Side Effects

Cancer therapy for non-Hodgkin lymphoma (NHL) can sometimes produce side effects. For most patients, treatment side effects are temporary and go away once therapy ends. For other patients, side effects can be more severe, sometimes requiring hospitalization. Some patients never have side effects.

Before you undergo treatment, talk with your doctor about potential side effects. In recent years, new drugs and other therapies have increased the ability to control side effects.

Common Side Effects

Suppressed Blood Cell Formation. Decreases in blood cell counts may occur in patients treated with chemotherapy. Blood transfusions may be necessary for some patients with low blood cell counts. If decreases in white blood cell counts are severe and continue over extended periods of time, infection may develop and require antibiotic treatment. Sometimes, chemotherapy dosages or the time between chemotherapy cycles must be altered to allow the patient’s blood counts to recover from the effects of treatment. To stimulate the production of depleted numbers of white blood cells, a granulocyte-colony stimulating factor (G-CSF) such as Neupogen® or Neulasta® is sometimes used. This subcutaneous injection is given to increase the number of white blood cells that help prevent infection.

Infections. Chemotherapy and radiation therapy can make patients more susceptible to infection because these treatments weaken immune cell function and can lower the number of normal white blood cells. Removal of the spleen, a treatment option for patients with some types of NHL such as splenic marginal zone lymphoma, also contributes to the risk of severe infection.

Infections can be very dangerous. It is very important to take fevers seriously and go to the hospital if you have a fever of over 100.4° F.

Patients with NHL are advised to receive certain vaccinations, including vaccinations for pneumococcal pneumonia and influenza, once they have finished their treatment. There are two types of pneumococcal vaccines available for adults: a pneumococcal polysaccharide vaccine (PPSV23) and a pneumococcal conjugate vaccine (PCV13). Patients with NHL should not be given vaccines that use live organisms or those with high viral loads, such as the herpes zoster (shingles) vaccine, but they can receive Shingrix® because it is an inactivated shingles vaccine. COVID-19 vaccines are also recommended. Your doctor can give you more information.

Viral Reactivation. Hepatitis B virus (HBV or Hep B) reactivation has been reported in some patients treated with chemotherapy, either with or without immunotherapy drugs. Carriers of the hepatitis B virus, especially those treated with anticluster of differentiation 20 (anti-CD20) monoclonal antibodies, including rituximab (Rituxan®), ofatumumab (Arzerra®) and obinutuzumab (Gazyva®), have a high risk of virus reactivation and disease.

Preventive antiviral therapy is recommended for patients who test positive for HBV if they are going to receive an NHL therapy. Cytomegalovirus (CMV) reactivation may occur in patients with chronic lymphocytic leukemia (CLL) or small-cell lymphocytic lymphoma (SLL) receiving alemtuzumab (Campath®) therapy. This occurs most frequently between 3 to 6 weeks after the start of therapy, when T-cell counts reach their lowest point. This complication happens in up to 25 percent of treated patients. Current practices to prevent the CMV reactivation include the use of a prophylactic antiviral drug (ganciclovir), to be administered if the patient tests positive for CMV prior to alemtuzumab treatment. Patients being treated with regimens containing alemtuzumab should be monitored frequently for the virus (every 2 to 3 weeks) during the treatment and for 2 months after the completion of therapy.

Bone Loss and Fractures. Drug regimens that contain corticosteroids have been associated with an increased risk of fractures and treatment-induced bone loss in patients with NHL. Evaluation of vitamin D levels and of post-treatment bone loss is recommended for patients receiving this type of therapy. Patients should also maintain an adequate calcium intake since corticosteroids block calcium absorption and increase the risk of fractures. Pamidronate and zoledronic acid are part of a group of drugs called “bisphosphonates.” These drugs can help stabilize bone mineral density, prevent bone loss and reduce the risk of new fractures in patients with NHL.

Neuropathy. Some chemotherapeutic agents, such as the drug vincristine (Oncovin®) or brentuximab vedotin (Adcetris®), can cause nerve damage called “neuropathy.” Initially, the patient experiences numbness and tingling in the fingertips and toes. The sensation might come and go, but if it continues, it may become permanent. In general, treatment options are limited. The patient should be monitored for these side effects between each cycle of chemotherapy that includes vincristine. If the neuropathy becomes severe, the dose of vincristine may need to be adjusted.

