Non-Hodgkin's lymphoma

Essential facts Non-Hodgkin's lymphoma (NHL) is a cancer of the lymphatic system. According to Cancer Research UK, it is the sixth most common cancer in the UK, with 13,413 new cases diagnosed in 2013. There were 4,801 deaths from NHL in 2014. The disease has many subtypes, with two main broad categories: high-grade or aggressive and low-grade or indolent.

High-dose methotrexate and primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a rare disease that is managed differently from other primary brain tumors and other types of systemic lymphomas. The use of high-dose methotrexate (HD-MTX) has improved survival rates. This article describes the experience of a patient treated with HD-MTX and outlines the essential aspects of care for the bedside practitioner. An understanding of the diagnostic workup and principles of treatment can minimize complications and maximize patient function as nurses care for the unique physical and emotional needs of this population.

Treatment approaches and nursing applications for non-Hodgkin lymphoma

Non-Hodgkin lymphoma (NHL), a malignancy that manifests in the lymphatic system, is one of the most commonly occurring hematologic disease types in the United States and other Westernized countries. NHL is divided into a range of subtypes with differing clinical features and outcomes. Depending on the type of NHL and the patient's overall clinical presentation, treatment varies from systemic combined chemotherapy regimens with or without immunotherapy, radioimmunotherapy, and transplants to investigational options. Oncology nurses play a vital role in implementing successful treatment and management of patients with NHL as oncology care moves into an era of novel targeted therapies.

Radioimmunotherapy for non-Hodgkin's lymphoma

OBJECTIVES

To describe the rationale for radioimmunotherapy as a treatment of non-Hodgkin's lymphoma. To present the similarities and differences in the two radioimmunotherapies and the nursing implications in caring for patients receiving these agents.

DATA SOURCES

Published literature and review of published clinical trials.

CONCLUSION

Radiolabeled monoclonal antibodies bind to specific antigens and provide a means of targeting tumor cells with cytotoxic radioactivity. The infusion of radiolabeled monoclonal antibodies requires an understanding of antibody therapy, radiation therapy, and principles of time, distance, and shielding.

IMPLICATIONS FOR NURSING PRACTICE

As the use of radioimmunotherapy grows, nurses must be aware of the background for, logistics of, and follow-up required for patients receiving this form of radiation treatment.

Overview of non-Hodgkin's lymphoma

OBJECTIVES

To provide an overview of non-Hodgkin's lymphoma (NHL).

DATA SOURCES

Review and research articles.

CONCLUSION

NHLs are divided primarily into two main categories based on their rate of growth: aggressive and indolent. Within these two groups are various subtypes that have various clinical features. Prognostic features have been useful in determining the potential outcome of treatment of patients with NHL.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an important role in the education of patients regarding the type of lymphoma they have and the steps necessary to make an accurate diagnosis, which is important in determining the appropriate treatment.

Hematopoietic cell transplantation in non-Hodgkin's lymphoma

OBJECTIVE

To explore the role and outcomes using hematopoietic cell transplantation (HCT) as a treatment option with aggressive, follicular, mantle, T-cell, and HIV related non-Hodgkin's lymphoma (NHL).

DATA SOURCES

Research and review articles and textbooks.

CONCLUSION

High-dose chemotherapy and/or radiation therapy followed by HCT has been used to overcome resistance to standard-dose therapy and has been explored over the past 40 years and has shown long-term survival of approximately 10% to 50% in patients with relapsed or refractory lymphoma.

IMPLICATIONS FOR NURSING PRACTICE

Nursing plays a significant role in the assessment and management of patients throughout the course of HCT.

Dose-dense chemotherapy for aggressive non-Hodgkin lymphoma

Non-Hodgkin lymphoma is a heterogeneous disease that represents the seventh leading cause of cancer death. Second-generation and third-generation chemotherapy regimens have only produced a marginal improvement in outcome over the administration of the cyclophosphamide, doxorubicin, vincristine, and prednisone regimen in aggressive forms of non-Hodgkin lymphoma. This has led to the development of different strategies for improving disease-free and overall survival in this disease. Dose intensification achieved by condensing the intervals between each chemotherapy cycle is possible with granulocyte colony-stimulating factor support, which reduces neutropenia and its complications. Clinical trials indicate that this strategy may improve the outcomes in patients with aggressive non-Hodgkin lymphoma, particularly elderly patients. Nurses can play a major role in the implementation of evidence-based supportive care strategies in clinical practice to ensure safe use of dose-dense chemotherapy regimens.

