COLLABORATIVE

Treatment is based on classification of the cell and staging of the disease (see Hodgkin's Disease, Table 2, for staging). Some of the indolent types of NHL do well with only supportive therapy. The disease process may be slow enough that treatment is saved until the disease takes a more aggressive path. Most patients with intermediate-grade and high-grade lymphomas receive combination chemotherapy.

Radiation is effective for many patients with stage I or II NHL. Radiation is delivered to the chest wall, mediastinum, axilla, and neck (the region known as the mantle field). Most patients, however, are at stage III or IV at diagnosis. Surgery has limited use in the treatment of NHL. It may be part of the diagnostic and staging process, but diagnostic laparotomy is much less common than in Hodgkin's disease. A therapeutic splenectomy may be performed for severe spleen enlargement. Gastric or bowel resection may be done if the patient has a primary gastrointestinal lymphoma or has obstructions from bulky nodes. Stem cell transplantation may be considered for patients who have relapsed, are at high risk for relapse, or have tried conventional therapy without success.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Biological therapy	Varies with drug	Interferon and monoclonal antibodies	May slow disease progression
Chemotherapy	Varies with drug	Some common regimens are CHOP (cyclophosphamide doxorubicin, vincristine, prednisone); BACOP (bleomycin, doxorubicin, cyclophosphamide, vincristine, prednisone); and MACOP-B (methotrexate with leucovorin rescue factor, doxorubicin, cyclophosphamide, vincristine, prednisone, bleomycin, plus trimethoprim-sulfamethoxazole and ketoconazole)	Chemotherapy is used for stage IVA and all stage B patients; usually lasts for 6–8 mo

Other Therapy: Common side effects are alopecia, nausea, vomiting, fatigue, myelosuppression, and stomatitis. Patients who are receiving chemotherapy are administered antinausea drugs, antiemetics, and pain medicines as needed to help control adverse experiences. Experimental drugs currently in clinical trials include paclitaxel, topoisomerase-3 inhibitors, and nucleoside analogues.

INDEPENDENT

Maintain the patient's comfort, protect the patient from infection, provide teaching and support about the complications of the treatment, and provide emotional support. Fatigue, one of the most common side effects of cancer treatment, can last for several months to several years. A program called Fatigue Initiative Research and Education (FIRE) is available through the Oncology Nurses Society (http://www.ons.org).

During irradiation, the patient may suffer from dry mouth, loss of taste, dysphagia, nausea, and vomiting, which can be managed with frequent mouth care. Explore ways to limit discomfort, such as ice chips. Attempt to provide desired foods to support the patient's nutrition. Keep any foul-smelling odors clear of the patient's environment, particularly during meals. Manage skin irritation and redness by washing the skin gently with mild soap, rinsing with warm water, and patting the skin dry. Encourage the patient to avoid applying lotions, perfumes, deodorants, and powder to the treatment area. Explain that the patient needs to protect the skin from sunlight and extreme cold. Before starting treatments, arrange for the patient to have a wig, scarf, or hat to cover any hair loss, which occurs primarily at the nape of the neck.

If the patient develops bone marrow suppression, institute infection controls. Treat the discomfort that may arise from chemotherapy—joint pain, fever, fluid retention, and a labile emotion state (euphoria or depression)—all of which need specific interventions, depending on their incidence and severity. The complexity of the diagnostic and staging process may make the patient feel lost in a crowd of specialists. It is important for the nurse to provide supportive continuity. Patience and repeated explanations are needed. Provide the patient with information about support groups, and refer the patient to a clinical nurse specialist, support groups associated with the American Cancer Society (http://www.cancer.org), or counselors.