The doctor develops a treatment plan to fit each patient's needs. Treatment for non-Hodgkin's lymphoma depends on the stage of the disease, the type of cells involved, whether they are indolent or aggressive, and the age and general health of the patient.

Non-Hodgkin's lymphoma is often treated by a team of specialists that may include a hematologist, medical oncologist, and/or radiation oncologist. Non-Hodgkin's lymphoma is usually treated with chemotherapy, radiation therapy, or a combination of these treatments. In some cases, bone marrow transplantation, biological therapy, or surgery may be options. For indolent lymphomas, the doctor may decide to wait until the disease causes symptoms before starting treatment. Often, this approach is called "watchful waiting."

Getting a Second Opinion

Before starting treatment, patients may want a second opinion to confirm their diagnosis and treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.

There are a number of ways to find a doctor who can give a second opinion:

• The patient's doctor may be able to suggest specialists to consult.
• Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.
• The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and medical background. This resource, produced by the American Board of Medical Specialties, is available in most public libraries and on the Internet.

Preparing for Treatment

Many people with cancer want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for people to think of everything they want to ask the doctor. Often, it helps to make a list of questions. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor--to take part in the discussion, to take notes, or just to listen.

These are some questions a patient may want to ask the doctor before treatment begins:

• What kind of non-Hodgkin's lymphoma do I have?
• What is the stage of the disease?
• What are my treatment choices? Which do you recommend for me? Why?
• What are the risks and possible side effects of each treatment?
• What side effects should I report to you? ? How long will treatment last?
• What are the chances that the treatment will be successful?
• Will treatment affect my normal activities? If so, for how long?
• Are new treatments under study? Would a clinical trial be appropriate for me?
• What is the treatment likely to cost?

Patients do not need to ask all their questions or remember all the answers at one time. They will have other chances to ask the doctor to explain things and to get more information.

Methods of Treatment

Chemotherapy and radiation therapy are the most common treatments for non-Hodgkin's lymphoma, although bone marrow transplantation, biological therapies, or surgery are sometimes used.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for non-Hodgkin's lymphoma usually consists of a combination of several drugs. Patients may receive chemotherapy alone or in combination with radiation therapy.

Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most anticancer drugs are given by injection into a blood vessel (IV); some are given by mouth. Chemotherapy is a systemic therapy because the drugs enter the bloodstream and travel throughout the body.

Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.

These are some questions patients may want to ask the doctor before starting chemotherapy:

• What is the goal of this treatment?
• What drugs will I be taking?
• Will the drugs cause side effects? What can I do about them?
• What side effects should I report to you? ? How long will I need to take this treatment?
• What can I do to take care of myself during treatment?
• How will we know if the drugs are working?

Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells. Treatment with radiation may be given alone or with chemotherapy. Radiation therapy is local therapy; it affects cancer cells only in the treated area. Radiation therapy for non-Hodgkin's lymphoma comes from a machine that aims the high-energy rays at a specific area of the body. There is no radioactivity in the body when the treatment is over.

These are some questions a patient may want to ask the doctor before having radiation therapy:

• What is the goal of this treatment?
• What are its risks and possible side effects?
• What side effects should I report to you?
• How will radiation be given? ? When will the treatments begin? When will they end?
• What can I do to take care of myself during therapy?
• How will we know if the radiation therapy is working?
• How will treatment affect my normal activities?

Sometimes patients are given chemotherapy and/or radiation therapy to kill undetected cancer cells that may be present in the central nervous system (CNS). In this treatment, called central nervous system prophylaxis, the doctor injects anticancer drugs directly into the cerebrospinal fluid.

Bone marrow transplantation (BMT) may also be a treatment option, especially for patients whose non-Hodgkin's lymphoma has recur (come back). BMT provides the patient with healthy stem cells (very immature cells that produce blood cells) to replace cells damaged or destroyed by treatment with very high doses of chemotherapy and/or radiation therapy. The healthy bone marrow may come from a donor, or it may be marrow that was removed from the patient, treated to destroy cancer cells, stored, and then given back to the person following the high-dose treatment. Until the transplanted bone marrow begins to produce enough white blood cells, patients have to be carefully protected from infection. They usually stay in the hospital for several weeks.

