4.2 Treatment options
The vast majority of patients with Hodgkin lymphoma or DLBCL are likely to benefit from systemic therapy.
Occasionally vascular access devices are required to deliver systemic therapy. Such devices should only be inserted by proceduralists experienced in such procedures.
Timeframes for starting treatment
Treatment should begin within two weeks of diagnosis and staging, unless the patient wants to delay treatment (e.g. to pursue fertility preservation measures).
In cases with critical organ compromise or rapid clinical progression, it may be necessary to start treatment within 24 hours of diagnosis.
Training and experience required of the appropriate specialists
Haematologists, medical oncologists and radiation oncologists must have training and experience of this standard:
- Fellow of the relevant specialist college
- adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).
Cancer nurses should have accredited training in these areas:
- anti-cancer treatment administration
- specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
- the handling and disposal of cytotoxic waste (ACSQHC 2020).
Systemic therapy should be prepared by a pharmacist whose background includes this experience:
- adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.
All patients must be primarily managed and overseen by an appropriately qualified specialist multidisciplinary team. In a setting where no haematologist or medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a specialist physician and an appropriately qualified nurse, and overseen by a specialist team. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the haematologist or medical oncologist or as clinically required.
The training and experience of the appropriate specialist should be documented.
Health service characteristics
To provide safe and quality care for patients having systemic therapy, health services should have these features:
- a clearly defined path to emergency care and advice after hours
- access to diagnostic pathology including basic haematology and biochemistry, and imaging
- cytotoxic drugs prepared in a pharmacy with appropriate facilities
- occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
- guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
- coordination for combined therapy with radiation therapy, especially where facilities are not co-located.
Patients with the following diagnoses may benefit from radiation therapy:
- localised disease
- advanced disease with a dominant bulky lesion.
Radiation therapy is usually used in conjunction with chemotherapy to treat patients with Hodgkin lymphoma or DLBCL. These considerations should be part of the multidisciplinary team planning.
Timeframes for starting treatment
Treatment should begin within two weeks of diagnosis and staging, unless the patient wants to delay treatment (e.g. to pursue fertility preservation measures).
In cases with critical organ compromise or rapid clinical progression, it may be necessary to start treatment within 24 hours of diagnosis.
Training and experience required of the appropriate specialists
Fellow of the Royal Australian and New Zealand College of Radiologists or equivalent, with adequate training and experience, institutional credentialing and agreed scope of practice in Hodgkin lymphoma or DLBCL.
The training and experience of the radiation oncologist should be documented.
Health service unit characteristics
To provide safe and quality care for patients having radiation therapy, health services should have these features:
- staff familiar with lymphoma-specific radiation therapy techniques
- access to PET-CT and electronic transfer of PET-CT data for planning
- linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
- dedicated CT planning
- access to MRI and PET imaging
- automatic record-verify of all radiation treatments delivered
- a treatment planning system
- trained medical physicists, radiation therapists and nurses with radiation therapy experience
- access to allied health, especially nutrition health and advice
- coordination for combined therapy with systemic therapy, especially where facilities are not co-located
- participation in Australian Clinical Dosimetry Service audits
- an incident management system linked with a quality management system.
Several novel agents are approved for relapsed lymphoma:
- brentuximab vedotin, which targets CD30 expressing cells, for treating recurrent Hodgkin lymphoma
- pembrolizumab for treating recurrent Hodgkin lymphoma and primary mediastinal B-cell lymphoma
- CAR T-cell therapy, Kymriah, for patients with recurrent DLBCL and primary mediastinal large B-cell lymphoma after autologous transplantation or two lines of systemic therapy.
A number of emerging therapies are being investigated for lymphomas. Therapies that show promise for treating lymphomas include epigenetic therapies, new targeted therapies, immunotherapies, combination therapies and cell therapies (Sermer et al. 2019; Skrabek et al. 2019).
The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue analysis is integral for access to emerging therapies and, as such, tissue specimens should be treated carefully to enable additional histopathological or molecular diagnostic tests in certain scenarios.