Nursing Considerations for Lymphoma Survivorship Care

February 04, 2021 by Kathleen Wiley MSN, RN, AOCNS®

Sample Lymphoma Survivorship Care Plan

History and physical examination

History and physical exam every three to six months for one to two years, then every 6–12 months until year 3, then annually.

Surveillance to detect recurrence, including blood work, symptom assessment, and imaging. Frequency is determined by age, comorbidities, staging, lymphoma type, and risk of recurrence.

Imaging

Use routine computed tomography (CT) or positron-emission tomography/CT for disease monitoring, dependening on lymphoma type or as clinically indicated. See NCCN guidelines (https://www.nccn.org/professionals/physician_gls/pdf/hodgkins.pdf) for specific recommendations.

Labs

Check complete blood counts and chemistry panels with lipids postchemotherapy.

Consider evaluating thyroid function if patients received radiation to the neck.

Additional considerations depending on treatment received

Consider LVEF evaluation if patients received anthracyclines or left-sided chest radiation.

Conduct bone density tests for patients on long-term steroids.

Recommend clinical and self-breast exams if patients received radiation to the chest.

Disease assessment

Educate patients on the signs and symptoms of disease recurrence: bone pain, palpable mass, lymphadenopathy, or B symptoms.

Conduct additional evaluation and diagnostic work-up for suspicious symptoms.

Genetic risk evaluation

Data do not suggest a genetic link for lymphomas, so family members may not need genetic testing.

Psychosocial care

Assess and manage psychosocial concerns (e.g., distress, anxiety, depression, infertility, financial toxicity).

Psychosocial care

Assess and manage psychosocial concerns (e.g., distress, anxiety, depression, infertility, financial toxicity).

As treatments have advanced and patients and providers have more options, cure and survivorship rates for lymphomas are improving (https://www.cancer.org/cancer/hodgkin-lymphoma/about/key-statistics.html): five-year survival rates for Hodgkin and non-Hodgkin lymphoma are 86% and 71%, respectively. Despite good results from treatment, research indicates that lymphoma survivors carry a significant amount of late and chronic effects. Even in a complete remission, late effects of treatment present (https://doi.org/10.1200/CCI.18.00015) a burden for patients' physical and psychosocial well-being.

Late and Long-Term Effects

Lymphoma survivors are at risk for various late and long-term effects largely dependent on the treatment modality, specific agents prescribed, and dosage received. For radiation, effects vary based on location and intensity but commonly involve skin effects, fatigue, cardiac arrythmias, and pneumonitis. Late effects (https://ascopost.com/issues/november-10-2017/life-after-treatment-managing-lymphoma-survivors) occurring months or years after treatment include (https://www.cancer.org/cancer/hodgkin-lymphoma/after-treatment/lifestyle-changes.html) pulmonary toxicities, radiation fibrosis, cardiomyopathy, coronary artery disease, hypothyroidism, and secondary malignancies (https://www.uptodate.com/contents/approach-to-the-adult-survivor-of-classic-hodgkin-lymphoma) such as myelodysplastic syndrome, leukemia, or breast cancer.

Chemotherapy side effects are also related to specific agents but generally include fatigue, peripheral neuropathy, fertility, sexual side effects, menopausal symptoms, pulmonary toxicity (pneumonitis), and cognitive dysfunction. If patients received combination therapy (https://www.cancer.org/cancer/hodgkin-lymphoma/after-treatment/lifestyle-changes.html) with anthracyclines, secondary malignancies and cardiovascular effects are also considerations (Olsen et al., 2019), or bone changes and immunosuppression may result from combination treatments with steroids (Ofshenko, 2019).

Cellular treatments such as stem cell transplantation and CAR T-cell therapy are associated with extensive long-term and late effects. Key considerations include (https://www.cancer.org/cancer/hodgkin-lymphoma/after-treatment/lifestyle-changes.html) immunosuppression, infection, graft-versus-host disease, organ toxicities, infertility, and secondary malignancies (https://www.nccn.org/professionals/physician_gls/pdf/hodgkins.pdf) such as post-transplant lymphoproliferative disorder.

Ongoing Screening and Prevention

Cardiovascular disease and secondary malignancies are the most common causes (https://www.uptodate.com/contents/approach-to-the-adult-survivor-of-classic-hodgkin-lymphoma) of morbidity and mortality in lymphoma survivors, so screening for and preventing future malignancies is a critical component of survivorship care. Recommendations should be tailored to specific patient factors, risks factors, comorbidities, and family history, but in general, lymphoma survivors should have routine blood work, including lipid panels, and monitoring for secondary malignancies. Health maintenance plans should encourage routine, age-appropriate cancer screening, regular exercise, smoking cessation, limited alcohol consumption, sun safety, and appropriate vaccinations. Dietary recommendations include (https://www.uptodate.com/contents/the-roles-of-diet-physical-activity-and-body-weight-in-cancer-survivors) high consumption of fruits, vegetables, and whole grains (https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf) and reduced amounts of fat, processed foods, and red meat.

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