Long-term Surveillance is Crucial in Patients with Lymphoma

Ingrid Glimelius, MD, PhD

Lymphoma typically has a high cure rate and often affects a younger population. Because of this, it is important that oncologists are aware of the long-term effects of lymphoma treatment on survivors.

According to Ingrid Glimelius, MD, PhD, a senior lecturer and assistant professor in the Department of Immunology, Genetics and Pathology, Experimental and Clinical Oncology at Uppsala Universitet, the long-term effects of lymphoma treatment are fertility, especially for younger woman, and secondary malignancies. More immediate adverse events (AEs) from chemotherapy include vomiting, nausea, infection, and diarrhea. However, most of these AEs tend to pass over time. 

Because of these long-term effects, surveillance remains crucial for this patient population. Even after up to 30 years after remission, second malignancies are possible. For example, if a patient received radiation to the breast, it’s important that she is regularly checked for breast cancer so that it can be removed as soon as possible, according to Glimelius.

In an interview with Targeted Oncology™, Glimelius discusses the importance of long-term surveillance in lymphoma survivors. 

TARGETED ONCOLOGY™: What is the magnitude of late effects in lymphoma survivors and rationale for long term surveillance?

GLIMELIUS: Late effects in lymphoma patients is a big issue since patients are often young and the diseases, they are burdened with are curative. Therefore, you have to think about late effects already from the start of treatment when you select the curative treatment for your patients. Or, in some cases, the palliative treatment. So, what my presentation is about is to describe the magnitude of the late effects in lymphoma patients, what actions we can do, and what kind of late effects that are mostly seen for those that have had a lymphoma and lymphoma treatment.

What are some common late effects that are typically seen in lymphoma survivors?

You can divide them into early late effects and more late-late effects. And that also depends on the age and your sex. But for example, for young females, the issue of fertility is something that we have to take into account. And then of course, you have the acute side effects from chemotherapy. For example, nausea, vomiting, infections, diarrhea, but they usually pass and go away. The more long-term adverse effects, such as cardiovascular disorders, that you can get both from chemo and radiotherapy. And in the very long run, you can see secondary malignancies, for example. A few years after intensive chemo, there's a risk of hematological malignancies. And 10, 20 or 30 years after radiotherapy, you can see an increased risk of solid tumors. And that is what we have to try the best to avoid.

What are the benefits of long-term surveillance on this patient population?

Well, that is a good question. And also, a tricky question. Because things happen as we grow older, and we would don't want to harm people by controlling them and causing more worries. So, we have to direct our interventions where we can really prevent things. For example, if you have been given radiotherapy to the breast and you're a young female, an MRI of the breast in the long run, then you can maybe detect, if there is an early breast cancer, you can detect it and you can remove it and the woman can be saved. So that is one thing. And also measures for primary prevention. For example, if you have had this intensive chemotherapy or radiotherapy, you shouldn't be smoking. I mean, you shouldn't anyway, but it's even more important to avoid smoking and advice around those factors is also important. And then of course, we have to meet the patients where they are, what are the problems they are burdened with? And what can we help them with?

How would you suggest that community oncologists take into account these long-term effects?

I think you should go where the evidence is, where you can really prevent things. And that is mostly some kind of screening measures for secondary malignancies. But also, primary prevention for cardiovascular disorders. For example, help the patients to maintain a healthy weight and stay out of smoking and other primary preventive measures, for example, check blood pressure, blood glucose, and so on. So that's one way of dealing with it. And then, of course, meet the patient where he or she is. For me, maybe the struggle would be with fatigue or that I have a risk of osteoporosis due to the number of steroids given. But I think you should really look at what kind of lymphoma has the patient had, what treatment has the patients received, and then look in specific guidelines. What should I look for? And how should I prevent those disorders from happening?

What is the most important thing for oncologists to keep in mind about this issue?

The most important thing that I see, is to do right from the beginning. So, the most important thing is to cure. If it’s a curable, lymphoma, try to give as much treatment as you can to cure the lymphoma upfront. So, do not be afraid of late effects. I mean, if you reduce treatment too much, you don't cure the lymphoma, it will come back and you have to give treatment again. And that is the group of patients that have the highest risk of long-term adverse effects. So, do the best thing and the right thing from the beginning. And from the patient side, if the doctor says, you need both chemo and radiotherapy, to be cured, you should go with that. That is the best thing because what is really burdensome on a group level is that if the lymphoma comes back and you need more treatment, then the risk of later adverse effects is high.

We are aware of the late effects. We know them quite well. The struggle now is to find the best way to do surveillance. And that is not harmonized worldwide. How we should follow our paces and what actions we should do. That is really not harmonized. And I've read through all the ESMO guidelines, and it's mentioned a lot in the Hodgkin lymphoma section, but for the other lymphoma subtypes, late effects and how to prevent them are not considered that much because it's usually elderly patients and they might not live that long. Now when prognosis is improving in many different kinds of lymphomas, we have to consider also those late effects and write guidelines for other groups of lymphoma patients than only Hodgkin lymphoma survivors. So that would be something that I would wish for the future.