These are some questions patients may want to ask the doctor before having a BMT: ? What are the benefits of this treatment? ? What are the risks and possible side effects? What can be done about them? ? What side effects should I report to you? ? How long will I be in the hospital? What care will I need after I leave the hospital? ? How will the treatment affect my normal activities? ? How will I know if the treatment is working?

Biological therapy (also called immunotherapy) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to lessen the side effects that can be caused by some cancer treatments. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. Biological therapy is sometimes also called biological response modifier therapy.

These are some questions patients may want to ask the doctor before starting biological therapy:

• What is the goal of this treatment?
• What drugs will I be taking?
• Will the treatment cause side effects? If so, what can I do about them?
• What side effects should I report to you? ? Will I have to be in the hospital to receive treatment?
• How long will I need to take this treatment?
• When will I be able to resume my normal activities?

Surgery may be performed to remove a tumor. Tissue around the tumor and nearby lymph nodes may also be removed during the operation.

These are some questions a patient may want to ask the doctor before surgery:

• What kind of operation will it be?
• How will I feel after the operation?
• If I have pain, how will you help?
• Will I need more treatment after surgery?
• How long will I be in the hospital?
• When will I be able to resume my normal activities?

Clinical Trials

Many people with non-Hodgkin's lymphoma take part in cancer trials (research studies). Doctors conduct clinical trials to learn about the effectiveness and side effects of new treatments. In some trials, all patients receive the new treatment. In others, doctors compare different therapies by giving the new treatment to one group of patients and the standard therapy to another group; or they may compare one standard treatment with another. Research like this has led to significant advances in the treatment of cancer. Each achievement brings researchers closer to the eventual control of cancer.
Doctors are studying radiation therapy, new ways of giving chemotherapy, new anticancer drugs and drug combinations, biological therapies, bone marrow transplantation, peripheral stem cell transplantation, and new ways of combining various types of treatment. Some studies are designed to find ways to reduce the side effects of treatment and to improve the patient's quality of life.

People who take part in these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science.

Patients who are interested in taking part in a clinical trial should talk with their doctor.

Side Effects of Treatment

Treatments for non-Hodgkin's lymphoma are very powerful. It is hard to limit the effects of therapy so that only cancer cells are removed or destroyed. Because treatment also damages healthy cells and tissues, it often causes side effects.

The side effects of cancer treatment depend mainly on the type and extent of the therapy. Side effects may not be the same for everyone, and they may even change from one treatment to the next. Doctors and nurses can explain the possible side effects of treatment. They can also lessen or control many of the side effects that may occur during and after treatment.

Chemotherapy

The side effects of chemotherapy depend mainly on the drugs and the doses the patient receives. As with other types of treatment, side effects may vary from person to person.

Anticancer drugs generally affect cells that divide rapidly. In addition to cancer cells, these include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected, the patient is more likely to get infections, may bruise or bleed easily, and may feel unusually weak and tired. The patient's blood count is monitored during chemotherapy and, if necessary, the doctor may decide to postpone treatment to allow blood counts to recover.

Cells in hair roots also divide rapidly; therefore, chemotherapy may lead to hair loss. Patients may have other side effects such as poor appetite, nausea and vomiting, or mouth and lip sores. They may also experience dizziness and darkening of skin and fingernails.

Most side effects go away gradually during the recovery periods between treatments or after treatment is over. However, certain anticancer drugs can increase the risk of developing a second cancer later in life.

In some men and women, chemotherapy causes a loss of fertility (the ability to produce children). Loss of fertility may be temporary or permanent, depending on the drugs used and the patient's age. For men, sperm banking before treatment may be an option. Women's menstrual periods may stop, and they may have hot flashes and vaginal dryness. Menstrual periods are more likely to return in young women.