Treatment Approaches and Nursing Considerations For Non-Hodgkin’s Lymphoma

OBJECTIVE

To discuss some common non-Hodgkin's lymphoma subtypes, and current systemic approaches including chemotherapy, monoclonal antibodies, radioimmunotherapy, and vaccines.

DATA SOURCES

Research and review articles, textbooks, and guidelines

CONCLUSION

Non-Hodgkin's lymphoma is one of the most common types of malignancies for both men and women. It manifests itself in the lymph nodes, bone marrow, and extranodal sites, with or without B symptoms (fevers, sweats, weight loss) and it continues to be on the rise. Recent advances in treatment options have improved the potential for cure within its various subtypes, although much more work remains to be done.

IMPLICATIONS FOR NURSING PRACTICE

Management of side effects remains a major challenge to nurses when caring for patients undergoing treatment.

Radioimmunotherapy with tositumomab and iodine-131 tositumomab for low-grade non-Hodgkin lymphoma: nursing implications

PURPOSE/OBJECTIVES

To review radioimmunotherapy approaches for low-grade non-Hodgkin lymphoma (NHL) with a focus on tositumomab and iodine-131 tositumomab (Bexxar, Corixa Corporation, Seattle, WA, and GlaxoSmithKline, Philadelphia, PA). Nursing implications for Bexxar therapy are reviewed, including radiation safety, patient education, and the management of therapy-related toxicities.

DATA SOURCES

Journal articles, published research data, and clinical experience.

DATA SYNTHESIS

The Bexxar treatment regimen (using an anti-CD20 antibody) consists of a dosimetric administration followed 7-14 days later by a patient-specific therapeutic administration. Infusion-related adverse events and myelosuppression are manageable. Patient and caregiver education regarding the benefits of radioimmunotherapy, treatment protocols, and radiation safety precautions is necessary.

CONCLUSIONS

Bexxar therapy represents an important new treatment option for patients with low-grade NHL and can be administered on an outpatient basis.

IMPLICATIONS FOR NURSING

Nurses play a vital role in the success of a Bexxar therapy program by providing patient and caregiver education, patient monitoring, and coordinating treatment schedules.

Fatigue and depression in patients with lymphoma undergoing autologous peripheral blood stem cell transplantation

PURPOSE/OBJECTIVES

To describe the patterns of depression and fatigue, including its dimensions, and the relationship between these two variables in patients with lymphoma undergoing autologous peripheral blood stem cell transplantation (PBSCT).

DESIGN

Prospective, descriptive, correlational, repeated measures.

SETTING

Midwestern university National Cancer Institute-designated clinical cancer center.

SAMPLE

27 patients with lymphoma aged 19 to 71 undergoing autologous PBSCT.

METHODS

The revised Piper Fatigue Scale was used to measure fatigue and its dimensions. The Center for Epidemiologic Studies' Depression Scale was used to measure depression on selected days at baseline and during chemotherapy and recovery.

MAIN RESEARCH VARIABLES

Fatigue and its four dimensions (behavioral/severity, sensory, cognitive/mood, and affective meaning) and depression.

FINDINGS

Total fatigue, fatigues four dimension scores, and depression scores changed significantly over time, with the highest scores at day + 7 after transplant. Total fatigue and the four dimension scores were highly and positively correlated with depression, with the highest correlation reported between the affective fatigue dimension and depression.

CONCLUSIONS

The findings support the importance of assessing fatigue and depression in patients undergoing autologous PBSCT at baseline, during chemotherapy, and throughout recovery.

IMPLICATIONS FOR NURSING

Routine clinical assessment with close observation around day +7 after transplant and patient education about the patterns of fatigue and depression will help the healthcare team to intervene at the appropriate time and may help patients to better manage these symptoms.

Understanding non-Hodgkin's lymphomas

NHLs are a complex group of diseases whose morphology and clinical presentation guide treatment choices. Nurses caring for these patients need to have an understanding about how these diseases present themselves and how the treatment options affect patients' emotional and physical well-being.

