1. CARE OF THE LYMPHOMA PATIENT
IMPORTANCE OF NURSING INVOLVEMENT

2. GOAL
To become more familiar with lymphoma as a disease, the treatment modalities, and side effect management strategies and to use this knowledge to improve and maximize patient care.

3. Objectives To become familiar with the disease lymphoma
To become familiar with the regimens and drugs used in the treatment of lymphoma
To be able to recognize toxicities and recommend treatment strategies associated with these drugs
To use this knowledge to become better communicators with patients, families, and healthcare providers.
To be able to provide compassionate and consistent knowledge based care to our lymphoma patients.

4. PATIENT CASE
JH 72 yo male
Diagnosed in 3/2012 with Diffuse Large B-Celll Lymphoma (DLBCL) with skin lesions
Received 6-cycles of CHOP-R (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone). Last treatment 6/2012
Complete remission by PET scan with skin lesions resolved.
Relapsed a couple of weeks later with rapidly growing lesions on arms and inguinal area.
To be admitted for cycle-1 of ESHAP-R

5. LYMPHOMA STATISTICS Approximately 70,000 new cases diagnosed in 2012
Will account for approximately 19,000 deaths in 2012
Account for about 54% of all blood cancers that occur each year
The seventh most common cancer in males and females

6. LYMPHOMA STATICS
United States has the highest prevalence of lymphoma in the world
Lymphoma is increasing at approximately 4% annually…. Unlike many other cancers which have shown a decrease.
Slightly more males diagnosed than females.
Currently approximately 500,000 people living with lymphoma

7. WHAT IS LYMPHOMA?
An immune cancer
Lymphoma is a diverse group of diseases that originate in the lymphatic system.
It develops as a malignant disorder of the reticuloendothelial system and results in an accumulation of dysfunctional, immature lymphoid cells

8. THE LYMPHATIC SYSTEM
Consists of lymph fluid and lymphocytes
Defends against invading microorganisms and disease
Returns excess interstitial fluid to the blood
Aids in absorption of fats and soluble vitamins from the digestive system

9. LYMPHATIC SYSTEM
Lymph fluid and cells circulate through the spleen, and lymphnodes which are located in the axillary, and the inguinal and cervical areas
The defense mechanism of the lymph system is composed of 2 types of cell (lymphocytes):
B-cells – mature in bone marrow
T-cells – mature in thymus gland

11. SYMPTOM PRESENTATION Rubbery, painless lymphnodes Fatigue Anorexia
Anemia
Increased LDH
B – symptoms
> 10% weight loss in < 6 months
Unexplained fevers
Night sweats
fatigue

12. LYMPHOMA TYPES Hodgkins Lymphoma Non-Hodgkins lymphoma
Disease of younger adults
Identified by presence of the Reed-Sternberg cell
80-85% cure rate
Successful treatment with ABVD or MOPP
Non-Hodgkins lymphoma
Disease of older adults
Classification dependent on the cell line proliferation
B-cell
T-cell

13. NON-HODGKINS LYMPHOMA (NHL)
Indolent
B-cell lymphomas
Most common is follicular
Slow growing
Survival without treatment often measured in years
More difficult to treat

14. NON-HODGKINS LYMPHOMA (NHL)
Aggressive
Most common is Diffuse Large B-Cell Lymphoma (DLBCL)
Survival without treatment measurable in months
80% cure rate
Includes B-cell and T-cell lymphomas

15. STAGING OF NHL Stage I Stage II
Cancer involved in one lymphoid area or organ (i.e. thymus)
Cancer in one area of a single organ outside the lymph system
Stage II
Cancer located in two or more groups on the same side of the diaphragm

16. STAGES OF LYMPHOMA Stage III Stage IV
Cancer located in lymphnode areas on both sides of the diaphragm
Cancer located in an area or organ next to lymphnodes, spleen or both
Stage IV
Cancer spread outside lymph system into an organ next to an involved node
Cancer spread to bone marrow, liver, brain or spinal cord

18. TREATMENT STRATEGIES FOR NHL
Surgery
Not used in metastatic disease
May be used in the palliative setting
Radiation
Rarely used in the relapsed NHL setting
Chemotherapy
Most common form of treatment for relapsed disease

19. TREATMENT OF NHL First line
CHOP - cyclophosamide, doxorubicin, vincristine, prednisone
CVP – cyclophosphamide, vincristine, prednisone
FC – fludarabine, cyclophosphamide

20. TREATMENT OF NHL Relapsed or refractory
ICE – ifosfamide, carboplatin, etoposide
DHAP – cisplatin, cytarabine, dexamethasone
ESHAP – etoposide, methylprednisolone, cisplatin, cytarabine
Hyper-CVAD/MTX-Ara-C – cyclophosphamide, vincristine, doxorubicin, dexamethasone,methotrexate, cytarabine
EVAP – etoposide, vinblastine, cytarabine, cisplatin
High dose methotrexate

21. ROLE OF RITUXIMAB IN THE TREATMENT OF NHL
Rituximab is a monocolonal antibody that targets the CD20 antigen on B-lymphocytes causing cell death(targeted therapy).
Therefore it can only be used in B-cell lymphomas.
Has shown good response in the treatment of follicular lymphoma (indolent lymphomas)
Can be used as maintenance therapy, i.e. monthly, every 6 months. The optimal maintenance regimen has yet to be determined.

