Late Effects Burden Lymphoma Survivors After Multimodality Treatment

Many patients with lymphoma need treatment with both chemotherapy and radiation, but these treatments may be accompanied by significant late-term effects, according to a new study presented during the 2018 American Society of Clinical Oncology Cancer Survivorship Symposium.

Over time, treatment for Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) have evolved, resulting in patients receiving both modalities, and radiation being given to sites that are persistent.

"I think we have really landed in a place now where we are trying to use chemotherapy and radiation in a way that is complementary, so that we can treat the disease as effectively as possible, but minimize risk of severe late toxicity," said Christine Hill-Kayser, M.D., who is an assistant professor of Radiation Oncology at the University of Pennsylvania (UPenn) in Philadelphia and senior author on the study.

Researchers from UPenn used a publicly available internet-based survivorship care plan tool to examine the type of cancer care received and the side effects experienced by 964 survivors, including 37 percent who had HL and 63 percent who had NHL.

The survivors were mainly Caucasian women, and median age was 28 years for HL survivors and 49 years for NHL survivors. The median follow-up was five years and two years, respectively. The majority (88 percent) of survivors were cancer free, 9 percent had a recurrent or secondary malignancy and 3 percent had metastatic disease.

Survivors previously received chemotherapy (89 percent of HL and 94 percent of NHL) and radiation therapy (64 percent of HL and 28 percent of NHL). The majority of patients with HL (96 percent) and NHL (61 percent) had received radiation therapy to the chest/mantle.

"Patients with lymphoma, per their patient reported outcomes, experienced a wide breadth of late- and long-term side effects from their previous treatment," said lead author Melissa Frick, a fourth-year medical student at UPenn.

The late-term effects experienced by those who received chemotherapy included chronic fatigue (56 percent), cognitive change (56 percent), peripheral neuropathy (35 percent), sexual changes (15 percent of men and 35 percent of women) and heart disease (10 percent).

Chest radiation therapy was most commonly associated with hyper- or hypothyroidism (35 percent). Other late-term effects were: speaking/swallowing changes (20 percent), heart disease (14 percent), pulmonary fibrosis/pneumonitis (12 percent), skin cancers within the radiation field (9 percent) and thyroid nodules (8 percent).

"One novel thing that we found of the survivors who had received chest radiation was that they reported secondary breast cancers (2 percent) compared with zero percent of those who had not received chest radiation," said Frick.

The best way to combat side effects is through knowledge, said Hill-Kayser. Screening and modifications, such as not smoking and living a heart-healthy lifestyle, can also help.

Health care providers also play an important role, however, the researchers concluded that survivorship information was not delivered as best as it could be. Thirteen percent of survivors reported that they received a survivorship care plan and just 4 percent received a treatment summary.

"I think it's hard to provide every patient with a survivorship care plan without a really good tool to help you do it because these documents are comprehensive and have to be customized," said Hill-Kayser. "With increased and improved infrastructure to support health care teams providing these to patients, I think it can be done."

Researchers didn't expect to find, looking 5 to 10 years down the road, a significant shift from care management of an oncologist to that of a primary care provider. Most patients (49 percent) reported continued care from an oncologist or in combination with a primary care physician (19 percent). However, the shift began later on from 2 percent of survivors at less than 2 years in follow-up to 30 percent once it was 2 years or more into follow-up.

"Recognizing that this transition from oncologic management to primary care is a critical transitional period in where communication is vital between providers," said Frick.

The team's next focus is diving more into what is being done for lymphoma survivors in terms of screenings, noted Frick.

"Over the next decade or so, I hope we will understand in a data-driven way more about the needs of survivors," said Hill-Kayser. "The more we can understand it in a scientific way the more we can customize our approach to cancer survivors."