Current therapeutic approaches in the treatment of Non-Hodgkin's lymphoma

OBJECTIVES

To review the causes, classification, treatment, and new treatment modalities of non-Hodgkin's lymphoma.

DATA SOURCES

Published literature and experimental therapies.

CONCLUSIONS

The increasing incidence of non-Hodgkin's lymphoma can be attributed to a growth in the number of immunodeficiency and autoimmune disorders, infectious agents, and human T-cell leukemia-lymphoma virus. Treatment options include watch-and-wait, radiation, chemotherapy, biologic therapy, and stem cell/bone marrow transplant. New therapies include the use of monoclonal antibodies and radioimmunotherapy. Experimental therapies include high-dose radioimmunotherapy and stem cell transplantation, vaccines, and antisense antiangiogensis agents.

IMPLICATIONS FOR NURSING PRACTICE

Nurses will need to become versed in this modality, and will play an important part not only in therapy but also in patient education.

Monoclonal antibodies conjugated with radioisotopes for the treatment of Non-Hodgkin's lymphoma

OBJECTIVES

To describe the use of monoclonal antibodies labeled with iodine-131 tositumomab and yttrium-90 ibritumomab-tiuxetan as treatment for non-Hodgkin's lymphoma.

DATA SOURCES

Literature review of trials of radioimmunotherapy.

CONCLUSIONS

Radiolabeled monoclonal antibodies recognize and react with specific antigens to provide targeted therapy to tumor cells, particularly hematopoietic tumor cells. This therapy delivers greater amounts of radiation to malignant cells than normal cells and spares critical organs that do not express the antigen. Strict safety and patient precautions must be in place with the use of radiotherapy.

IMPLICATIONS FOR NURSING PRACTICE

As the use of radiommunotherapy in the treatment of non-Hodgkin's lymphoma grows, the role of nursing in the care of these patients will also grow. Nurses will play an important part in patient and family education, as well as staff preparation.

Immunotherapy: a novel treatment for Non-Hodgkin's lymphoma

OBJECTIVES

To provide an overview of the principles of immunology, including immunotherapy, and information about monoclonal antibody therapy in the treatment of non-Hodgkin's lymphoma.

DATA SOURCES

Published literature.

CONCLUSIONS

Immunotherapy is a form of disease treatment that enhances the immune system with the use of biologic agents. One such agent is the monoclonal antibody, which can be combined with a radioisotope (e.g., iodine-131 or yttrium-90) or chemotherapeutic drug to deliver treatment directly to tumor cells with less toxicity to normal cells.

IMPLICATIONS FOR NURSING PRACTICE

As the field of monoclonal antibody therapy continues to grow, nurses will play an important role in treatment and patient education. Nurses need to become knowledgeable in this area of cancer treatment and gain a better understanding of basic principles involved in immunotherapy.

Establishing a radioimmunotherapy outpatient care clinic for Non-Hodgkin's lymphoma

OBJECTIVES

To describe an outpatient treatment model for treating non-Hodgkin's lymphoma with radioimmunotherapy.

DATA SOURCES

Experiences of The Hoag Cancer Canter (Newport Beach, CA) in developing an outpatient treatment model.

CONCLUSIONS

The Hoag Cancer Center has put an outpatient radioimmunotherapy treatment model into place. Goals include providing coordinated, collaborative care, safe delivery of radioimmunotherapy in an outpatient setting, and establishing an education program for the medical team, patient, and patient's family.

IMPLICATIONS FOR NURSING PRACTICE

In providing outpatient treatment for non-Hodgkin's lymphoma, nurses will have many functions, including educating patients and family, coordinating treatment schedules, adhering to radiation safety guidelines, and reviewing post-therapy and long-term side effects that might occur at home.

Rituximab: a new monoclonal antibody therapy for non-Hodgkin's lymphoma

PURPOSE/OBJECTIVES

To review the use of monoclonal antibodies (MAbs), specifically rituximab, in the treatment of non-Hodgkin's lymphoma (NHL) and to describe the nursing management of patients receiving rituximab.

