Lymphoma and Infection: Do I Need to Take Medication to Prevent Infection?

By Jessica Lewis, PA

In some instances, patients may be started on medicines to prevent or minimize infection. Infection in patients with impaired immune system function (due to lymphoma or treatment of lymphoma) can be life threatening. Ultimately, your doctor will determine whether to start such medications, but some current literature helps medical providers make this decision. The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance between 21 different cancer-treating centers within the USA. Research generated from physicians in these institutions is used to develop evidence-based recommendations to help guide healthcare providers. The American Society of Clinical Oncology (ASCO) is a not-for-profit group of physicians, who focus on patient-oriented clinical research, education, prevention, and delivery of patient care.

The NCCN and ASCO provide summaries of factors that predict a lymphoma patient’s risk of developing fever and infection. These factors include age, performance status, type of cancer, status of disease (remission vs. active disease), type of treatment, the presence of a low infection-fighting white blood cell count (neutropenic), and prior episodes of fever with chemotherapy treatment. Patients with lymphoma are generally classified as having intermediate risk, although some patients with CLL or T-cell lymphoma may be considered high risk.

Prevention of bacterial infections: Common prophylactic medications include levofloxacin or ciprofloxacin. Prophylaxis is recommended for intermediate or high-risk patients, including patients that are expected to have neutropenia. There have been few randomized-controlled trials that have investigated the use of antibiotics to prevent development of fever and infection in lymphoma patients that are receiving chemotherapy. The largest randomized-controlled study, by Cullen et al in 2005, included 1,565 patients with solid cancers and lymphomas treated with chemotherapy that would lower the white blood cell count.  In this study, patients were randomly assigned a placebo or levofloxacin. The authors found a decrease in the incidence of fever and decreased rates of probable infection and hospitalization. However, patients who received levofloxacin did not have a statistically significant decreased rate of severe infection (including lethal infections). As per 2012 NCCN and ASCO guidelines, the use of levofloxacin prophylaxis is only recommended for patients with neutropenia that lasts longer than 7 days.

Prevention of fungal infections: Medications to prevent fungal infections are not usually needed in lymphoma patients. ASCO guidelines recommend considering prophylaxis only for patients with profoundly low white blood cell counts (ANC <100) longer than 7 days. Additionally, patients should limit exposure to construction or demolition sites, and quit cigarette smoking to reduce risk of fungal infections.

Prevention of viral infections: Antiviral medications may be recommended. If you have been exposed to hepatitis B infection, you may be started on medication to prevent this from becoming an active infection. If you had the chicken pox as a child you are at risk of developing shingles, and you may benefit from preventative medication. Patients with lymphoma should not receive the shingles vaccine.

PCP prevention: Some patients are at risk of developing pneumonia, caused by Pneumocytus jirovecii (also referred to as PCP). You may require preventative medication, typically with TMP-SMX, if you are on steroids for a prolonged period of time (>1 month), or are receiving treatment with alemtuzumab or purine analogs (i.e., fludarabine).

Other preventative measures: ASCO 2012 guidelines recommended all patients who are receiving cancer treatment to receive the seasonal flu vaccine, along with their family and household contacts. Guidelines from the Centers for Disease Control (CDC) include administration of a pneumococcal vaccine in all patients with lymphoma.

Lymphoma in Pregnancy

By Rebecca Elstrom, MD

Although rare, cancer, including lymphoma, does occur in pregnant women. The effect of both the cancer and treatment on the fetus is a major concern to expectant parents, adding to the stress of dealing with a diagnosis of malignancy. Some types of anti-cancer treatment, such as the anti-folate drug methotrexate, are best avoided at all stages of fetal development, and the effects of other classes are likely dependent in part on the physical characteristics of each drug, which can affect the ability of each to cross the placenta. For example, certain anthracyclines, which are critical in the treatment of lymphoma and other hematologic malignancies, cross the placenta poorly, whereas others, such as idarubicin and liposomal formulations of doxorubicin, have physical characteristics which allow greater penetration into the fetal circulation.

Fortunately, evidence is mounting that exposure of the fetus to many common types of chemotherapy after the first trimester does not produce negative effects on normal development, either in terms of organ development or neurologic function. A recent study published in the Lancet Oncology observed children born to mothers that were treated for cancer and compared their physical, behavioral and cognitive development to established norms in similar populations. The authors found that children born to mothers that were exposed to chemotherapy for treatment of cancer after the first trimester did not show notable differences in development from children in the general population matched for other characteristics. Although the numbers were too small to compare different chemotherapy regimens in their effects, the general finding of no significant decrement in development in this prospective study was encouraging. Of note, the most powerful predictor of cognitive developmental delay was premature birth, comparable to that seen in children born prematurely for other reasons. Although it is not possible to definitively rule out an additional effect of chemotherapy in this group, this finding argues that “iatrogenic prematurity,” or delivery of a baby before term for purposes of treating the mother’s cancer, is likely to be counter-productive, unless undertaken for a specific reason other than sparing the fetus exposure to chemotherapy.

Another critically important question involves the outcome of treatment for the patient. Pregnancy affects blood volume and could affect the body’s handling and metabolism of chemotherapy drugs. No large prospective studies are available to address this issue, but a presentation by Dr. Andrew Evens of the University of Massachusetts at the most recent meeting of the American Society of Hematology in December of 2011 showed excellent outcomes in a retrospective study of 88 women diagnosed with lymphoma during pregnancy. Weill Cornell Medical College participated in the study. Although the retrospective nature of the study and heterogeneity of the patients preclude definitive conclusions, this study provides more encouraging data for women facing a diagnosis of lymphoma during pregnancy. Click here to read the abstract.

Lymphoma in the news: Exercise after completion of cancer treatment improves quality of life

By Peter Martin, MD

A recently published meta-analysis focused on the effects of physical activity in adults who had completed their cancer therapy (click here to read the abstract). Fong and colleagues compiled data from 34 randomized studies that assigned participants to either exercise or no exercise. Most of the studies evaluated aerobic exercise, and the average duration of activity was 13 weeks. Not surprisingly, participants randomized to exercise experienced significant improvements in body mass index, weight, and power output among other measures. Importantly, they also experienced significant gains in quality of life and other psychological outcomes (e.g., fatigue, depression).

A meta-analysis is a study that combines results from multiple related studies to derive a more powerful estimate of a true effect (click here to read more about meta-analyses). Although meta-analyses are often derided and are subject to various forms of bias, a well-performed meta-analysis is one of the most powerful methods of controlling for variation between studies and determining a true effect size in a population.

The results of this meta-analysis strongly suggest that patients who have completed cancer therapy can benefit from an exercise program. Moreover, it behooves oncologists to discuss the potential role of an exercise program with their patients. Patients should be encouraged to discuss the potential role of exercise with the oncologists and primary care physicians.

%d bloggers like this: