Paolo Strati, MD, is the deputy chief of the Indolent B-Cell Lymphomas Working Group, chair of the Scientific Review Committee, and program leader of the CARTOX Committee at the University of Texas MD Anderson Cancer Center in Houston. He's also an associate professor of lymphoma and myeloma and translational molecular pathology.
B-cell lymphoma is a type of blood cancer. It affects your lymphatic system, which includes organs, vessels, and other tissues that make up part of your body's defenses against germs and infections. B cells are white blood cells that normally play a key role in protecting you. But when you have B-cell lymphoma, your B cells turn cancerous and grow out of control. There are many types of B-cell lymphoma. In general, they can be aggressive (fast-growing) or indolent (slow-growing). Its symptoms vary a lot, depending on the type of B-cell lymphoma you have and the parts of your body it affects. It's possible to have B-cell lymphoma and no symptoms.
Many treatments can help control B-cell lymphoma, make the symptoms lessen or go away for a time, or offer the chance for a cure. We spoke with Paolo Strati, MD, of the University of Texas MD Anderson Cancer Center, about the latest treatments, how to get relief from side effects, and why there's more hope today than ever before after a diagnosis of B-cell lymphoma.
Q: What are some of the new and most promising treatments for B-cell lymphoma?
A: We have many treatment options for B-cell lymphoma today. Immunotherapy has meaningfully increased as an option for B-cell lymphoma over the last few years. These are treatments that use the immune system to fight cancers. The only immunotherapy we used to have for either indolent or aggressive lymphomas were antibodies that recognize one protein on lymphoma cells. More recently, the FDA has approved what's called bispecific antibodies. Instead of recognizing one molecule, they're able to recognize two. They physically bring the immune system closer to the lymphoma.
We also have cellular therapy. For many years, what we have done for either indolent or aggressive B-cell lymphoma has been a stem cell transplant. While we still do those, the utilization of this treatment approach has been meaningfully decreased with the introduction of a specific type of cellular therapy called CAR T-cell therapy. In CAR T-cell therapy, we collect the white blood cells of patients with lymphoma and engineer them in the lab with a virus to make them able to recognize better proteins on lymphoma cells (currently a very specific protein called CD19). Then we infuse those cells back into the lymphoma patient.
Finally, we have what we call antibody-drug conjugates (ADCs). ADCs bring chemotherapy right to the lymphoma cells. So it's kind of a combination of immunotherapy and chemo, with an antibody linked to a small amount of chemo.
Q: Are newer treatment options like these changing the outlook for people with B-cell lymphoma, even if their cancer comes back (relapses) or becomes worse (progresses)?
A: Yes, very significantly. As a matter of fact, in the recent past, our inpatient services in the main academic centers in the U.S. were filled with lymphoma patients who had complications from subsequent lines of treatment. We don't see those anymore. So we're definitely curing a significantly higher proportion of patients who relapse.
Q: Any treatment comes with various potential side effects or complications. What are a few examples of these in the case of B-cell lymphoma, and how should someone get help for them?
A: Any complication from lymphoma treatments should be discussed with a specialized oncologist. The patient should never attempt to address those alone. An internist or primary care physician may not be comfortable giving recommendations either.
Chemotherapy, in the short term, can cause all the familiar side effects that we can think of, including nausea, vomiting, hair loss, and – due to a decrease in the immune system – also infections. All of these are now less frequent than they used to be because we have medications that can help us to prevent or mitigate those side effects.
When it comes to immunotherapy, what can happen is that the immune system will become so strong that it could attack not only the lymphoma, but also normal parts of the body. The presentation of immune-related symptoms can range from diarrhea to skin rash to difficulty breathing. Finally, the cellular therapy and bispecific antibody treatments that I mentioned have two very specific complications: One is called CRS, which stands for cytokine release syndrome. This typically presents as a fever. The other is called neurotoxicity, which is a neurological complication that can be as simple as just difficulty finding words or writing, but sometimes can lead to seizures or a coma. CRS and neurotoxicity can both be life-threatening, but potentially they're also completely addressable and curable in a specialized hospital.
Q: What are some common symptoms that B-cell lymphoma itself might cause?
A: There are some symptoms that are stereotypical for lymphoma. They're what we call constitutional symptoms. These include unexplained fever, typically at night, and profuse sweating, also typically at night – although both can happen throughout the day. Unintentional weight loss is another common symptom. However, depending on where the lymphoma is growing, the symptoms may be very variable. They may range from cough to shortness of breath to abdominal pain.