DATA SOURCES

Published articles, abstracts, book chapters, drug manufacturer, lectures, and personal experience with rituximab.

DATA SYNTHESIS

NHL ranks sixth among malignancies in incidence and mortality in the United States. The most common subtype, low-grade follicular lymphoma, is considered incurable. Lack of specificity may limit the usefulness of chemotherapy for low-grade follicular NHL. However, MAb therapy may deliver a cytotoxic effect specifically to the targeted cancer cell. Rituximab is the first MAb approved for cancer therapy. Clinical trials indicate that rituximab is efficacious and safe for recurrent or chemotherapy-resistant, B-cell, low-grade NHL. Infusion-related side effects are the most common and can be managed effectively by following the infusion rate recommendations.

CONCLUSIONS

Monoclonal antibody therapy is an effective and safe treatment modality for cancer. Infusion-related side effects are managed effectively by following infusion rate recommendations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to be knowledgeable about MAb therapy to educate patients and families regarding the mechanism of action and side-effect profiles of these agents, which often differ from those of chemotherapy or radiation therapy. Nurses should be familiar with the unique side effects of rituximab and also specific infusion-rate instructions, measures to reduce the incidence of side effects, and criteria for stopping the infusion when necessary.

Feelings of oncology patients about being nursed in protective isolation as a consequence of cancer chemotherapy treatment

This qualitative research explores the feelings of oncology patients nursed in protective isolation following high-dose chemotherapy. Five patients described their feelings about the isolation experience during audio-taped interviews lasting between a half and one hour. Tapes were transcribed and analysed, with emergent themes considered in relation to the other interviews and to the literature. The research findings indicate that cancer patients have specific concerns with regard to their experience in the isolation environment, which fall into four distinct categories of: 'being shut in'; 'coping with the experience'; 'being alone'; and 'maintaining contact with the outside world'. In addition, patients have concerns with regard to the experience of having cancer, that impinge upon the isolation experience. These are: 'having cancer'; 'suffering chemotherapy'; 'knowing what to expect'; and 'developing relationships with the health professionals'. The core variable is 'something that I have to go through'. The nature of the relationship between the categories led to the development of an integrative model for exploring the feelings of cancer patients nursed in isolation. Most of the informants coped well with the isolation experience and described feeling supported by the nursing staff. Their overriding concern in fact, reflected a desire to receive information about their disease and reassurance regarding their treatment. Being in isolation appears to inhibit communication about these issues.

Non-Hodgkin's lymphoma

OBJECTIVES

To review the etiology, epidemiology, classification, diagnosis, staging, prognosis, treatment, and nursing implications of non-Hodgkin's lymphoma.

DATA SOURCES

Research studies, review articles, and book chapters pertaining to non-Hodgkin's lymphoma.

CONCLUSIONS

Non-Hodgkins's lymphomas are a heterogeneous group of lympho-proliferative disorders, increasing in frequency, for which therapy ranges from supportive to curative.

IMPLICATIONS FOR NURSING PRACTICE

An understanding of the variety of presentations and treatments of non-Hodgkin's lymphomas will enable the oncology nurse to assist patients and their families to cope with the disease, make treatment-related decisions, and optimize the patient's quality of life.

Acquired immunodeficiency syndrome-related lymphoma

OBJECTIVES

To discuss the presentation, treatment, and aggressiveness of acquired immunodeficiency syndrome (AIDS)-related non-Hodgkin's lymphoma and AIDS-related primary central nervous system lymphoma, and to address the differences of these lymphomas in the human immunodeficiency virus (HIV)-negative individual.

DATA SOURCES

Published review articles, clinical studies, and abstracts pertaining to HIV and AIDS-related lymphomas.

CONCLUSIONS

Many believe that as the therapies and supportive care for HIV-positive individuals improve, the incidence of malignancy in this patient population will continue to increase. Great controversy exists surrounding the most effective therapies for AIDS-related lymphomas. These patients should be entered into clinical trials to test appropriate hypotheses and answer the remaining questions.

IMPLICATIONS FOR NURSING PRACTICE

As the HIV epidemic continues and HIV-associated malignancies increase, the nurse must understand the co-morbidity associated with both diseases. Oncology nurses play many roles in caring for this patient population and their support and intervention contribute to the response of the patient.

