Chemotherapy for T-Cell Lymphoma (part 1 of 3)

By: Amila M. Patel, Pharm.D., BCOP

Overview

There are a variety of treatment options available for the treatment of T-cell lymphoma and leukemia.  One of the most common forms of treatment is chemotherapy, which consists of drugs used to treat a disease, such as cancer.  While surgery and radiation therapy are used to remove or kill cancer cells in a particular area, chemotherapy can act on the rapidly dividing cancer cells throughout your entire body.

The type of chemotherapy treatment you receive will depend on the subtype of T-cell lymphoma or leukemia you have, the stage of your disease, and your overall health status.  Chemotherapy may be given as a single-agent (such as pralatrexate and romidepsin) or, more commonly, as a combination of several chemotherapy drugs (CHOP regimen).  When chemotherapy is given as a combination, each drug acts in a different way to kill the cancer cells in your body.

You and your doctor will discuss what the best chemotherapy regimen is for you, how often and for how long it will be given, and the ultimate goal of giving this chemotherapy.

How is chemotherapy given?

Chemotherapy for the treatment of T-cell lymphoma or leukemia may be delivered in several ways.  The treatment that you receive may all be given by a single route of administration or by a combination of different routes, as described below.

Intravenous (IV)

Most chemotherapy is given into the vein, or intravenously (IV).  When given by the IV route, drugs are delivered quickly throughout the body.   Often times, patients receiving chemotherapy have an implantable venous access port placed.  This device is surgically placed under the skin of the chest or upper arm.  A port allows for the administration of several drugs at once, helps provide reliable access to the vein to avoid damage to surrounding muscle and skin tissue, and is intended for long-term therapy.

Oral (PO)

Oral chemotherapy is medication taken by mouth, usually as tablets or capsules.  This route of administration may not always be available for a particular chemotherapy or may not be the best choice for patients with severe nausea/vomiting or for patients who are unable to swallow pills or liquids.

Intrathecal (IT)

Intrathecal chemotherapy is given directly into the fluid surrounding the brain and spinal cord (the cerebrospinal fluid, or CSF).  Because systemic chemotherapy in the bloodstream has a difficult time reaching the brain and spinal cord, this localized IT chemotherapy allows for drug to treat cancer cells in the central nervous system.  IT chemotherapy is usually given by a lumbar puncture, or spinal tap.  A thin needle is placed between the bones of the lower spine and drug is injected into the space through which the CSF surrounds the spinal cord.

There are other routes of administration of chemotherapy which are less commonly used in the treatment of T-cell lymphoma and leukemia.  You and your oncology team will discuss how each of your chemotherapy drugs will be given in detail.

What side effects should I expect while on chemotherapy?

Chemotherapy is given to kill cancer cells, but may also harm normal cells in the body.   Because chemotherapy attacks any rapidly dividing cells, the normal cells that are most likely to be harmed are those that also rapidly divide, including normal blood cells, hair follicle cells, and cells lining the intestinal tract.  Damage to these cells account for many of the side effects experienced while on chemotherapy.

Some of the more common side effects are detailed below.

Fatigue

Fatigue is one of the most common side effects experienced while on chemotherapy.  Fatigue can range from feeling a bit tired to feeling completely “wiped out.”  This symptom is typically worst the week after you receive your chemotherapy and generally resolves after chemotherapy is complete.

Hair Loss

While many people associate chemotherapy with hair loss, it is important to remember that not all chemotherapy drugs cause hair loss.  Your oncology team will be able to tell you whether the chemotherapy regimen you receive will likely cause hair loss or thinning.  Typically, hair loss occurs after a few treatments of chemotherapy, at which point the hair starts to fall out in clumps.  Some people choose to shave their heads entirely when this happens.  You can discuss with your oncology team what resources are available for managing hair loss during chemotherapy.

Anemia

Anemia occurs when you have too few red blood cells.  Your red blood cells carry oxygen to your tissues, and when they fall low due to chemotherapy you may experience shortness of breath, fatigue, dizziness, weakness, and a rapid heartbeat.  While you are receiving chemotherapy, your doctor will order a lab called the complete blood count (CBC) to check your red blood cells and determine if you have anemia.  If your red blood cells fall too low, you may require a red blood cell transfusion.

Neutropenia

Neutropenia occurs when you have too few white blood cells, specifically a type of white blood cells known as neutrophils, which help to fight off infections.  When you experience neutropenia, your risk of developing an infection increases.  If your white blood cells drop too low, your doctor may hold your chemotherapy, give lower doses of chemotherapy, and/or give you a special injection to help boost your white blood cell count.  In order to minimize your risk of infection, it is important to take precautions such as washing your hands often each day, keeping away from any sick contacts and large crowds.  Additionally, it is important to report any signs of infection to your doctor, including fever, chills, sweats, severe cough or sore throat, abdominal pain, and any unusual redness or tenderness on your skin.

Thrombocytopenia

Thrombocytopenia occurs when you have too few platelets.  These are the cells that help stop bleeding and cause your blood to clot when there is damage to the blood vessels.  When you experience thrombocytopenia, you may notice an increased tendency for bruising or bleeding, even with minor injuries.  If you notice any unusual bleeding, such as blood in your urine or stool, bleeding gums, or a bloody nose, you should report this to your doctor.  During treatment, your doctor will check your platelet count and determine whether you have thrombocytopenia.  If the platelet count is very low, you may require a platelet transfusion.  Due to the risk of thrombocytopenia, it is also important to avoid medications such as aspirin, ibuprofen or other non-steroidal anti-inflammatory medications (NSAIDs), and other blood thinners.

Nausea and Vomiting

Nausea and vomiting can be a troubling experience for many patients receiving chemotherapy.  The amount of nausea and vomiting you may experience depends on the types of chemotherapy agents you are receiving and can also vary from person to person.  Some people may have little to no issues with this side effect, while others can have severe nausea and vomiting that lasts for many days after receiving chemotherapy.  The good news is that nausea and vomiting can be managed well with drugs called anti-emetics which help to relieve nausea and vomiting related to chemotherapy.   Your doctor will prescribe an antiemetic regimen for you based on the chemotherapy regimen you receive and which drugs works best for you.

Constipation

Some chemotherapy agents can cause constipation.  It is important to drink plenty of fluids while on chemotherapy.  You may need to take a laxative or stool softener in conjunction with your chemotherapy regimen to help minimize constipation.  If you have not had a bowel movement in 2 or more days, you should notify your doctor.

Diarrhea

Some chemotherapy drugs may directly cause diarrhea.  However, diarrhea can also result because chemotherapy disrupts the cells lining the intestinal tract.  If you are experiencing diarrhea, you may need to take anti-diarrheal medicines, but this should be discussed with your doctor.

Each chemotherapy agent has its own unique side effect profile.  Also, not every person gets every side effect, and the number and severity of side effects experienced can vary greatly from person to person.   It is important to discuss your particular chemotherapy regimen with your doctor and pharmacist.  We will be discussing some of the more common chemotherapy regimens used to treat T-cell lymphoma and leukemia and their expected side effects in greater detail in the following sections.