Ask The Experts About Lymphoma and Myeloma

TraceyS

The Personalized Medicine Foundation and CancerConnect are pleased to provide patients and caregivers the opportunity to ask questions about lymphoma. We have put together a panel of leading cancer experts to answer questions and publish a forum for the exchange of information.

Michael L. Grossbard M.D. Professor of Medicine, NYU Grossman School of Medicine Chief, Section of Hematology Perlmutter Cancer Center
C.H. Weaver M.D. Is the Executive Editor of CancerConnect who’s clinical research interests included stem cell transplantation in lymphoma and myeloma where he authored ~ 75 articles in major medical journals.

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Lymphoma

I am in remission from follicular lymphoma. Are there any characteristics of the lymphoma that help predict the likelihood of transformation? Phenotype? Mixed histology?

Transformation of follicular lymphoma represents a change to a more aggressive subtype, diffuse large B-cell lymphoma. Two major risk factors for transformation are the bulk of disease at presentation and the duration for which an individual has had the disease. Those patients with more extensive disease and those who have had follicular lymphoma for a long time are at greater risk of transformation. More information about transformation....

Can breast silicone implants cause blood cancers like lymphoma or polycythemia vera?

A particular type of breast implants referred to as textured silicone implants have been associated with the development of a subtype of lymphoma in the breast known as anaplastic large cell lymphoma. This remains a rare entity with only 1000-2000 cases reported worldwide. The lymphoma can often be treated by removal of the implants which can lead to regression of the lymphoma. I am not aware of a relationship between silicone implants and polycythemia.

Bone Pain

I have completed R-CHOP chemotherapy 8 weeks ago. I have been feeling overall pain throughout my bones and muscles, which I know is expected after treatment. My understanding is the cause of the pain in my bones is from my immune system working hard to replenish itself. If I receive the Covid vaccine, can I expect this pain to worsen while my immune system learns what to make to fight Covid?

It is not common to have bone pain 8 weeks after completing R-CHOP chemotherapy. It is possible that this is related to Neulasta, Neupogen or a similar drug given to stimulate your white blood cells. This is not related to activation of your immune system and I would not expect a similar reaction to the COVID-19 vaccine.

I finished R-EPOCH on 1/1/22 for primary bone lymphoma and just finished Imbruvica on 1/20. I’m having joint and bone pain in arms and legs. Scans are coming up in a few weeks. Is bone and joint pain after chemo typical?

Your bone and joint pain a few weeks after chemotherapy can be related to the chemotherapy, to a drug like Neupogen or Neulasta or due to menopausal symptoms in a woman. This is likely to improve soon.

Are you recommending the vaccine to your patients with lymphoma

Having cancer regardless of treatment status is a risk factor for worse outcome from infections including influenza and COVID-19. The short answer is yes once COVID-19 vaccines become more widely available. In terms of prioritization, and according to CDC guidelines, cancer patients will be part of the phase II wave of vaccination which will occur sometime in February. The vaccine is given in 2 doses at 21 days interval and we expect patients receiving the vaccine to be immune 2-3 weeks after their second dose of vaccine.

Is there a difference between the Pfizer and the Moderna vaccines?

These two vaccines appear to have similar effectiveness and no differences between the two are yet apparent.

Should Rituxan Maintenance be held during COVID vaccination?

I assume you are asking whether holding Rituxan for three months will optimize the response to a COVID-19 vaccine. The answer to this is unknown but B-cell suppression typically lasts for at least 9 months after the completion of Rituximab. I would discuss with your oncologist whether Rituxan can be held safely for a prolonged period of time. If not, I would proceed with the COVID-19 vaccine whenever you can get it. Unfortunately, we still do not know the efficacy of the COVID vaccine for lymphoma patients who are actively receiving therapy.

Should I get the Flu Vaccine as well? "I have follicular nhl in remission and am getting the Moderna vaccine this week. I didn't get the flu vaccine this year should I get it now?"

There are no data regarding the timing of the flu vaccine and the COVID19 vaccine but I would probably not get the flu vaccine until at least a few weeks after the Moderna vaccine. My advice in the future would be to make sure you obtain the flu vaccine very year early in the flu season.

I’ve had multiple types of chemo, radiation and stem cell transplant. My immune system did not recover and I’ve been getting IVIG since 3/2020. Are there recommendations of when to get the vaccine?

There are no firm guidelines as to when to receive the COVID-19 vaccine in relation to an IVIG infusion. For my own patients, I am trying to do this at least 2-3 weeks after IVIG.​

Is there an estimate of the efficacy of the vaccine in the immunocompromised (percentage-wise)?

No data yet - it is however likely to be less effective than it is in people with a normal immune system - this however is not a reason to not get vaccinated.

Would there be any particular timing for a vaccination for a patient with marginal cell lymphoma, first Rituximab treatment March 2020, being followed by maintenance every 6 months (October 2020, May 2021 etc for 2 years) Pretty sure only mRNA is available.

We have no data on the optimal timing of COVID-19 vaccines for patients receiving Rituximab. The effects of Rituximab on B-cell numbers and the immune system last a long time and it is possible that the effectiveness of the vaccine may be lower in patients on Rituximab or other immunosuppressive agents, but it is still valuable to receive the vaccine. We and others are studying the question of the effectiveness of the COVID-19 vaccine in patients receiving therapy for lymphoma.