Replenishing the spirit by meditative prayer and guided imagery

OBJECTIVES

To review relevant literature describing prayer and guided imagery, and to demonstrate via the use of a vignette, the use of both prayer and guided imagery as one approach to offer spiritual care to oncology patients.

DATA SOURCES

Review and research articles from multiple disciplines, and personal clinical experience.

CONCLUSION

Meditative prayer and guided imagery are two approaches that can be used to provide spiritual care to cancer patients and families. While research has focused on elements of spirituality, research related to clinical interventions is limited.

IMPLICATIONS FOR NURSING PRACTICE

Guided imagery, metaphors, meditative prayer, and prayers of silence are effective approaches the nurse can implement when caring for the patient with cancer.

Blood cell transplantation: its impact on one family

OBJECTIVES

To share a story about being the wife of a cancer survivor who had a blood cell transplantation (BCT).

DATA SOURCES

Personal experience, and published articles related to the impact of cancer on the family.

CONCLUSIONS

Cancer affects not only the patient but the entire family unit. Yet, family members are a forgotten population. With advances in cancer treatment, survivorship has increased resulting in caregiving demands that can last for years. The lack of research related to the impact of BCT on family members must be addressed.

IMPLICATIONS FOR NURSING PRACTICE

There are many ways that nurses can provide holistic care to family members who have a loved one going through a BCT. Physical, psychological, social, and spiritual aspects of care can make a tremendous impact on the lives of patients and family members.

Survivors of acute leukaemia and highly malignant lymphoma--retrospective views of daily life problems during treatment and when in remission

Fifty-four former patients, in remission after acute leukaemia or highly malignant lymphoma, responded to a questionnaire covering their physical problems, their view of the help they received, who was most helpful to them during the treatment phase, and the impact of the disease and treatment on their current life. Energy loss and nutritional problems were most troublesome during the treatment phase, signifying many other physical problems. Patients with acute leukaemia had more problems, and thought the care was worse than did patients with highly malignant lymphoma. Serious physical problems correlated with low satisfaction with practical help received, indicating that the nurses failed to meet the needs of those suffering the most. Reduced psychological and sexual energy persisted in remission, showed no correlation with the extent of physical problems during the treatment phase, but correlated with co-existing problems and sensitivity to infections, with a great need for intimate help and counselling and with a low sense of coherence. Family relationships were said to have improved, while work and finances were negatively affected. The results indicate that nursing care should actively focus on physical problems, especially on energy loss and nutritional problems. The overwhelming fatigue hinders patients in taking physical care of themselves, and may be overlooked by the nurse since their motor capability seems intact. The long-term effect of the illness means a reduced psychological and sexual energy and a high degree of existential problems and sensitivity to infections, which indicates the importance of follow-up care, and perhaps especially of counselling for the long-term reactions and disturbance of equilibrium.

HIV-related non-Hodgkin's lymphoma

Non-Hodgkin's lymphoma (NHL) is the second most prevalent malignancy in patients infected with HIV. Approximately 30,000 new cases of NHL are diagnosed annually, and individuals with immunodeficiencies have a greater likelihood than the general population of developing NHL. Moreover, individuals who are seropositive for HIV have a fourfold greater risk of acquiring NHL. Most of these individuals will manifest NHL as a high-grade B-cell lymphoma with extranodal presentation. Response to standard chemotherapy and/or irradiation occurs frequently. However, because of opportunistic infections, overall survival is approximately five months. The expert nurse's role in assessment and management of symptoms associated with infection and side effects of therapy is critical.

Nursing care of the patient with non-Hodgkin's lymphoma. A case study

A patient's significant life events, such as the diagnosis of cancer, coupled with critical developmental milestones provide particular challenges to nurses caring for young adults. A case study format is used to identify nursing care priorities throughout the diagnosis and treatment of a young adult male with non-Hodgkin's lymphoma. Diagnosis and treatment protocols are discussed to provide a background for nursing assessment and interventions. Nursing implications related to the treatment protocol are incorporated as are implications based on the physical and psychological impact of the disease and necessary life-style changes. Stressors created by the disease and treatments are identified, and the support of patient coping strategies and continued achievement of developmental tasks are addressed.