Treating Hodgkin lymphoma

Chemotherapy are powerful drugs to kill fast growing cells. Cancer cells tend to be fast growing cells, however there are also fast growing healthy cells in the body. It is the effect of the chemotherapy on the healthy cells in the body which produces side effects. Chemotherapy can be delivered in tablets or through the vein and is administered by nurses specially trained in chemotherapy. It is normally a combination of drugs and given in blocks or cycles of treatment, therefore allowing a period of time for the healthy cells to recover.

The combination of chemotherapy drugs and length of treatment is determined by the stage of your Hodgkin lymphoma, your age, how fit you are and also how your lymphoma has responded to treatment. It is common for the treatment to extend across a period of months and it is delivered on an outpatient basis, which means you should not have to stay in hospital overnight. However, there may be times when your symptoms or the side effects of treatment become particularly troublesome and an inpatient hospital stay may be needed.

Chemotherapy can have several side effects, the most significant of which is the potential damage to your bone marrow. Bone marrow is responsible for producing the components that make up your blood; white bloods cells which fight infections, platelets that help the blood to clot and red cells that deliver oxygen around your body. Chemotherapy can interfere with the production of these cells in the bone marrow which can possibly cause the following problems:

• increased vulnerability to infections
• bleeding and bruising more easily
• anaemia or low red cells causing breathlessness or fatigue

This effect of chemotherapy on the bone marrow is generally temporary and is experienced in the first one to two weeks following treatment. This is why chemotherapy is given in cycles to allow a period of time for the healthy cells to recover.

You will be monitored closely whilst on chemotherapy but should you experience any of the above you would need to contact your team. You will be given a '24-hour hotline' number to call when you start your treatment so that any problems relating to your treatment can be addressed as soon as possible.

Other possible side effects of chemotherapy include:

• nausea and vomiting
• diarrhoea / constipation
• loss of appetite / alterations in taste
• mouth ulcers
• tiredness
• skin rashes
• hair loss
• infertility, which may be temporary or permanent (see complications of Hodgkin lymphoma treatment for more information)
• lung problems
• peripheral neuropathy or nerve damage
• heart problems

Most side effects can be managed and should pass once your treatment has finished. However, some side effects may continue or develop in the future and are referred to as late effects of treatment. It is therefore important to adopt a healthy lifestyle by maintaining your weight, not smoking and being active, once your lymphoma is in remission. This will help further reduce, the small chance of developing these late effects of treatment.

It is important to inform your team about any side effect particularly if troublesome, as there are often supportive treatments that can help.

Radiotherapy is most often used to treat early-stage Hodgkin lymphoma and follows after completing short course of chemotherapy. Radiotherapy treatment is normally given in short daily sessions as an outpatient, Monday to Friday, over the space of several weeks. You will not have to stay in hospital between appointments.

Before radiotherapy begins, the radiographer (radiotherapy specialist) will need to first carefully plan your treatment over one or more appointments. The radiographer uses a machine to 'map' out the lymphoma and decide what parts of your body the radiotherapy should be directed at. This planning may involve making small tattoo marks on your skin or making a special cast to ensure that you are kept in exactly the same position for each treatment session.

Radiotherapy uses high energy x-rays to kill lymphoma cells and is a painless and quick procedure. It can however also produce side effects and this is due to healthy tissue being effected in the area being treated. These side effects can vary and will be directly related to the part of your body that is being treated. For example, radiotherapy to your throat can lead to a sore throat, while radiotherapy to your chest could possibly lead to a cough and shortness of breath.

Other common side effects include:

• tiredness
• skin reactions in the treatment area
• nausea and vomiting
• dry mouth
• loss of appetite
• Hair loss in the treatment area

Most side effects are temporary, but similarly as with chemotherapy there are also the small possibility of long term side effects which may present years after the treatment has finished.

Steroid medication is sometimes used in combination with chemotherapy or where initial treatment has been ineffective.

Common side effects of steroid medication include:

• increased appetite, which can lead to weight gain
• indigestion
• problems sleeping
• feeling agitated or euphoric
• alterations in blood sugars

The side effects of steroid medication will usually start to improve once treatment finishes.

Targeted therapies or monoclonal antibodies work by attaching themselves to proteins on the lymphoma cell and either making the cell die or help the person’s immune system to destroy it.

If you are diagnosed with a rare type of Hodgkin lymphoma called lymphocyte-predominant Hodgkin lymphoma, you may have chemotherapy in combination with a medication called rituximab.

Brentuximab is another targeted biological therapy which is used if a person’s Hodgkin lymphoma does not respond to different chemotherapy regimens or combinations.

If your Hodgkin lymphoma does not resolve with initial treatment or comes back, you may require more intensive chemotherapy treatment. This may involve a stem cell transplant either from you or possibly from a donor.

After your course of treatment ends and your lymphoma is in remission (not detected on your final scan) you enter into a period of follow-up. As Hodgkin lymphoma is considered curable, you may be offered to enter into our self-supported management programme.

For the first year you will come to clinic for regular follow-up appointments at three monthly intervals. Thereafter your follow up will be triggered by yourself. During this time, you will be supported and educated by your clinical nurse specialist to know what to look out for and when to seek advice.

It can sound very daunting but there is much research to show that traditional follow up does not prevent your lymphoma from returning and most importantly symptoms and concerns are addressed more quickly if patients report them. Should this be the case, you would have fast and swift access into the lymphoma service for assessment.

After three years of remission you will also be discharged from the service.

Supported self-management follow-up is a new approach to follow-up care after your cancer treatment has finished. It replaces routine clinical appointments, which means that you do not have to come to hospital when you are feeling well and are not experiencing any symptoms. Instead, you can contact your specialist team and arrange to see them as and when you need to.