22. PATIENT CASE JH is admitted to start ESHAP-R for relapsed NHL
Etoposide 40 mg/m2 days 1-4
Cisplatin 25 mg/m2 days 1-4
Cytarabine 2000 mg/m2 day 5
Methylprednisolone 500 mg IV daily x5 days
Rituximab 375 mg/m2 day 1

23. NURSING MANAGEMENT OF SIDE EFFECTS
Most of the patients that we treat in the hospital have been treated previously and will be receiving more toxic regimens These factors will make them more susceptible to complicated adverse effects.
Nurses are very important in identifying and reporting toxicities.

24. SIDE EFFECT MANAGEMENT
Myelosuppression
Shortness of breath
Tachycardia
Bruising or bleeding
Temperature!!

25. SIDE EFFECT MANAGEMENT
Mucositis
Potential access point for bacteria
Prevention is key with good and consistent mouth care
Treatment
Bland rinses such as saline and sodium bicarb rinses
Topical anesthetics such as lidocaine, benzocaine, Magic Mouthwash
Mucosal coating agents – Amphojel, Kaopectate
Analgesics i.e. morphine

26. SIDE EFFECT MANAGEMENT
Fatigue
Encourage patient to be as active as possible. Studies have shown that increasing activity does help to relieve fatigue associated with chemotherapy
Cardiotoxicity
These patients generally have received anthracyclines (“red drugs”) as part of many of their regimens
Cardiotoxicity may present as:
Dyspnea on exertion
Orthopnea
Shortness of breath

27. SIDE EFFECT MANAGEMENT
Hyperglycemia
Many of the regimens used in this setting contain steroids
Observe for high BS
Patients may need to be started on a SS insulin
Diarrhea
Nausea/vomiting

28. SIDE EFFECT MANAGEMENT
Changes in taste and appetite
Maintenance of nutrition is very important for recovery
Have patients drink plenty of fluids
Eat smaller meals more often
Eat what tastes good

29. SIDE EFFECT MANAGEMENT
Depression
Estimated anywhere from 20-60% of cancer patients experience depressive symptoms.
Often overlooked by oncologist
Our NHL patients may be more susceptible due toxic regimens and relapsed disease
Depressive symptoms may often mimic side effects of chemotherapy

30. SIDE EFFECT MANAGEMENT - DEPRESSION
Look for symptoms
Persistant sad, anxious or “empty” mood
Feelings of hopelessness and pessimism
Feelings of guilt, worthlessness, helplessness
Loss of interest or pleasure in hobbies and activities
Insomnia or over sleeping
Restlessness and irritability

31. SIDE EFFECT MANAGEMENT
Tumor lysis syndrome
Can occur in patients with heavy tumor burden (enlarged lymphnodes, increased WBC)
Caused by the breakdown of WBC and consequent release of uric acid into the blood with cytotoxic therapy.
Potential to cause end-organ damage and death

32. SIDE EFFECT MANAGEMENT - TLS
Monitor:
Uric acid - ↑
n/v, diarrhea, anorexia, metabolic acidosis, pruritis
Potassium level -↑
Tachycardia, muscle weakness, twitching, muscle cramps, n/v, diarrhea, lethargy
Phosphorous level (↑) and calcium level (↓)
Azotemia, oliguria, hypertension, mental status changes, tetany, anxiety, hallucinations
Renal function (SrCr) - ↑

33. SIDE EFFECT MANAGEMENT
Prevention of tumor lysis syndrome
Hydration!!!
Urine alkalinization (sodium bicarb infusions)
Allopurinol
rasburicase
Nurse’s role:
Monitor patients closely
Provide proper patient education
Identifying risk factors through good medication histories
Assessing the appropriateness of the route of drug delivery

34. SIDE EFFECT MANAGEMENT
Infusion related reactions
Rituximab – incidence as high as 70%
Patient at greater risk with first treatment, heavy tumor burden, and decreased CrCl
Patients should be premedicated with acetaminophen and an antihistamine
Monitor patient carefully and slow down infusion as needed
Intervention drugs are available on override for easy access

35. CNS INVOLVEMENT IN LYMPHOMA
Primary
Present at time of initial diagnosis
Secondary
Result of secondary spread of systemic disease
Prophylaxis
Weekly treatments of intrathecal methotrexate or cytarabine
Treatment
Ommaya
Treat three times weekly until CNS cleared.

36. WHAT CAN NURSES DO? Be aware of your patient’s regimen
Watch for toxicities associated with the drugs your patient received
Share information with your pharmacist and the patient’s provider
Be proactive…your suggestions and interventions are vital to the safe and rapid recovery of our patients!

37. REFERENCES
Vogel, Wendy H. Infusion Reactions: Diagnosis, Assessment, and Management. Clinical Journal of Oncology Nursing 2010;14:E10-E21
Lymphomas. Update on Cancer therapeutics 2006;
NCI
Lymphoma Leukemia society – 2012
Lymphoma.LPN June 2009;5:18-23
ONS Journal Symposium Spotlight. May
Treatment of Oral Mucositis in Cancer Patients. Nursing Best Practice 1998;2:1-6
Cancer.net
Lymphoma Research Foundation