Treatment for Follicular Lymphoma

Treatment for Follicular Lymphoma

Once you’ve received a diagnosis of Follicular Lymphoma (FL), your doctor will talk to you about your options for treatment. They will use your individual diagnosis, stage and grade of Follicular Lymphoma and your age and general health to recommend the best treatment to help you live well with this currently incurable blood cancer.

Most people who are diagnosed with Follicular Lymphoma are told they either have early or advanced stage FL. Around 15-20% of people are diagnosed with early stage (stage 1 or 2) Follicular Lymphoma. The rest are diagnosed with advanced (stage 3 or 4) Follicular Lymphoma, which means it can be found in multiple areas of the body.

We know that being told a cancer is advanced is frightening. Don’t worry, it’s very typical for people newly diagnosed with FL to be told that their disease is advanced. That’s because Follicular Lymphoma doesn’t behave in the same way as most other cancers so it’s important to know that the term ‘advanced’ doesn’t necessarily mean that you are going to be at greater risk of a poor outcome. You’ll still be offered the same choice of medical treatments as someone in early-stage Follicular Lymphoma too

Treatments

There’s a variety of different treatments for Follicular Lymphoma. Your Follicular Lymphoma treatment will depend on:

  • Your individual diagnosis
  • Your grade of Follicular Lymphoma
  • Your stage of Follicular Lymphoma
  • Your age and general health
  • Whether your lymphoma is classed as indolent (slow-growing) or not
  • Whether you have any active symptoms

Follicular Lymphoma treatment plan

Every Follicular Lymphoma treatment plan is unique and reflects each individual patient. Through the FLF community, you may meet someone with the same grade and stage of lymphoma as you, but your treatment plans may not be the same.

Your doctor will explain everything to you and give you the opportunity to ask any questions that you have. At your chosen hospital or facility, you’ll also have a specialist nurse and wider team assigned to you.

Early-stage Follicular Lymphoma will usually be treated using either radiotherapy as a standalone treatment, or in combination with immunotherapy or chemotherapy.

Advanced stage Follicular Lymphoma treatment will depend on whether or not you are experiencing symptoms of FL. If you do have symptoms, you may be offered a combination of immunotherapy and chemotherapy. If you don’t presently have any symptoms, your doctor may suggest active monitoring/watch and wait, or rituximab therapy alone.

Active monitoring/watch and wait

If you are diagnosed with indolent/slow-growing lymphoma and you aren’t currently experiencing any symptoms, you may not need treatment immediately. In fact, it could be months or even years before treatment is needed. Instead, your doctor may recommend that you simply watch and wait.

We understand that not actively undergoing any sort of treatment while living with cancer can seem scary and a little unproductive. But sometimes, it really is the best thing to do. Clinical trials have previously shown that active monitoring doesn’t adversely affect the survival rate of Follicular Lymphoma.

While you are on active monitoring, your doctor will still ask you to attend regular check-ups, which normally include physical examinations and blood tests. If you develop any Follicular Lymphoma symptoms or other indications that you need treatment, this will be detected, and action can be taken right away.

Radiotherapy

If you are diagnosed with stage 1 or stage 2 Follicular Lymphoma, you may be treated with radiotherapy alone. Radiotherapy uses high-energy beams to target the cancer cells and stop them from growing. It’s possible for your radiation oncology team to change the size of the beams of radiation to as close to the same size as the tumour as possible, and this will help prevent any damage being done to healthy cells nearby.

Radiation is usually given in small doses each day over a period of a few weeks. The doses, its delivery and your “treatment plan” are carefully worked out by your radiation oncology team. Each treatment should take no more than 30 minutes, is completely painless and you’ll be able to talk to your radiation oncologist throughout.

Side effects from radiotherapy can vary between patients, but it’s normal to experience some or all of the following:

General side effects:

  • Tiredness

Local side effects can be dependent on where your lymphoma is and what area is treated and can include:

  • Sore, red skin (at the site of treatment)
  • Dry mouth (if treatment is in the head and neck area)
  • Nausea/vomiting (if treatment is around the abdomen)
  • Upset stomach/diarrhoea (if treatment is around the abdomen)
  • Hair loss (if treatment is around the head)

Immunotherapy

Immunotherapy is a treatment technique that targets the immune system, making it work more effectively to fight disease – in this case, cancer. The most common immunotherapy drug used to treat Follicular Lymphoma is rituximab. Rituximab can be used as a standalone medication, or in combination with other chemotherapy drugs. 

Rituximab is also referred to as a targeted therapy and belongs to a group of medications called monoclonal antibodies. These are man-made proteins that are designed to attack a specific part on the surface of the cancerous cells causing their destruction.