Sometimes, particularly for the indolent lymphomas, they can be completely asymptomatic. That's very important for our patients to know because if they have a history of lymphoma and they get treatment and then they have no symptoms, they may make the wrong decision not to seek regular surveillance or medical attention. They need to be aware that even in the absence of symptoms, the lymphoma may still be present. It's always important to be regularly restaged through follow-up checkups to find out if the cancer has come back or has gotten worse after treatment.
Q: What role can palliative care play in easing B-cell lymphoma symptoms?
A: Even if we're treating a lymphoma patient with a curative intent, they may still benefit from palliative care – which we like to call supportive care – because they may have symptoms, including fatigue, pain, or neuropathy, which is tingling and numbness on the hands and feet due to either the lymphoma or lymphoma treatment. It's very important from the beginning, if any of those symptoms are present, to integrate supportive care.
Now, this may be a little bit less relevant in lymphoma than in solid tumors like lung cancer or breast cancer. The reason is that most of the time, symptoms related to lymphoma resolve very quickly once you start lymphoma treatment. So, our patients may be disease-free more frequently and, as such, symptom-free. But sometimes, even if they are cured and off treatment, they may still have long-term complications from the treatment. Once again, integrating supportive care earlier rather than later may increase the chance that those complications will not be irreversible.
Q: Along with the main oncologist and supportive care doctors, what other health care professionals might be helpful to someone during or after treatment for B-cell lymphoma?
A: Many times patients, either due to baseline conditions or toxicity from treatment, can become very deconditioned or out of shape. At that point, it becomes crucial for us to work very closely with physical therapists and occupational therapists. We also work closely with our pharmacists, particularly for older patients, where there could be interactions between multiple medications they're taking for other conditions and the treatment for lymphoma. Based on the specific complication from treatment or from lymphoma, sometimes other specialized care is required.
It's always important to be in a center that has the ability to get access to ancillary services, including cardiology, pulmonary medicine, and nephrology. Psychological care is also important. Mental health concerns are very common in patients with cancer in general. This is particularly true in younger patients when they get diagnosed the first time because they're adjusting to a completely new lifestyle. They're understandably concerned that things may not go well and that they may die. They may develop what we call adjustment disorder, which is very similar to posttraumatic stress disorder (PTSD).
Everybody knows about PTSD from veterans and warriors. The analogy between cancer and war is very similar. When you are at war, you fear about your life every day. You do fear about your life every day when you know that you have a potentially life-threatening condition like cancer. So for those patients – when they get the news the first time, when they go through treatment, and even afterwards, when they fear that the lymphoma may come back – working with a mental health professional is really important.
Q: Cancer treatment, tests, and related health care can be expensive. What steps can someone take to offset the financial hardships of a B-cell lymphoma diagnosis?
A: While all our institutions do try to provide patient assistance whenever possible, I always recommend that my patients also keep in mind that, beyond the medical provider, there are patient-partner organizations that are very committed to lymphoma patient care. They include the Lymphoma Research Foundation, Blood Cancer United (formerly the Leukemia & Lymphoma Society), and the American Cancer Society. All of those organizations have some mechanism in place where some funds could be provided for travel, for example.
Q: What lifestyle changes would you recommend to anyone with B-cell lymphoma?
A: There's no really specific lifestyle that triggers lymphoma, but we know that there are things that can be done to improve our immune system, and it mainly applies to indolent, or slow-growing, B-cell lymphoma. This has been proven for aerobic exercise – such as walking for 30 minutes every day. Some vitamins, like vitamin D, can also increase the strength of our immune system. There's some evidence for supplements like green tea. Research is ongoing into other approaches, including meditation and massage. I always recommend to my patients with an interest or curiosity about these alternative approaches to ask your oncologist for a referral to an integrative medicine specialist.
Q: Is there anything that you wish more people knew about B-cell lymphoma?
A: I want them to be aware that in the vast majority of cases, when they're diagnosed the first time, they do have a chance for a cure. Even if the first treatment doesn't work, not everything is lost. Just over the last five to eight years, treatment for lymphoma has meaningfully improved.
The conversation that we had with our patients until a few years ago, at the time of a relapse, was along the lines of: "There's not much else that we can do. We can just prolong your life." Now that conversation has completely changed. So the take-home message is that there's a lot of hope for patients with B-cell lymphoma.
