Treatment for follicular lymphoma is not one-size-fits-all. Many treatments are available for this form of non-Hodgkin's lymphoma. While it may be overwhelming to face so many choices, a wide range of options is a good thing. It increases the odds that one will work for you. Also, if one treatment works for a while and then stops working, you can move on to another treatment.
Many factors will go into your doctor’s recommendation for how to treat your follicular lymphoma. Your doctor will weigh your symptoms, the severity of the tumor, your age, and your overall health. Here’s what you and your doctor will consider when choosing your treatment for follicular lymphoma.
Your Symptoms and Aggressiveness of the Tumors
Follicular lymphoma can progress very slowly – so slowly that at first you may not need treatment. This is especially true if you have fewer or smaller tumors (“low tumor burden”) and you don’t have any symptoms.
If your cancer is slow growing and you don’t have symptoms, your doctor might suggest you “watch and wait.” People who take this approach will have regular physical exams, imaging tests, and bloodwork to keep tabs on the progress of the cancer.
Some people have a high tumor burden that comes along with symptoms. Tumor burden and symptoms are key factors that doctors consider when it comes to when to start treatment and what therapies to use.
Signs that suggest it’s time to start treatment include the following:
- Your lymph nodes get bigger
- Fever and night sweats
- Weight loss
- Low blood counts
The Stage of Your Cancer
When it is time to start treatment, the specific strategy will depend a lot on the stage of the cancer. Here’s a look at different treatments based on lymphoma stage.
Stage I - Early Stage II. When follicular lymphoma is only in one lymph node area or two areas next to each other, doctors may treat it with radiation alone.
In this treatment, a radiation oncologist will direct high-energy beams of radiation right at the affected area to help slow or stop the growth of the cancer. About half of people who get this treatment at this stage are cured.
You’ll get this treatment in small doses spread out across several weeks. This helps minimize the side effects, which can include the following:
- Skin changes, such as peeling, redness and blisters, where you get the radiation
- Nausea
- Diarrhea
- Fatigue
Stage II to IV. Most people within these stages, once they start treatment, get chemoimmunotherapy. That’s chemotherapy plus monoclonal antibodies (antibodies made in a lab).
You usually get chemotherapy for follicular lymphoma through an IV, a pill, or an injection into your spine. You’ll get chemo a couple of days a week for several weeks to a few months.
Chemotherapy kills cancer cells but can kill normal cells, too. That’s why it can cause many side effects, such as:
- Hair loss
- Mouth sores
- Loss of appetite
- Nausea, vomiting
- Diarrhea, constipation
- Higher risk for infections
- Easy bleeding or bruising
- Fatigue, shortness of breath
The monoclonal antibodies given for follicular lymphoma belong to a class of drugs called anti-CD20 antibodies. They take aim at a specific protein, called CD20, on the surface of follicular lymphoma cells. The anti-CD20 antibodies most commonly used to treat follicular lymphoma are rituximab (Rituxan) and obinutuzumab (Gazyva), but there are also others. Like chemotherapy, these are also IV drugs that you will get at an infusion center.
Because monoclonal antibodies target cancer cells and don’t hurt normal cells, they may have fewer side effects than chemotherapy. But you could still have:
- Itching
- Fever
- Chills
- Nausea
- Rash
- Fatigue
- Headache
These are usually mild and short-lived. Before your infusion, you will take medicine to help prevent some of the following more serious reactions like:
- Racing heart, chest pain
- Swelling of face or tongue
- Cough
- Trouble breathing
- Feeling lightheaded, dizzy, faint
If chemoimmunotherapy shrinks your tumors, you might continue on monoclonal antibodies as maintenance therapy to help further delay progression of the disease.
Your Overall Health
Because chemotherapy is made up of very strong drugs and can cause lots of side effects, you have to be strong enough to tolerate it. If you are an older adult, have other health conditions, or are otherwise too sick for chemotherapy, you may receive anti-CD20 antibodies alone without chemotherapy.
If you have very large lymph nodes and you can’t tolerate chemotherapy, you may receive radiation in addition to anti-CD20 medicine to help shrink the lymph nodes and relieve symptoms.
Past treatments
Follicular lymphoma is hard to cure. Treatment keeps symptoms under control and can keep the cancer at bay for years at a time. But many people eventually relapse, and it can happen more than once. If your disease progresses after one type of treatment, your doctor will recommend that you move onto another.
These are some of the treatments that might be available to you after your first treatment:
Other chemotherapy. Your doctor might try you on a chemotherapy drug or combination of drugs that you haven’t had yet.
Targeted drugs. These are drugs that block a specific process in cancer cells that is helping them grow or survive. There are several different types of targeted drugs that may work in people who have follicular lymphoma.
CAR T-cell therapy. In this treatment, doctors remove immune-system cells from your body, reengineer them to recognize and fight cancer cells, and then put them back in your body.
Stem cell (bone marrow) transplant. This treatment allows doctors to give you a higher dose of chemotherapy. Usually, doctors have to limit the chemotherapy dose because it can damage your bone marrow, where your body makes new blood cells. But doctors can give very high doses of chemotherapy when the treatment is followed by a stem cell transplant, which will regenerate the bone marrow.
Novel agents. These are newer drugs that are not traditional chemotherapy. Doctors may try these after patients progress or relapse. Some options include lenalidomide (Revlimid), PI3K inhibitors, and tazemetostat.
Radioimmunotherapy. This treatment uses a radioactive drug to carry radiation directly to cancer cells. That helps keep radiation away from healthy tissue, which can prevent certain consequences down the road. That said, this type of treatment is hard to administer and it can come with some serious short- and long-term side effects. So doctors may not prescribe this therapy as often as other approaches.
Clinical trials. You might have access to a new drug before it hits the market by participating in a clinical trial. Clinical trial participants try experimental treatments under close medical supervision. If you are interested in a clinical trial, ask your doctor how you might find one that would be right for you.