Some people have an allergic-type reaction to rituximab, most commonly with the first infusion. This is not uncommon and can occur after any antibody-based drug. Reactions can be successfully controlled by reducing the rate or temporarily stopping the infusion and using anti-histamines and sometimes steroid medications. Your nurses will monitor you very closely during your treatment, and manage you if you have a reaction to rituximab, or whatever antibody you are receiving.

"We do not have to do this alone, we have a community that stands behind us. There is hope and I live with the understanding that a positive outlook on life will help me to live a longer and fuller life"

Thomas Watson

Chemotherapy

Chemotherapy, or ‘chemo’ as it’s shortened to, is the best-known form of cancer treatment. It has a reputation of causing debilitating and unpleasant side effects, but huge advances have been made in treatment that mean that it can now be given as an outpatient and many people continue to work and live a fulfilling life while undergoing chemotherapy.

If you are recommended to have chemotherapy for Follicular Lymphoma, it’s important to find out what type of chemotherapy you’ll be receiving and what you can expect from your treatment. Ask your doctor whatever questions you have , including what you can do to help manage your tolerance to the treatment. 

How does chemotherapy work?

Cancer is caused by abnormal cells dividing and reproducing, usually at an abnormal rate, clumping together until they form a mass, referred to as a tumour.

Chemotherapy stops cancer cells from reproducing and spreading throughout the body. Unlike radiotherapy which targets a specific tumour site, chemotherapy works throughout the body. Unfortunately, this means that any non-cancerous cells that are constantly renewing – such as those responsible for our skin, hair, bone marrow and digestive system – are also affected. As a result, there are a range of side effects that may occur with chemotherapy treatment.

Chemotherapy drugs are often administered intravenously through a vein in the hand or arm. However, some people need to have their chemo administered via a PICC line or implantable port. A PICC line is a long, thin silicone tube (IV catheter) that is inserted into the upper arm, with the tip ending at the largest vein in the body.  It is usually placed by a specialist nurse under ultrasound guidance. An implantable port is a device surgically inserted under the skin on the chest. PICC lines and ports can stay in your body for long periods of time, making them useful if you are undergoing a lengthy treatment plan. They also mean that blood tests can be performed without a separate needle.

Intravenous chemotherapy must be performed in a chemo unit or hospital, where you may be treated as an outpatient or inpatient. Treatment can take anywhere from a few minutes to a few hours and most people read, watch TV or relax while having treatment.
An increasing number of chemotherapy drugs, including many of the newer targeted agents, are given by mouth, so you may be prescribed it in tablet form instead. These can be taken at home as directed by your doctor. Regardless of how they’re administered, you’ll need to have regular blood tests to check how well your body is functioning while you are having treatment.

An increasing number of  chemotherapy drugs, including many of the newer targeted agents, are given by mouth, so you may be prescribed it in tablet form instead. These can be taken at home as directed by your doctor. Regardless of how they’re administered,  you’ll need to have regular blood tests to check how well your body is functioning while you are having treatment.

Side effects of chemotherapy for Follicular Lymphoma

Side effects are a normal and unavoidable occurrence with most medications. Your health care team will review the expected side effects of your particular treatment. Remember that different regimens have different potential side effects, and you may or may not experience them. Common side effects of chemotherapy include:

  • Increase risk of infection
  • Anaemia and, if severe, associated weakness and breathlessness
  • Bruising, bleeding gums and/or nosebleeds if platelet counts are low
  • Nausea and/or vomiting (often preventive medications are given)
  • Skin rashes
  • Tiredness
  • Sore mouth
  • Hair loss
  • Tingling in hands or feet
  • Headaches
  • Metallic taste
  • Diarrhoea or constipation
 

Tips for managing chemotherapy

If you are having chemotherapy, there are some things that you can do to help manage the effects.

  • Drink plenty of water. Being hydrated helps to flush the chemotherapy drugs through your body and can make you feel better.
  • Chemo can affect your taste buds, meaning the foods you usually eat aren’t as appealing. Oncologists recommend that you eat whatever tastes good and fuels your body. Many people who have chemo recommend ice lollies and frozen fruit to help eliminate the metallic taste that is a common side effect of treatment.
  • Try and take regular walks to keep your circulation moving, your heart healthy and boost your natural endorphins.

Combined immune-chemotherapy treatments for Follicular Lymphoma

There are several different combinations of immunotherapy and chemotherapy combinations used to treat Follicular Lymphoma.

R-CHOP and R-CVP

R-CHOP and R-CVP are acronyms for treatments that combine chemotherapy with Rituximab.

R-CHOP contains:

  • Rituximab (Rituxan®)
  • Cyclophosphamide
  • Doxorubicin (Adriamycin®)
  • Vincristine (Oncovin®)
  • Prednisolone (Prednisone)

R-CVP contains:

  • Rituximab (Rituxan®)
  • Cyclophosphamide
  • Vincristine (Oncovin®)
  • Prednisolone (Prednisone)

Both of these combinations are administered intravenously and via tablets. Commonly these are given as an outpatient, although you may need a hospital stay especially for the first cycle. The intravenous treatment is given on day 1 of a 3 week cycle (the prednisolone tablets are given for 5 days), with most people requiring 6 cycles. This means that you can expect your treatment plan to take in the region of 4 to 6 months.