​I have a blood cancer and am taking hydroxyurea and have compromised immune system and take prolia for bones, is it ok to get covid vaccine. I am 83 yrs old in ok health.

The short answer is yes, the vaccines however were not evaluated in patients with blood disorders and compromised immune systems so we are not certain how effective they will be - the CDC is recommending cancer patients should get the vaccine. You should however discuss vaccination with the doctor.

I am on Revlimid 20 mg daily for 21 days and then 7 days off plus every 2 month infusion of Rituxan. Can I receive the Covid vaccine? Does it make sense to stop these drugs to get the vaccine?

Immune suppression from Rituxan lasts for many months after therapy. B lymphocytes are markedly decreased for at least 9 months after Rituxan dosing. As such there is no known advantage to holding Rituxan prior to the COVID-19 vaccine, it would probably need to be held for awhile if its going to have an impact. It is also unknown whether holding the revlimid will enhance your immune response. Holding these medications must also be balanced against the impact that their absence would have on controlling your disease. This can only be determined in discussion with the physician managing your cancer. You should however get the vaccine.

I am concerned about the safety of the two RNA vaccines in general. Are there any studies on the safety and efficacy in lymphoma patients and these vaccines.

So far data shows excellent safety, most of vaccines adverse events occur on short term historically and there had been no concerns with the mRNA vaccines and enough follow up now in terms of safety, we don’t have data on efficacy among patients with MPN, there is zero harm as the vaccine does not contain any virus killed or attenuated.

What is your approach to timing of the Covid vaccination for patients with lymphoma who have not have had prior Covid 19, and are about to start chemotherapy?

If possible to delay, is it advised to delay starting chemo until 2 weeks after completing the Covid 19 vaccine series in order to max out the protective benefit from the vaccine. If starting Jakafi maybe delay starting Jakafi if possible by 2 weeks because it does affect T cell function.

My friend says that the Pfizer mRNA vaccine may cause covid19 illness in some people, is it true?

Absolutely not , there is no virus in the vaccine​.

Covid vaccination seems to cause adenopathy. I received the vaccine ...currently waiting for second dose...I have a PET SCan scheduled for recent diagnosis of follicular lymphoma for two weeks after second dose. Will the vaccine give false positive for more aggressive cancer?

It is very unlikely that the PET/CT will show findings consistent with a higher grade lymphoma. However, if you re concerned about this possibility, you can speak with your oncologist about deferring the PET/CT for another two weeks.

I was diagnosed with Follicular Non Hodgkin Lymphoma and Peritoneal Mesothelioma in 2014. Had radiation for the NHL. In 2017 it returned but so did a breast cancer for the 2nd time. My oncologist said we could only treat the breast cancer, lumpectomy, chemo and radiation. Almost a year later started Retuxin treatment and just finished 2 year maintenance in December 2019 and NHL started progressing October 2019. Diagnosed with ER+ PR+ HER- negative metastatic breast cancer in Jan 2020. So Jan 2020 MBC, NHL and Peritoneal cancer all at the same time. My oncologist says there are no other treatments for the NHL (which my oncologist/hemotologist believes is a lot) that is compatible with Ibrance targeted therapy and Letrozole for the MBC. My question is are there any avenues I can take to see if I have any other options? Because of the Ibrance I haven’t had any biopsies to confirm NHL since finishing Rituxan. I just don’t know what direction to go and I really feel I need to do more.

Your case sounds very complex and requires a thorough review in order to answer your question. Although it sounds like your oncologist has done a terrific job, I would recommend you get a second opinion at a comprehensive cancer center from a lymphoma specialist. There are certainly many options available for treatment of your follicular lymphoma if it requires therapy and some of those options also can be effective in treating your breast cancer.

Multiple Myeloma

My spouse has multiple myeloma. In remission one year. Takes 10mg revlimid for 21 days & 40mg dexamethasone once a week. Dr wants to stop dexamethasone. Is this a good idea?

Your doctor obviously thinks so and it makes sense. Long term use of steroids is associated with suppression of the immune system and other side effects and Revlimid alone is good maintenance therapy.

The "Ask The Experts About COVID-19 and Cancer" Series

The Ask The Expert Series is made possible by support from The Personalized Medicine Foundation, Incyte Oncology, Abbvie, and CancerConnect. The "Ask The Expert" series is not medical advice nor is it a substitute for your doctor. It should serve as a guide to facilitate access to additional information and enhancement of a shared decision making process with your treating physician.
Comments (1)
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Louise Kappers
Louise Kappers

My spouse suffers from Burkitt stage IV. We live in the Netherlands and are treated in the netherlands. We have had several chemo’s inclusieve R-CHOP, R-CODOX-M, R-IVAC and currently an R-DHAP. However the Burkitt remains present in throat area. Now we are in anticipation on radiology to attack these remains of the Burkitt. Even though the odds are against us. We would like to know which treatment is common voor Burkitt in The USA? Car t cell therapy for example? I also contacted M.D. Weaver via LinkedIn, unfortunately no response. My spouse is 36 years old and his bones, bonemarrow en brain fluids are untouched by the Burkitt. We would very much appreciate information about treatment for Burkitt in The USA. Thanks in advance.


Non Hodgkins Lymphoma

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