Increasing Quality of Life Using Survivorship-Focused Care for Patients With Hodgkin and Non-Hodgkin Lymphoma

At the 2023 Great Debates & Updates in Hematologic Malignancies conference in New York, New York, Matthew Matasar, MD, Rutgers Cancer Institute, New Brunswick, New Jersey, discussed the importance of utilizing survivorship-focused care models and increasing the quality of life of lymphoma patients, focusing specifically on Hodgkin/non-Hodgkin survivorship. 

Transcript:

Hi, I'm Dr. Matt Matasar. I'm the chief of blood disorders at the Rutgers Cancer Institute of New Jersey in partnership with RWJBarnabas Health. It was my pleasure to speak at the Great Debates and Updates [meeting] in New York City about survivorship in lymphoma. It was a very active and interactive session. We spoke about issues that are pertinent to the care of lymphoma survivors, focusing both on Hodgkin as well as non-Hodgkin survivorship and talking at the end about survivorship care models and how we can best structure the care of these complex patients.

In speaking about survivorship, we recognize that we are doing a good job in lymphoma in terms of creating survivors and outcomes have continued to improve over these last decades with the advent of more effective and less toxic therapies. That being said, we still recognize full well that there's progress yet to be made. When you look at the long-term effects in long-term outcomes that our lymphoma survivors can experience, if you focus on the most critical aspects of their care, acknowledging certainly that patients can have a global burden of morbidity with multiple comorbidities related to both their prior diagnosis and its therapies.

If you drill down on what's driving the key outcomes of long-term survival, and premature death, where can we make the most impact? It's really focusing on two core issues as your top two. The first is cardiovascular health, and the second is considerations of second primary delinquency. Cardiovascular health is obviously always on our minds as lymphoma physicians because we recognize the potential cardiotoxicity of many of our treatments, most critically anthracycline chemotherapy and when needed, radiation therapy to the chest or great vessels. 

We reviewed some of the data underlying these concerns, recognizing it's very well characterized in Hodgkin survivors that there's an incremental risk that we expose our patients to with incremental doses of doxorubicin. Even more importantly, the use of radiation therapy to the chest is clearly associated with late effects and late risks of cardiovascular disease, including myocardial infarction, congestive heart failure, and even valvular heart disease.

There is an interaction between doxorubicin and radiation therapy, such that patients receiving combined modality therapy are at even heightened risk of cardiac events and may benefit from more sophisticated cardiovascular screening and surveillance. Standards of care were reviewed on the subject, including the use of echocardiography with speckled strain rate mapping, as well as newer technologies that may be relevant now or in the future, such as cardiac MRI, which may have the ability to not only detect cardiovascular disease but to help differentiate the underlying mechanism looking at cardiac fibrosis from radiation therapy versus coronary artery disease, which may be less clearly a pure radiation injury phenomenon.

When thinking about how to take care of these patients, we looked at the data about the interaction between therapeutic exposures and the risk they pose as well as cardiovascular comorbidities and understanding that the patients who are at the highest risk of cardiac events are those that have these therapeutic exposures and also have either pre-existing or post-therapy comorbidities, including hypertension, diabetes, dyslipidemia.

This is not only true for our Hodgkin survivors. We reviewed some of the data that we've generated for non-Hodgkin lymphoma survivors, acknowledging the risk posed by incrementally increased doses of anthracycline, 4 versus 6 cycles of [cyclophosphamide, doxorubicin,   vincristine, and prednisolone] (CHOP)-based chemotherapy, for instance. For those patients who may need mediastinal ration therapy in the treatment of their non-Hodgkin lymphoma, we see similar interactions there between radiation, chemotherapy, and cardiovascular risks. Most importantly, recognizing the dominant role that hypertension plays in increasing risks of [congestive heart failure] (CHF) later in life for our non-Hodgkin lymphoma survivors.

In the area of second malignancy, there's a greater literature around the subject in our Hodgkin survivors. This is largely because this is an illness diagnosed more commonly at younger ages, and we recognize that women under the age of 30 who receive radiation therapy that includes breast tissue in the field are at increased risk for breast cancer later in life. This is clearly related both to dose as well as critically to age at treatment. The younger a woman is at radiation therapy exposure of breast tissue, the greater the risk, such that women who are treated at a young age carry a lifetime risk that is really analogous to if they were a BRCA1 carrier. 

We discussed some surveillance guidelines around taking care of patients at heightened risk for breast cancer, including the use of both mammography and breast MRI starting 8 years after patient therapy for those that are treated at adult age rather than waiting until they're older to initiate screening, acknowledging that the time of onset of breast cancer can be premature in our survivors.

Lastly, we talked about principles of care, including the critical role that a survivorship care plan can play in empowering our patients to live more successfully, and fully, to protect their health in the post-treatment period. Sharing a survivor care plan with their care provider so that everybody's on the same page in terms of the patient's specific risks, as well as guideline-based recommendations regarding their care going forward, [and] thinking through the potential roles that a survivorship clinic can play in coordinating and applying complex multidisciplinary care for those patients at highest risk for late effects.

Again, my name is Matt Matasar from Rutgers. Thanks for your attention.

Source: 

Matasar, M. Quality of life and survivorship in lymphoma patients. Presented at Great Debates & Updates in Hematologic Malignancies Conference; April 13-15, 2023; New York, NY.