Progressive Multifocal Leukoencephalopathy (PML). This is a rare but serious and potentially fatal central nervous system infection caused by the reactivation of the latent John Cunningham (JC) virus. Cases of PML typically occur in severely immunocompromised individuals, such as AIDS patients or blood cancer patients, who have profound immunosuppression due to the underlying disease or its treatment.

The use of rituximab (used in combination with chemotherapy) may be associated with an increased risk of PML in immunocompromised patients with CLL/SLL and other types of NHL. Signs and symptoms of PML include confusion, poor coordination, motor weakness and visual and/or speech changes. To date, there is no effective treatment for this condition. Patients at risk should be carefully monitored for the development of any neurological symptoms.

Tumor Lysis Syndrome. Patients with NHL, especially those with very high white blood cell counts before the beginning of treatment, may be at high risk for developing acute tumor lysis syndrome (TLS). TLS is characterized by metabolic abnormalities that are caused by the sudden release of the cellular contents of dying cells into the bloodstream, a phenomenon induced by chemotherapy. If untreated, TLS can lead to heart arrhythmias, seizures, loss of muscle control, acute kidney failure and even death. Patients with a high level of uric acid may be given the drug allopurinol (Zyloprim®) to minimize the buildup of uric acid in the blood. Allopurinol is taken by mouth. Another drug, rasburicase (Elitek®), is given in a single intravenous dose and can rapidly lower an elevated uric acid level.

Other Side Effects. Chemotherapy affects tissues that normally have a high rate of cell turnover. Thus, the lining of the mouth, the lining of the intestines, the skin and the hair follicles may be affected. Common side effects of therapy include:

  • Mouth Sores
  • Nausea and vomiting
  • Diarrhea
  • Temporary hair loss
  • Fatigue
  • Cough
  • Fever
  • Rash

Side effects can range from mild to severe. They depend on the medications and dosages used and the individual patient’s susceptibility. Fortunately, there are drugs and other supportive measures to either prevent or manage many side effects. Click here to read more about managing side effects.

Long-Term and Late Effects

It is important to know about the potential for long-term and late effects of treatment so that any problems may be identified early and managed.

  • Long-term effects of cancer therapy are medical problems that persist for months or years after treatment ends.
  • Late effects are medical problems that do not develop or become apparent until years after treatment ends. 

It is important to know about the potential for long-term and late effects of treatment so that any problems may be identified early and managed. 

Many survivors of NHL do not develop significant long-term or late effects of treatment. However, it is important for all adult patients and for parents of children who will be treated for NHL to discuss possible long-term and late effects with members of the treatment team so that the proper planning, evaluation and follow-up care can take place.

 Use the Survivorship Workbook to collect all the important information you need throughout diagnosis, treatment, follow-up care and long-term management of a blood cancer.

Heart Disease. Radiation therapy to the chest and treatment with chemotherapy containing alkylating agents (eg, cyclophosphamide) or anthracyclines (eg, doxorubicin) have been linked to heart disease, including inflammation of the sac surrounding the heart (the pericardium), valve dysfunction or classic heart attack (myocardial infarction).

Secondary Cancers. For as long as 3 decades after diagnosis, patients are at a significantly elevated risk for second primary cancers, such as lung, brain and kidney cancers, melanoma, and Hodgkin lymphoma. Therapy with autologous bone marrow or peripheral blood stem cell transplant and treatment with chemotherapy containing alkylating agents are associated with an increased risk of developing myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML).

Fertility. Patients may be less fertile after treatment for NHL. The risk of infertility varies according to the nature of the treatment, including the type and amount of chemotherapy, the location of radiation therapy and the patient’s age. Men who are at risk of infertility should consider sperm banking before treatment and women should discuss all of their fertility options. Women who have ovarian failure after treatment experience premature menopause and require hormone replacement therapy.

It is important to discuss all your options and treatment concerns with your doctor. If possible, you may also want to discuss these options with a doctor who specializes in fertility and reproduction. Many cancer centers have reproductive specialists who will suggest specific options for each patient. In couples of childbearing age in which one partner has received treatment, the incidence of pregnancy loss and the health of a newborn are very similar to those of healthy couples. 

To download lists of suggested questions to ask your healthcare providers, click here.

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