Palliative and Supportive Care for Non-Hodgkin Lymphoma
Patients with non-Hodgkin lymphoma (NHL) often benefit from care aimed at helping with problems related to the NHL and its treatment. For example, some patients with NHL have problems with infections or low blood counts. Although treating the NHL may help these over time, other therapies may be needed as well.
Treatments to prevent infections
Antibiotics and anti-virals
Patients getting certain chemotherapy drugs (such as fludarabine and other purine analogs) and the antibody drug alemtuzumab (Campath) have a high risk of infections seen mainly in people with impaired immune systems, like infection with CMV (a virus) and pneumonia caused by Pneumocystis jirovecii. An anti-viral drug like acyclovir is often given to try to prevent CMV infections. To help prevent Pneumocystis pneumonia, a sulfa antibiotic is often given (trimethoprim with sulfamethoxazole, which is also known by the brand names Septra® and Bactrim®). Other treatments are available for people who are allergic to sulfa drugs.
Antibiotics and anti-viral drugs are also given to treat infections. Often, active infections require higher doses or different drugs than those used to prevent infections.
Intravenous immunoglobulin (IVIG)
Some patients with NHL have low levels of their own antibodies (immunoglobulins) to fight infection. This can lead to lung and/or sinus infections that keep coming back. The level of antibodies in the blood can be checked with a blood test, and if it is low, antibodies from donors can be given into a vein (IV) to raise the levels and help prevent infections. This is called intravenous immunoglobulin or IVIG. IVIG is often given once a month at first, but may be able to be given less often based on blood tests of antibody levels.
For more information on infections, see our document Infections in People With Cancer.
Treatments for low blood counts
White blood cells, especially a certain kind of white blood cell called the neutrophil, are needed to fight infection. Having too few neutrophils (neutropenia) can lead to serious or even life threatening infections. If you become neutropenic from chemotherapy (chemo), you may be treated with injections of a white blood cell growth factor, such as filgrastim (Neupogen®) or pegfilgrastim (Neulasta®), to boost your neutrophil count. This lowers the risk of serious infections and can allow chemo to continue on time. If you are neutropenic and have signs or symptoms of infection (like a fever), you will be treated with antibiotics.
Some patients develop low red blood cell counts (anemia) from NHL or its treatment. This can lead to patients feeling tired, light headed, or short of breath from walking. Anemia that is causing symptoms can be treated with transfusions. These are often given on an outpatient basis. Drugs that boost red blood cell production can also be used, but these are linked to worse outcomes, and so are generally only used for patients who refuse to have transfusions.
If platelet counts get very low, it can lead to serious bleeding. Transfusing platelets can help prevent this.
In NHL, low red blood and platelet counts can also be caused by the cells being destroyed by abnormal antibodies.
When antibodies lower the numbers of platelets, it is called immune thrombocytopenia. Before diagnosing this, the doctor often needs to check the bone marrow to make sure that there isn’t another cause for the low platelet counts. In immune thrombocytopenia, giving platelet transfusions doesn’t usually help increase the platelet counts much, if at all, because the antibodies just destroy the new platelets, too. This can be treated by drugs that affect the immune system, like corticosteroids and IVIG. Another option is to remove the spleen, since after the antibodies stick to the platelets, they are actually destroyed in the spleen. Another option is treatment with a drug that tells the body to make more platelets, like eltrombopag (Promacta®) or romiplostim (Nplate®).
When antibodies lower red blood cell counts, it is called autoimmune hemolytic anemia (AIHA). This also can be treated with drugs that affect the immune system, like corticosteroids and IVIG. Removing the spleen is also an option. If the patient was being treated with fludarabine (Fludara) when the AIHA developed, the drug may be the cause, and so the fludarabine will be stopped.
Whether your lymphoma is being treated or not, it is important to have treatment to relieve your symptoms. This type of treatment, sometimes called palliative care, can be given along with cancer treatment as well as when cancer treatment is no longer working.
Sometimes, the treatments you get to control your symptoms are similar to the treatments used to treat cancer. For example, when lymph nodes become enlarged, they may press on nerves and cause pain. Radiation therapy to these areas may help relieve the pain. Pain medicines, ranging from ibuprofen and similar drugs to more potent medicines such as opioids (like morphine), may also be given.
Nausea and loss of appetite can be treated with drugs and high-calorie food supplements. If the lymphoma has spread to the lungs, patients may get short of breath. Oxygen may be used to help treat this symptom.
It’s important that you tell your health care team about any symptoms you have, including any side effects from treatment. There are often ways to help control or lessen these symptoms. This is an important part of your overall treatment plan.
For more information on palliative care and getting help with side effects, see the Palliative or Supportive Care section of our website.
Last Medical Review: August 26, 2014 Last Revised: February 29, 2016
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