Non-Hodgkin lymphomas: Treatments
The treatment of non-Hodgkin lymphoma has been the subject of very significant progress in the last two decades. More efficient and better tolerated, they can now cure a large number of cases, including half of the aggressive lymphomas. Indolent lymphomas are highly susceptible to chemotherapy, but relapses are observed.
Therapeutic strategies differ depending on whether it is indolent or aggressive lymphoma.
Aggressive forms are treated as soon as they are diagnosed by chemotherapy, most often associated with immunotherapy. We're talking about Immunochimiothérapie. For indolent lymphomas without clinical manifestation and little spread, the start-up of the treatment can be deferred. For other non-Hodgkin indolent lymphomas, first-line treatment is a immunochimiothérapie. Radiation therapy is also prescribed. Finally, in some relapse situations, a bone marrow stem cell transplant is required. In the course of treatment, the responses to the therapy are evaluated by PET imaging and by blood tests (dosage of LDH) which allows to adapt the patient's management.
Setting up the treatment
The choice of treatment is made during a multidisciplinary consultation meeting (RCP). Several professionals – Medical specialists (radiologist, Hematologist, Radiotherapist...), nurse, psychologist... – are gathered to study the patient's file. Different criteria guide the choice of treatment: the type and stage of lymphoma, the number of organs affected (we talk about the number of extra-ganglion locations), the pretherapeutic balance sheet and certain characteristics of the patient. These, such as age, general condition or the LDH rate, are prognostic factors. For example, a high rate of the initial LDH enzyme is less good prognosis than a low rate. The dosage of this enzyme also helps to monitor the evolution of lymphoma and the response to treatment. Doctors also take into account the ongoing clinical trials for which the patient may be eligible.
Chemotherapy
The principle
Hematologist generally chooses a combination of three or four medications: some directly destroy tumor cells and others prevent their proliferation. We're talking about polychemotherapy. These medications are administered according to a precise chronology, and usually by infusion. To avoid too many punctures in the veins, a catheter can be put in place, usually at the collarbone level. In general, the treatment is punctuated by resting phases. We are talking about cycles of chemotherapy, the number of which is determined by the doctor. In total, chemotherapy treatment lasts between three and six months.
Side effects
Chemotherapy-induced side effects depend directly on the nature of the drug being used. The treatment of non-Hodgkin lymphomas often causes severe nausea. The other frequently encountered effects are diarrhea, vomiting, hair loss, a higher risk of infections related to lower levels of certain blood cells... In most cases, treatment is proposed to eliminate or reduce these events. As chemotherapy destroys blood cells and can cause anemia, the doctor may decide to prescribe growth factors that stimulate the manufacture of these cells. Sometimes the patient receives a transfusion of red blood cell concentrates and platelets.
Immunotherapy
The principle
Since 2000, physicians have laboratory-produced monoclonal antibodies that form the basis of immunotherapy. Its principle: to help the patient's immune system to fight against cancer cells. Since the immune cells of the patient do not produce effective antibodies against lymphoma cells, antibodies are brought directly by intravenous injections. These are attached to the lymphoma cells, attracting the immune cells that destroy the sick cell. Several injections (between four and eight) are performed at intervals of one to several weeks. The doctors realized that antibody injections improved the results of chemotherapy without increasing the adverse effects. This explains why the association of immunotherapy and chemotherapy has become the reference treatment for the vast majority of non-Hodgkin lymphomas.
This therapeutic tool, which has improved patient healing, is still being researched and many antibodies are in the clinical trial phase.
Side effects
At the onset of immunotherapy, the patient may show signs such as fever, nausea or headache. The doctors then offer medicines to improve these events. Few patients have an allergy, but this risk needs to be monitored because it is a more serious side effect. Treatment with immunotherapy is not interrupted but anti-allergic medications are prescribed.
Radiation therapy
The principle
Radiation therapy consists of the administration of high energy rays at the level of the lymph nodes or tissue to destroy the cancer cells. Used for well-localized lymphoma forms or some specific forms, it can complement chemotherapy or be prescribed alone. However, physicians have less recourse than before, in the Immunochimiothérapie's progress.
Side effects
These are the usual adverse effects of radiation therapy (nausea, vomiting, fatigue, skin rash,...) that depend on the region of the organism being treated. Advice on diet, body care and drug delivery helps prevent and/or alleviate these side effects effectively.
Bone marrow stem cell transplant
Sometimes the disease reappears after treatment. It is a relapse, or recurrence, which results in a recurrence of symptoms and biological signs.
The hematologist can then decide to use high-dose chemotherapy – an intensification of treatment – which has heavy consequences for bone marrow. But it contains stem cells that give birth to the different cells of the blood: white blood cells or lymphocytes, which fight against the infections, the red blood cells that ensure the oxygenation of the cells, as well as the platelets that Allow good coagulation.
To reduce the risk of complications associated with the decrease in the number of blood cells, it is sometimes necessary to regenerate the bone marrow by using a stem cell transplant. They may be those of the patient, taken before chemotherapy, or those of a compatible donor. Present in the bloodstream, they are collected by cytaphérèse, a technique that allows to separate the different blood cells. For a few hours, the patient or the donor, lying or sitting, is connected to a machine that collects blood and reinjects it unloaded from its stem cells which are then frozen. Once the treatment is completed they are injected to the patient.
Support Care
In addition to the hematologist and the team that directly supports the patient, professionals can provide additional care called also support care. Pain management, psychological support, etc., can be provided by doctors, psychologists and social workers. These professionals can be seen in the hospital, at home (during a home hospitalization) or in a city consultation (as part of a health network or a patient association).
Therapeutic forbearance
Most of the time, the diagnosis of non-Hodgkin's lymphoma is followed by the setting up of a treatment. However, in some specific cases of asymptomatic and low-spread indolent lymphomas, physicians prefer to take another step: therapeutic forbearance. This does not mean that the patient is neglected. On the contrary, he must take regular visits to his Onco-hematologist, which monitors the evolution of the disease through clinical, blood and imaging tests. The objective of therapeutic forbearance is to defer treatment until it is profitable and avoid side effects.
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