Rituximab and Bendamustine (BR)

Bendamustine is a chemotherapy drug that works by disrupting the DNA in cancer cells so that they can’t divide and grow. Clinical studies have shown that combining Rituximab with Bendamustine is highly effective in patients with both newly diagnosed and relapsed indolent Follicular Lymphoma.

This combination of immune-chemotherapy is taken every 28 days or 4 weeks on day 1 and day 2 of your cycle with Rituximab usually given on day 1 only. Each 4 week period represents a single cycle, and patients can have up to 6 cycles of treatment with a 26 day break between each. The bendamustine treatment is delivered intravenously in a process that takes around 15-60 minutes. Rituximab is given over 4-6 hours cycle 1, then can be given somewhat faster in later cycles.

Rituximab and Chlorambucil

Chlorambucil (Leukeran®) is an oral chemotherapy medication It is one of the original chemo drugs developed and not used as much anymore. It is most often recommended for elderly patients or those who have poor fitness.

Obinutuzumab (Gazyva)

Obinutuzumab is a newer, targeted antibody treatment that is similar to rituximab, but has some different properties. It can be used alone but commonly is used in combination with chemotherapy for the treatment of Follicular Lymphoma.

Obinutuzumab is administered intravenously, usually over several hours as an outpatient on a weekly or less frequent schedule depending on the regimen. The treatment is sometimes referred to as O-CHOP or O-Bendamustine depending on which chemotherapy treatment you have.

Rituximab and Lenalidomide (Revlimid®/R2)

In 2019, lenalidomide and rituximab were approved by the US Food & Drug Administration (FDA) for use in patients who have previously been treated for Follicular Lymphoma.

Lenalidomide is referred to as an immunomodulatory drug which can boost the immune system. At the present time, this combination of drugs is the only one which does not involve the use of standard chemotherapy. Studies comparing this combination with other chemo-based combinations in both relapsed FL and as initial therapy for FL found the results to be comparable, although some of the side effects were different, making a Rituximab and Lenalidomide combination a viable alternative. In some countries, this combination is approved for the first line of treatment against Follicular Lymphoma.

Side effects of Lenalidomide include low blood count, constipation or diarrhoea, itching, skin rash and fatigue. It carries a risk of causing birth defects so must not be taken during pregnancy. Strict controls are required for women of childbearing age. It also can increase the risk of blood clots, so your doctor will discuss whether to take aspirin or a stronger blood thinner.

Remission

If your Follicular Lymphoma treatment is successful, you’ll be told that you have had a response and are in remission. Remission means that your body has responded positively to your treatment and your lymphoma is much smaller or gone completely. A complete response (CR) is when all the areas of the body affected by lymphoma are completely normalised by whatever measure is being used, usually a CT scan, though in some countries PET scans are used. If the enlarged areas affected by lymphoma overall have reduced in size by at least 50% but are still larger than normal, this is termed a partial response (PR).

The overall response rates (this includes both complete and partial response) to initial immunochemotherapy for FL are 80-90%. Around 50% of people with Follicular Lymphoma will have a first remission lasting 5-10 years after their initial treatment.

Although complete response (CR) means current tests can no longer detect any evidence of visible cancer, unfortunately we know that a low level of lymphoma cells can still remain and the likelihood is that it will return in the future. You will be monitored closely and this enables you to restart treatment when you need to.

Maintenance therapy

If you are in remission, your doctor may suggest that you have something that’s referred to as ‘maintenance therapy’. This is where further treatments are provided for a period of time to help keep the cancer at bay for longer.

At the present time, maintenance therapy involves further Rituximab treatments – usually a dose every 2 months for 2 years. Rituximab maintenance therapy has been shown to keep lymphoma under control and postpone its reappearance, but not affect overall survival. The risks and benefits should be discussed with your doctor. Because rituximab can suppress your immune system, and in particular block response to vaccines including Covid vaccines, this may affect the decision on whether you should have maintenance or not.
Obinutuzumab can also be used for maintenance therapy in a similar way if you received it as part of your initial therapy.

If your doctor thinks that you would benefit from maintenance therapy, this will be discussed with you at your appointment.

"When looking into my type of cancer, I realised how unknown it is to most people, however, in my search I found The Follicular Lymphoma Foundation that aims to find a cure. I know how important and rewarding it is to exchange experiences with people who are living in situations similar to ours, with the same doubts, fears, weaknesses and hopes, and how rewarding the mutual help of a group is."

Lilia Luzes