Treating lymphoma is an aggressive process. While treatment – which includes surgery, chemotherapy, and radiation – can cure the patient, it can also cause serious side effects and reduce quality of life. HIV-infected patients with relatively high T-cell counts (greater than 200), a low-stage form of lymphoma, less than 35 years of age, and no prior history of an AIDS-related problem stand the best chance of curing the lymphoma and surviving radiation and/or chemotherapy.
The standard treatments for lymphoma include:
Surgery: Removing the tumor by way of surgery is often performed. Surgical removal of a tumor often requires chemotherapy and/or radiation to improve success rates.
Radiation (radiotherapy): Radiation uses high-energy x-rays to kill cancer cells and shrink individual tumors. Early-stage lymphomas (Stages I and II) can often be treated using radiation alone. However, most HIV-related lymphomas are diagnosed in their late stages, thus requiring chemotherapy in combination with radiation. Large doses of whole-brain radiation is the standard therapy for CNS lymphoma, curing between 20% and 50% of all patients who undergo therapy.
Chemotherapy for NHL: Drug therapy for lymphoma almost always involves a combination of three or more chemotherapy compounds. For NHL, there are three generally recommended regimens.
Here are the three most common regimens:
mBACOD: A combination of methotrexate, bleomycin, Adriamycin®, cyclophosphamide, Oncovin®, and dexamethasone. While standard doses of this combination are most effective, lower doses can be prescribed for HIV-positive patients with low T-cell counts to help maintain as much immune function as possible. A clinical trial has determined that lower-dose mBACOD is just as effective as standard-dose mBACOD in HIV-positive people with lymphoma. However, in order to get the maximum benefit from treatment, patients who have high T-cell counts (more than 200 cells) before starting chemotherapy are often given the full dose of mBACOD.
CHOP: A combination of cyclophosphamide, hydroxydaunomycin (doxorubicin), Oncovin®, and prednisone. As with mBACOD, a low-dose version of this regimen has been established for HIV-infected NHL patients. However, one study found that low-dose CHOP is not as effective as standard-dose CHOP.
CDE: A combination of cyclophosphamide, doxorubicin, and etoposide. This combination is usually given over a four-day period through an intravenous (IV) line.
Rituxan (rituximab): This is a monoclonal antibody that circulates around the body and marks lymphoma cells for destruction by other immune system cells. It is still experimental in terms of treating HIV-related lymphomas and not all HIV-related lymphomas can be treated with rituximab. However, clinical trials involving non-HIV-positive people with certain types of lymphoma found that rituximab, combined with standard chemotherapy drugs, increased the chance of curing the cancer. It is administered through an IV line, much like chemotherapy.
Chemotherapy for HD: The most common combination regimen, called ABVD, includes Adriamycin®, bleomycin, vinblastine, and dacarbazine.
CNS lymphoma prevention (prophylaxis): If the lymphoma is found to be in a high stage (stage III or IV), patients are often encouraged to undergo therapy to prevent cancer cells from spreading to the brain. To do so, a drug called cytarabine (Ara-C) is infused directly into the brain or spinal column every week, usually for four weeks, either at the beginning or the end of NHL therapy. The drug is administered either through a shunt, or port, surgically implanted in the skull, or through an IV line placed into the spinal column every week.
Opportunistic infection prevention (prophylaxis): Chemotherapy can cause T-cells and other white blood cells to decrease. This can increase the risk of developing infections like Pneumocystis carinii pneumonia (PCP). It is recommended that all HIV-infected patients undergoing lymphoma chemotherapy, regardless of their pre-treatment T-cell counts, receive prophylaxis to prevent PCP (e.g., Bactrim/Septra).
Side-effect therapies: Chemotherapy can have a serious effect on white blood cell counts (WBCs) and red blood cell counts (RBCs). Luckily there are treatments available to help manage these two serious side effects during chemotherapy. For decreased WBCs, particularly the bacteria-fighting neutrophils, drugs called colony stimulating factors (Neupogen® and Leukine®) are usually started within days after chemotherapy is initiated to protect these important cells. As for decreased RBCs due to chemotherapy, which can cause anemia and fatigue, blood transfusions are sometimes recommended, along with the drugs leucovorin calcium (Leukovorin®) and/or epoetin-alfa (Procrit®).
Nausea is another common side effect of chemotherapy. Drugs used to help control nausea are available and are often given to patients during and after chemotherapy infusion. Combating nausea is a process of trial and error. Patients often have to try several different anti-nausea drugs before finding one that works for them. While not approved by the Food and Drug Administration, smoking marijuana has been said to be highly effective for nausea and increasing appetite
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