What Are the Treatments for Advanced Non-Hodgkin's Lymphoma?

by Amy Hendel, P.A. Health Writer

If you or someone you love has been diagnosed with non-Hodgkin's lymphoma (NHL), then you may be concerned. This type of cancer, which originates in lymph tissue, can grow and spread at different rates, depending on the type diagnosed. Some types grow and spread slowly, while others are fast-growing and spread quickly. Let’s delve into the types of NHL and then discuss treatment options.

Oncologist talking to female cancer patient.
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Indolent NHL grows slowly

Your oncologist will likely discuss the type of NHL that you have. Slow growing types of this cancer are called indolent lymphomas. Some indolent lymphomas don’t need to be treated right away, but are closely monitored for changes. The most common type within this group in U.S. is follicular lymphoma. In this case, the body makes abnormal B-lymphocyte cells (white cells that fight infection). The most common symptoms: painless swelling in the neck, armpit, and groin.

Doctor checking senior man's neck and lymph nodes.
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Aggressive NHL needs immediate treatment

Aggressive lymphoma grows, spreads quickly, and needs immediate treatment. The most common type of aggressive lymphoma is diffuse large B cell lymphoma (DLBCL). It affects B cells, which are responsible for producing antibodies that fight infection in the body. It can occur in childhood, but most patients are over age 60 at the time of diagnosis. It can be localized to one spot or spread throughout the body. It can occur in lymph nodes or in any organ. It’s considered potentially curable.

Mother holding hand of child in hospital bed.
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Other types of NHL require differing treatments

Some lymphomas don’t fall neatly into either of the previous categories. Mantle cell lymphoma (MCL) tends to grow faster than indolent, but doesn’t usually respond to treatment as well as aggressive types. Burkitt lymphoma is rare in adults, more commonly found in kids. It grows quickly, needs immediate treatment, but can be cured by intensive chemotherapy. T cell lymphomas are fairly rare. One type – peripheral T-cell lymphoma – includes several subtypes that have different growth patterns and prognoses.

Doctor talking to senior woman patient.
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All NHLs can spread if not treated

It’s important to recognize that all types of NHLs have the potential to spread if not treated. If watchful waiting is recommended, patients have to discuss with their doctor just how comfortable they are with that approach. As mentioned, each NHL type has an identified “usual timing and pattern of spread” and treatment response. Identifying your type of lymphoma and setting up a treatment protocol is crucial. A second opinion is reasonable.

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A tailored treatment plan is key to successful treatment

The oncologist should identify the type of lymphoma, whether it is slow-growing or aggressive, the stage or extent of your cancer, molecular and genetic features, your overall health status including age, physical fitness, any other medical conditions, and personal goals and preferences. Quality of life is key in determining your overall best treatment option: do you want an aggressive treatment that might have poor quality of life, or a less aggressive treatment with better health? Only you can decide.

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Active surveillance needed for indolent lymphoma

Slow-growing indolent lymphoma in the absence of symptoms may be well-matched to active surveillance. Your doctor will watch for any signs of changes by seeing you regularly and monitoring your physical health, and by performing regular blood tests and imaging studies. The key is to avoid any spread of disease that would involve other organs, making prognosis less optimal. Some patients in this group can remain under watch for years. If the lymphoma becomes active, treatment is started.

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Chemotherapy effective treatment for NHL

Chemotherapy has the potential to treat some aggressive and non-aggressive forms of lymphoma and can also be used to prevent recurrences. When treating NHL, several drugs are typically used in a set protocol. CHOP is one such chemotherapy formula. Chemotherapy is designed to destroy the rapidly dividing cells. It has a number of side effects including cardiotoxicity, anemia, fatigue, hair loss, nausea, and vomiting. It is sometimes combined with targeted therapy and radiation.

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Stem cell transplantation for NHL another treatment option

Initial high dose chemotherapy first destroys the cancer cells. Autologous or allogenic stem cells are then administered and other drugs may be given to reduce the risk of infection from reduced immunity and to limit the risk of graft-versus-host disease – donated stem cells attacking the patient’s tissues. Supportive specialists (nutritionist, naturopathic doctor, pain practitioner, mind-body therapist, exercise specialist) can help you tolerate the months following stem cell transplant.

Woman undergoing radiation therapy.
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Radiation therapy (RT) often main treatment for NHL

RT may be used as the main treatment in some early stage subtypes. It may be combined with chemotherapy regimens in advanced stage or more aggressive lymphomas. Full body radiation may precede stem cell transplant to kill as many cancer cells as possible. Radiation is also used to palliate or alleviate nerve pain caused by the spread of lymphoma to internal organs like the brain and spinal cord. External beam radiation is a carefully focused beam delivered to a specific location.

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Targeted therapy gaining in popularity

New drugs are designed to search for and kill specific gene mutation cells or proteins on cancer cells. Monoclonal antibody therapy is one targeted therapy. It uses engineered immune cel,ls which are injected into the patient to target specific features in cells, killing them or preventing further proliferation. Targeted therapy may be combined with chemotherapy or radiation therapy drugs. Targeted therapy can have fewer side effects than chemotherapy.

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Immunotherapy another treatment option for NHL

Immunotherapy uses the immune system to attack the cancer cells, similar to how it attacks a virus or bacterial infection. Immunotherapy can be administered in the form of drugs or as a cell-based therapy, which involves extracting cells from the body, modifying them and then infusing them back into the body to “do battle.” Checkpoint inhibitors, Car T cell therapy, and cancer vaccines are some immunotherapy options. There are also ongoing clinical trials in immunotherapy for treating NHL.

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Surgery rare in NHL cases

Surgery is used to obtain a biopsy sample to diagnose and classify lymphoma. It also may be needed as treatment in rare cases. If lymphoma starts in the spleen or in certain organs outside the lymph system, and it’s well contained to that site, then surgery may be an option. Usually in those cases, radiation therapy is still the preferred treatment and the radiation can be targeted to that specific NHL location for precise treatment.

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Genetic testing plays role in NHL treatment decisions

Researchers are looking at how changes in the DNA inside a normal lymphocyte cause mutation into lymphoma cells. Findings may help guide development of drugs that specifically target and block this process. In recent years, genetic tests have helped cancer experts understand the nuances of different NHL subtypes, which has in turn helped identify best treatment practices. The goal is to choose therapies with best outcomes and the least amount of unpleasant side effects.

Senior woman on exercise ball in park with exercise instructor.
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Whole body medicine helpful in reducing stress, symptoms

If you are diagnosed with advanced NHL, it’s important to view the whole body, known as whole body medicine, when you are creating a treatment plan with your doctor. In addition to traditional medical treatments like those discussed in previous slides, you could consider complementary modalities that help reduce stress and minimize anticipated symptoms. Pain management is crucial. Nutrition, exercise, mediation, acupuncture, massage, art therapy, and music therapy can be supportive.

Amy Hendel, P.A.
Meet Our Writer
Amy Hendel, P.A.

Known as "The HealthGal", Amy Hendel P.A. is a medical and lifestyle reporter, nutrition and fitness expert, health coach and brand ambassador. Trained as a physician assistant, she maintains a health coach private practice in New York and Los Angeles. Author of The Four Habits of Healthy Families, find her on Twitter @Healthgal1103 and on Facebook @TheHealthGal. Check “Daily Health News” at healthgal.com. Her personal mantra? “Fix it first with food, fitness, and lifestyle.”