Palliative and Supportive Care for Non-Hodgkin Lymphoma

For most people with non-Hodgkin lymphoma (NHL), treatment of the lymphoma itself is the main concern. But people can also often benefit from care focused on helping with problems related to the NHL and its treatment. For example, some people with NHL have problems with infections or low blood counts. Although treating the NHL may help these problems over time, other treatments 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) or the antibody drug alemtuzumab (Campath) have a high risk of some types of infections that are seen mainly in people with impaired immune systems, like infection with CMV (a virus) and pneumocystis pneumonia (PCP, which is caused by a type of fungus).

An anti-viral drug like acyclovir is often given to try to prevent CMV infections. To help prevent PCP, a sulfa antibiotic such as trimethoprim with sulfamethoxazole (Septra or Bactrim) is often given. 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 people with NHL have low levels of antibodies (immunoglobulins), which are immune system proteins that fight infections. 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’s low, antibodies from donors can be given into a vein (IV) to help prevent infections. This is called intravenous immunoglobulin (IVIG). IVIG is often given once a month at first, but it may be given less often based on blood tests of antibody levels.

For more information on infections, see Infections in People With Cancer.

Treatments for low blood counts

Chemotherapy (chemo) and some other lymphoma treatments can affect the bone marrow, which is where new blood cells are made. This can lead to low levels of some types of blood cells.

Low white blood cell count

White blood cells, especially certain white blood cells called neutrophils, are needed to fight infection. Having too few neutrophils (neutropenia) can lead to serious or even life-threatening infections.

If you become (or are likely to become) neutropenic from 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 can lower the risk of serious infections and help lower the chances that chemo treatments might need to be delayed.

If you are neutropenic and have signs or symptoms of infection (like a fever), you will be treated with antibiotics.

Low platelet count

Platelets help blood to clot, which stops bleeding. If your platelet count gets very low, it can lead to serious bleeding. Transfusions of platelets can often help prevent this.

In NHL, low platelet counts can also be caused by the cells being destroyed by abnormal antibodies. This is called immune thrombocytopenia (ITP). Before diagnosing this, the doctor often needs to check your bone marrow to make sure that there isn’t another cause for the low platelet counts. In ITP, giving platelet transfusions doesn’t usually help because the antibodies just destroy the new platelets, too.

ITP 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. A third option might be treatment with a drug that tells the body to make more platelets, like eltrombopag (Promacta) or romiplostim (Nplate).

Low red blood cell count

Some people develop low red blood cell counts (anemia) from NHL or its treatment. This can lead to feeling tired, lightheaded, or short of breath.

Anemia that is causing symptoms can be treated with red blood cell transfusions. Drugs that boost red blood cell production such as epoetin alfa can also be used, but these are linked to worse outcomes, so they are generally only used for people who decline blood transfusions.

In some people with NHL, abnormal antibodies can also lower red blood cell counts. This is called autoimmune hemolytic anemia (AIHA). It can be treated with drugs that affect the immune system, like corticosteroids and IVIG. Removing the spleen is also an option. If a person is being treated with the chemo drug fludarabine (Fludara) when the AIHA develops, the drug may be the cause, so the fludarabine may be stopped.  

Palliative care

Whether your lymphoma is being treated or not, it’s important to have treatment to relieve your symptoms. This type of treatment, sometimes called palliative care or supportive care, can be given along with cancer treatment as well as if cancer treatment stops 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.

You might also be given pain medicines, ranging from ibuprofen and similar drugs to more potent medicines such as opioids (like morphine).

Nausea and loss of appetite can be treated with drugs and high-calorie food supplements.

If the lymphoma has spread to the lungs, you may get short of breath. Oxygen may be used to help treat this.

It’s important that you tell your cancer 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.