According to Surveillance, Epidemiology, and End Results (SEER) data, patients with Hodgkin lymphoma and non-Hodgkin lymphoma (NHL) have 5-year survival rates of 86% and 71%, respectively.1 Although the increased number of survivors is welcome proof of the success of new treatment regimens, it also creates challenges for providers who must continue to manage the lasting side effects of chemotherapy, radiation, and steroids.
Many patients are told they should feel victorious and physically strong after treatment, but in reality, many feel anything but.— Sharyn L. Kurtz, PA-C, MPAS, MA
“Many patients are told they should feel victorious and physically strong after treatment, but in reality, many feel anything but,” said Sharyn L. Kurtz, PA-C, MPAS, MA, of the Dana-Farber Cancer Institute. “Survivors are carrying with them many physical and emotional effects and often feel somewhat in a fog about what their life should look like after treatment.”
At the National Comprehensive Cancer Network® (NCCN®) 13th Annual Congress: Hematologic Malignancies™, Ms. Kurtz described the late and long-term side effects associated with curative treatments of Hodgkin lymphoma and NHL and identified risk factors associated with developing these complications.2
Long-Term and Late Treatment Effects by Organ System
As Ms. Kurtz reported, per the NCCN Guidelines, surveillance of lymphoma recurrence with computed tomography/positron-emission tomography (CT/PET) scan is not indicated 24 months after treatment; images are obtained based solely on individual patient symptoms. However, surveillance for treatment-related side effects, which can often affect multiple organs, is a critical part of survivorship care.
Brain: The risks of cognitive dysfunction include treatment with chemotherapy; radiation to the brain/skull; and preexisting cognitive dysfunction. Neurocognitive testing administered by neuropsychology departments can be helpful in identifying deficits.
Thyroid: Hypothyroidism and thyroid nodules can result from lymphoma treatment. Interventions should include thyroid monitoring and thyroid replacement therapy. For patients who received radiation therapy, a thyroid exam and thyroid-stimulating hormone is recommended, and for patients with a palpable thyroid nodule, a thyroid ultrasound should be done. Referral to endocrinology may be appropriate.
Heart: Possible cardiac complications include 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 is a risk factor, along with mantle, mediastinal, and neck radiation therapy and use of concomitant therapies. A baseline echocardiogram and retesting every 1 to 2 years along with an annual lipid panel are recommended. Patient education regarding cardiac risk factor modification (hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking) is also key.
Lungs: Possible thoracic toxicities include pulmonary fibrosis, obstructive lung disease, radiation pneumonitis, and bleomycin toxicity. A baseline pulmonary function test at the time of entry into a survivorship clinic is recommended for any patient who received bleomycin.
Bone/Bone Marrow: Although steroids place patients at risk for osteopenia and osteoporosis, radiation therapy, alkylating agents, and the chemotherapy regimen BEACOPP (bleomycin, vincristine, cyclophosphamide, doxorubicin, etoposide, procarbazine [Matulane], prednisone) can lead to myelodysplastic syndromes and leukemia. A baseline bone density evaluation is advised 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 cell count monitoring is recommended.
Multisystem: Fatigue is a frequent and persistent symptom among Hodgkin lymphoma and NHL survivors and is strongly associated with depression/anxiety. Interventions include exercise, sleep hygiene, and depression/anxiety screening.
Secondary Cancer Risk
Secondary malignancies can also occur as a result of treatment of Hodgkin lymphoma and NHL. Radiation therapy, especially mantle-field radiation, confers a risk for breast cancer, and patients receiving radiotherapy at a younger age are at a higher risk. Annual mammogram screening (8–10 years after completion of mantle-field radiation therapy or after age 40) is the recommended intervention. For patients younger than age 30 at the time of radiation therapy, annual breast magnetic resonance imaging screening is recommended.
The risk of lung cancer is also 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 for patients aged 55 to 74 with a greater than or equal to 30 pack-year smoking history.
Finally, depending on the radiation sites, patients may be at risk for esophageal dysmotility/strictures and increased gastrointestinal cancers. Chemotherapy (procarbazine) can also contribute to gastric cancer, Ms. Kurtz reported. Interventions include esophagogastroduodenoscopy and/or colonoscopy periodically.
Survivorship Clinics and the Future of Survivorship Care
Overseen by the Survivorship Center and Lymphoma Department at Memorial Sloan Kettering Cancer Center (MSK), the MSK Lymphoma Survivorship Clinic has been organized for patients diagnosed with lymphoma subtypes that have a high probability of cure after treatment—diffuse large B-cell lymphoma, Burkitt lymphoma, and Hodgkin lymphoma—and have completed therapy for 2 years.
“MSK survivorship clinics are embedded within the individual departments,” said Ms. Kurtz. “This model of survivorship care can be reassuring for patients because they are cared for in a familiar place.”
In the clinic, patients are under the care of an advanced practice provider and are monitored for late and long-term side effects of therapy. Psychosocial assessments are also utilized, said Ms. Kurtz, to support the emotional health of survivors throughout the remainder of their surveillance treatment. If patients are diagnosed with depression, social work and psychiatric referral are considered.
In addition, Ms. Kurtz added, to promote patient health, 150 minutes per week of moderate cardiac intensity exercise or 75 minutes of high-intensity exercise is recommended. Survivors should also maintain an optimal body mass index, undergo cholesterol screening annually, and receive an annual influenza vaccine. Sun protection factor (SPF) skin protection and smoking cessation are also strongly encouraged.
In the future, said Ms. Kurtz, efforts are being made to reduce the dose of radiation therapy or omit it altogether, particularly in female patients. There is also an increased focus on data collection, with the aim of developing evidence-based survivorship practices, and collaboration with specialists to improve survivorship care guidelines. Finally, suggested Ms. Kurtz, there is a growing role for advanced practice providers in the survivorship care model.
Asking the Right Questions
Andrew D. Zelenetz, MD, PhD, Medical Director of Quality Informatics at MSK, said the transition to survivorship can reveal chronic issues that have been overlooked during the treatment course of care. “Either [survivorship clinics] are better at asking questions or patients are more
Chronic issues that have been ongoing often are revealed only in a survivorship clinic.— Andrew D. Zelenetz, MD, PhD
forthcoming if they’re seeing a different provider, but chronic issues that have been ongoing often are revealed only in a survivorship clinic,” said Dr. Zelenetz. “I think, in part, some patients are reluctant to disclose these issues to their physician, because they don’t want to seem ungrateful for a good outcome, which is why it’s important to have a survivorship program. These problems frequently go unreported.” ■
DISCLOSURE: Drs. Kurtz and Zelenetz reported no conflicts of interest.
1. Cancer Stat Facts: Non-Hodgkin Lymphoma. Available at https://seer.cancer.gov/statfacts/html/nhl.html. Accessed October 18, 2017.
2. Kurtz SL: Managing lymphoma survivors. 2017 NCCN Hematologic Malignancies Congress. Presented October 7, 2017.