored by providers in survivors, according to Sharyn L. Kurtz, PA-C, MPAS, MA, of Dana-Farber Cancer Institute, Boston, MA, who is also associated with the Lymphoma Survivorship Clinic at Memorial Sloan Kettering Cancer Center (MSKCC).

“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 Ms Kurtz. “Patients are often told that they should feel victorious and physically strong after treatment, but in reality, many feel anything but.”

Although the surveillance of lymphoma recurrence using imaging studies is not indicated after 24 months posttreatment, surveillance for treatment-related side effects is an integral part of survivorship care, Ms Kurtz said. She discussed the long-term side effects associated with treatments for Hodgkin lymphoma and NHL.

Posttreatment Side Effects

Cognitive dysfunction
Treatment with chemotherapy, radiation of the brain or skull, and preexisting cognitive dysfunction are all risk factors for posttreatment cognitive dysfunction. Neurocognitive testing administered by neuropsychology departments is recommended to identify cognitive deficits in lymphoma survivors.

Thyroid complications
Curative treatments for lymphoma can put patients at risk for hypothyroidism and thyroid nodules. The recommended interventions for these complications include thyroid monitoring and thyroid replacement therapy. Thyroid examination and thyroid-stimulating hormone are recommended for patients who received radiation therapy. A thyroid ultrasound should be administered to patients with palpable thyroid nodules. Referral to an endocrinologist may also be appropriate.

Cardiac events
Many cardiac complications are associated with lymphoma treatment, including cardiomyopathy (congestive heart failure), coronary artery disease, arrhythmia, pericardial or valvular damage, and noncoronary vascular disease. Risk factors for cardiac complications include a cumulative anthracycline dose of at least 250 mg/m2; mantle, mediastinal, and neck radiation therapy; and the use of concomitant therapies. An echocardiogram is recommended 2 years after treatment has ended and every 1 to 2 years thereafter. Ms Kurtz also recommended obtaining an annual lipid panel, in addition to patient education regarding the modification of cardiac risk factors (eg, hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking). Patients aged >60 years and those with compromised cardiac function before or during treatment have an increased risk for cardiac complications.

Pulmonary abnormalities
Potential pulmonary complications include pulmonary fibrosis, obstructive lung disease, radiation pneumonitis, and bleomycin toxicity. A baseline pulmonary function test for survivors is recommended for patients who received bleomycin. A referral to a pulmonary specialist may be indicated based on the pulmonary abnormalities.

Bone-related symptoms
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. A bone density evaluation should be performed to assess the integrity of a patient’s bones. Providers should also consider recommending bisphosphonates, calcium and/or vitamin D replacement, weight-bearing exercise, and smoking cessation. Annual complete blood count monitoring is recommended for patients with myelodysplastic syndromes or leukemia.

Fatigue is a common and persistent symptom in survivors of Hodgkin lymphoma or NHL and is strongly associated with depression and anxiety. Interventions include exercise, sleep hygiene, and screening for depression and anxiety.

Screening for Secondary Cancer

Secondary malignancies can occur as a result of treatment for Hodgkin lymphoma and NHL. Radiation therapy, especially mantle-field radiation, confers risk for secondary breast cancer, and patients receiving radiotherapy at a young age are at an increased risk for breast cancer, said Ms Kurtz. The recommended intervention for breast cancer is annual breast cancer screening (8-10 years after the completion of mantle-field radiation therapy or after age 40 years). Semiannual breast cancer screening is recommended for patients younger than age 30 years at the time of mantle-field radiotherapy.

In addition, smokers and patients who received radiation therapy (>30 Gy) or alkylating agent–based chemotherapy are at a significant risk for lung cancer. Smoking cessation should be discussed and encouraged at each physician visit, in addition to low-dose computed tomography lung screening, advised Ms Kurtz.

Depending on the radiation sites, patients are also at risk for esophageal dysmotility or strictures and gastrointestinal (GI) cancers (eg, esophagus, stomach, colorectal, pancreas, and liver). Procarbazine chemotherapy can also contribute to gastric cancer, reported Ms Kurtz. Interventions to detect GI cancers include esophagogastroduodenoscopy and/or colonoscopy.

Maintaining Good Health

To promote survivors’ health, Ms Kurtz suggested up to 150 minutes of moderate-intensity cardiac exercise or 75 minutes of high-intensity cardiac exercise weekly. The literature indicates that it is important to maintain regular exercise and optimal body mass index.

In addition, Ms Kurtz recommends annual cholesterol screening, dietary counseling, and annual influenza vaccinations.

Finally, supporting the emotional health of survivors is an important component of posttreatment care, said Ms Kurtz. At the Lymphoma Survivorship Clinic at MSKCC, psychosocial assessments are used to screen for depression; if the results are positive, social work and/or psychiatric referral may be needed.

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