Radiation Therapy

The side effects of radiation depend on the treatment dose and the part of the body that is treated. During radiation therapy, people are likely to become extremely tired, especially in the later weeks of treatment. Rest is important, but doctors usually advise patients to try to stay as active as they can.
It is common to lose hair in the treated area and for the skin to become red, dry, tender, or itchy. There may also be permanent darkening or "bronzing" of the skin in the treated area.

When the chest and neck are treated, patients may have a dry, sore throat and trouble swallowing. Some patients may have tingling or numbness in their arms, legs, and lower back. Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. Often, changes in diet or medicine can ease these problems.

Radiation therapy also may cause a decrease in the number of white blood cells, cells that help protect the body against infection. If that happens, patients need to be careful to avoid possible sources of infection. The doctor monitors a patient's blood count during radiation therapy. In some cases, treatment may have to be postponed to allow blood counts to recover.

Although the side effects of radiation therapy can be difficult, they can usually be treated or controlled. It may also help to know that, in most cases, side effects are not permanent. However, patients may want to discuss with their doctor the possible long-term effects of radiation treatment on fertility and the increased chance of second cancers after treatment is over.

Bone Marrow Transplantation

Patients who have a bone marrow transplant face an increased risk of infection, bleeding, and other side effects from the large doses of chemotherapy and radiation they receive. In addition, graft-versus-host disease (GVHD) may occur in patients who receive bone marrow from a donor. In GVHD, the donated marrow attacks the patient's tissues (most often the liver, the skin, and the digestive tract). GVHD can range from mild to very severe. It can occur any time after the transplant (even years later). Drugs may be given to reduce the risk of GVHD and to treat the problem if it occurs.

Biological Therapy

The side effects caused by biological therapy vary with the specific type of treatment. These treatments may cause flu-like symptoms such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients also may bleed or bruise easily, get a skin rash, or retain fluid. These problems can be severe, but they usually go away after treatment stops.

Surgery

The side effects of surgery depend on the location of the tumor, the type of operation, the patient's general health, and other factors. Although patients are often uncomfortable during the first few days after surgery, the pain can usually be controlled with medicine. People can talk with their doctor or nurse about pain relief. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each patient

Risk Factors Associated with Non-Hodgkin's Lymphoma

The incidence of non-Hodgkin's lymphoma has increased dramatically over the last couple of decades. This disease has gone from being relatively rare to being the fifth most common cancer in the United States. At this time, little is known about the reasons for this increase or about exactly what causes non-Hodgkin's lymphoma.

Doctors can seldom explain why one person gets non-Hodgkin's lymphoma and another does not. It is clear, however, that cancer is not caused by an injury, and is not contagious; no one can "catch" non-Hodgkin's lymphoma from another person.

By studying patterns of cancer in the population, researchers have found certain risk factors that are more common in people who get non-Hodgkin's lymphoma than in those who do not. However, most people with these risk factors do not get non-Hodgkin's lymphoma, and many who do get this disease have none of the known risk factors.

The following are some of the risk factors associated with this disease:

• Age/Sex--The likelihood of getting non-Hodgkin's lymphoma increases with age and is more common in men than in women.
• Weakened Immune System--Non-Hodgkin's lymphoma is more common among people with inherited immune deficiencies, autoimmune diseases, or HIV/AIDS, and among people taking immunosuppressant drugs following organ transplants.
• Viruses--Human T-lymphotropic virus type I (HTLV-1) and Epstein-Barr virus are two infectious agents that increase the chance of developing non-Hodgkin's lymphoma.
• Environment--People who work extensively with or are otherwise exposed to certain chemicals, such as pesticides, solvents, or fertilizers, have a greater chance of developing non-Hodgkin's lymphoma.

People who are concerned about non-Hodgkin's lymphoma should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor's advice will be based on the person's age, medical history, and other factors.

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