Starting Lymphoma Immunotherapy: What to Expect

If you and your doctor decide to try immunotherapy for your lymphoma, you know it’s going to use your immune system to target your cancer. But do you know what the treatments will be like and what the side effects may be? It can vary based on the type of immunotherapy that you get.

Monoclonal Antibodies That Target CD20

These drugs home in on a protein called CD20 on B lymphocytes (a type of white blood cell). They include obinutuzumab (Gazyva) and rituximab (Rituxan). You get them by IV infusion in the hospital, but you won't need to stay overnight. You can also get rituximab as a shot under your skin.

Your treatment schedule will depend on a number of things, including the specific drug your doctor prescribes. "Some, like rituximab, can be given once a week for maybe 4 weeks. If you're getting chemotherapy as well, you could adjust it to line up with the chemotherapy schedule: perhaps once every 3 or 4 weeks," says Daniel Persky, MD, associate professor of medicine and director of the Clinical Trials Office at the University of Arizona Cancer Center.

If you're going to have a bad reaction to monoclonal antibodies, it's most likely to happen while you're getting your first infusion. "The most common reactions include shaking, chills, fluctuations in heart rate, changes in blood pressure, hives, or sometimes shortness of breath or chest pressure," says Loretta Nastoupil, MD, director of the Lymphoma Outcomes Database at the University of Texas MD Anderson Cancer Center.

To manage those problems, your doctor may need to temporarily stop your treatment so you can take an antihistamine, acetaminophen, or a steroid medication.

Side effects are unlikely to start once you finish the infusion and head home, though your immune system will be suppressed a little. You should also know that just because you had a bad reaction during your first infusion, it doesn't mean that it will happen next time. Most people can tolerate the doses that follow, even if they had a bad reaction at first, says Nastoupil, who's also an assistant professor in the cancer center's Lymphoma/Myeloma Department.

You will need a series of blood tests as well as imaging tests (like MRIs or PET scans) and maybe bone marrow biopsies to see how your treatment is working. 

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Checkpoint Inhibitors That Target PD-1

PD-1 is a “checkpoint” on T cells, which are a type of immune cell. These medicines include nivolumab (Opdivo) and pembrolizumab (Keytruda). You get them by IV infusion every few weeks, usually for 2 years.

Side effects during PD-1 infusions are rare, Nastoupil says. Bad reactions, when they occur, are more apt to happen at home than during the infusions.

"PD-1 inhibitors tend to be associated with more immune-related adverse events, which can lead to inflammation of the lungs, inflammation of the bowels, rashes, hypothyroidism, or hypopituitarism," Nastoupil says. "These problems aren't common, but it's important to recognize them. If you continue to dose the drug and these issues go unchecked, they can worsen and become life-threatening."

If you get a rash, diarrhea, or have shortness of breath, be sure to call your doctor right way.

As with other cancer treatments, your doctor will track your progress with blood and imaging tests.

CAR T-Cell Therapy

The newest, most high-tech, and most personalized immunotherapy option is CAR T-cell therapy. You get it by IV. CAR T-cell therapy for lymphoma includes axicabtagene ciloleucel (Yescarta) and tisagenlecleucel (Kymriah).

Before you can get this therapy, you'll need a thorough evaluation to make sure your organs are working well enough to handle it, Persky says.

Once your doctor gives you the green light, the next step is for you to get leukapheresis. This procedure removes T cells from your body. It takes a few hours. During that time, you go through a process like giving blood -- except the point is to collect white blood cells, and a second IV returns blood to your body.

Next, a lab separates out your T cells and sends them to a manufacturing site where they're tweaked to zero in on your cancer. "After you modify the T cells, you reinfuse them into the patient," Persky says. Basically, scientists use your own immune cells to make a custom treatment.

Waiting for those cells to be altered can take a while. In the meantime, you might need a "bridge" treatment like chemotherapy or steroids, Nastoupil says.

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After your T cells are altered and pass a quality control check, you'll have to do lymphocyte-depleting chemotherapy. That means you'll need a few days of chemo to kill off many of the T cells that are still in your body so that they don't end up competing with the altered T cells that are about to go back in.

Once you're ready to get your T cells put back into your body, you'll head back to the hospital. Unlike with monoclonal antibodies and PD-1 inhibitors, you won’t go home right after the procedure. You'll need to stay in the hospital for at least a week so your doctors can watch you closely to see if you have any side effects.

Almost everyone who gets CAR T-cell therapy has some mild side effects, Persky says. It’s possible, but less common, to have severe side effects. Serious reactions include cytokine release syndrome, which can give you a very high fever or extremely low blood pressure. Others get neurological symptoms, which can range from headaches and sleepiness to seizures and coma, Nastoupil says.

During the weeks and months that follow, you'll need to watch out for infections like bronchitis and pneumonia. And you’ll get follow-up testing, such as bloodwork and imaging tests, to see if the treatment worked.

WebMD Feature Reviewed by Laura J. Martin, MD on May 20, 2018

Sources

SOURCES:

American Cancer Society:  "CAR T-Cell Therapies," "Immune Checkpoint Inhibitors to Treat Cancer," "Immunotherapy for Hodgkin Lymphoma," "Immunotherapy for Non-Hodgkin Lymphoma," "Lymphoma."

Canadian Cancer Society: "The Immune System."

Loretta Nastoupil, MD, director, Lymphoma Outcomes Database, and assistant professor, Department of Lymphoma/Myeloma, University of Texas MD Anderson Cancer Center.

Daniel Persky, MD, associate professor of medicine and director, Clinical Trials Office, University of Arizona Cancer Center.

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