Introduction

Follicular lymphoma (FL) is a type of blood cancer that targets white blood cells known as B lymphocytes. In the United Kingdom, follicular lymphoma affects about 2,300 individuals annually, and it is most likely to develop in people over 60. Since FL usually develops slowly and may not present with noticeable symptoms, it is sometimes diagnosed in advanced stages. Moreover, this condition is chronic or lifelong, with the possibility of relapsing (coming to the previous condition after improvement). Thus, treatment aims to improve patients' quality of life (QoL) in addition to merely curing the condition.¹

For patients with FL, understanding and prioritising quality of life is crucial as it includes everyday functioning and overall well-being, both of which can be greatly influenced by the FL and its treatment.¹ This article will explore the importance of QoL for patients with FL and provide insights into effective management strategies that might enhance their general experience and well-being.

Overview of follicular lymphoma

Lymphoma appears when B lymphocytes multiply uncontrollably. It is one of the most common forms of non-Hodgkin’s lymphoma. It begins in the lymph nodes or other lymphatic tissues like the spleen or bone marrow and blood or circulatory systems carry them around. FL can be of two grades (indicates its growth rate). Low-grade lymphomas (grades 1, 2, and 3A) grow slowly and are treated similarly. While high-grade lymphomas (grade 3B) grow faster and require more aggressive treatment.

Some people with FL might have no symptoms, while others may experience painless swollen lymph nodes, heavy night sweats, unexplained fever, and significant weight loss. Diagnosis primarily involves a lymph node biopsy, with potential follow-up blood tests, PET-CT scans, and bone marrow tests to assess the severity of FL.

Understanding quality of life

Quality of life in a medical context refers to a person's overall well-being. It includes their physical health, mental health or state, social interactions, and day-to-day functioning. It is not just about how well a disease is managed but also how it affects everyday life. It is usually measured using approaches including surveys, questionnaires, and interviews that evaluate physical health, emotional well-being, social interactions, and overall life satisfaction.²

Factors influencing the quality of life in follicular lymphoma

Disease-related factors

Severity of lymphoma

If you have advanced stages or severe cases of FL, it can affect your QoL more significantly. More severe disease often leads to more intense symptoms. It will also have a greater impact on your QoL which can worsen from the first to the third line of treatment.^{1, 3} A study on the impact of FL on health-related QoL revealed that patients with reappearing FL have the lowest QoL and experience the highest levels of activity impairment.³ On the other hand, patients classified as disease-free had the highest QoL scores. They reported the lowest levels of anxiety and depression and the least activity impairment. 

Symptoms

Difficulties caused by the symptoms of FL can lower your quality of life. Especially, you may experience fatigue, which can be challenging as it can reduce overall enjoyment of life due to persistent tiredness.⁴ It may-

• Prevent you from performing daily self-care tasks like climbing stairs and cooking
• Leave you with insufficient energy for other daily activities
• Negatively affects your work performance and productivity
• Adversely affects your capacity to care for others, be interested in relationships and interact socially
• Contribute to irritability, anxiety, and a greater risk of developing depression. 

Not just fatigue, but also symptoms like night sweats, fevers, and weight loss can impact your QoL. Additional difficulties related to the affected body sites may further influence it, such as:

• Chest pain and difficulty in breathing where FL affects your lungs
• Discomfort or pain in the abdomen and indigestion in case of abdominal or gastrointestinal involvement
• Bruises or bleeding problems due to low platelet counts

Treatment side effects

Depending on the stages or severity, FL treatment options may include radiation therapy, radio-immunotherapy, and chemotherapy (with or without the use of monoclonal antibodies). 

Chemotherapy 

In chemotherapy, powerful medications are used to destroy cancer cells that divide quickly. However, it can result in side effects which depend on the kind of medications utilised. Some of the common side effects that can influence your QoL are:

• Fatigue
• Anaemia
• Neutropenia
• Thrombocytopenia
• Sore Mouth and Skin
• Nausea and Vomiting
• Lack of Appetite
• Gastrointestinal Distress
• Alopecia or hair loss
• Mucositis
• Dysphagia⁴

Monoclonal antibodies 

Currently, the gold standard for treating FL is the use of rituximab/cancer drug (a monoclonal antibody) along with chemotherapy. This has made a huge improvement in survival rate and also has a great positive influence on patients' QoL. Monoclonal antibodies help more precisely target cancer cells and are frequently used in conjunction with chemotherapy. However, it has side effects impacting your QoL:

• The infusion may cause a temperature rise, a chill, or other flu-like symptoms
• Rituximab can lower immune cell counts, making it easier to catch infections
• Like chemotherapy, rituximab can cause extreme fatigue.⁴

Radiation therapy

Radiation therapy uses high-energy rays to target and destroy cancer cells. It can also lead to side effects that affect your QoL like:

• Skin changes (redness, blistering)
• Fatigue
• Nausea
• Diarrhoea
• Mouth sores and trouble swallowing (radiation therapy aimed at head/neck)

Radiation therapy can also have long-term side effects including thyroid problems causing fatigue and weight gain, headaches and memory issues. It can also cause personality changes from brain radiation and a slightly increased risk of developing new cancers in the treated area.

Psychological and emotional factors

Receiving a diagnosis of lymphoma can lead to a rollercoaster of feelings like shock, disbelief, denial, fear, anxiety, helplessness, anger, irritability, sadness, and withdrawal. Living with the uncertainty of FL,(especially since it cannot be fully cured and often reappears) can intensify these emotions, causing serious anxieties during and after treatment. This constant anxiety can contribute to depression, interfering with your daily routines, disrupting sleep and eating patterns, impairing concentration, leading to social withdrawal, and ultimately lowering your QoL.

Strategies to improve quality of life

Importance of QoL in FL treatment

Given that many patients with FL may survive over 20 years with or without treatment, considering QoL is crucial when choosing treatment options. Patients with FL may have substantial QoL reduction due to fatigue, and cancer therapy may worsen the patient's QoL than the FL itself.¹ Combining the drug rituximab with chemotherapy, followed by ongoing maintenance treatment, has led to better outcomes. 

Recently, individuals who did not react to chemotherapy have demonstrated significant success, longer-lasting benefits, and improved QoL with a novel treatment called CAR T-cell therapy.¹ Being actively involved in your treatment can improve outcomes. It is important to maintain a positive attitude, ask questions, and work closely with your physician to ensure you’re comfortable with your treatment plan.

Psychological support

Both the individual with FL and those close to them must continually adjust to life with the disease. Managing emotions and anxiety involves understanding their causes and seeking support from loved ones like openly discussing your feelings with family and friends.

These emotional difficulties can also be addressed through psychological assistance. This encompasses counselling, therapy, support groups, and self-help organisations. Especially, joining a support group may be a helpful way to discuss your thoughts and experiences with others who have had similar challenges and to understand how they overcame them. If you would like to gain more information and support, the Lymphoma Association is a great option.

Sometimes, medication like antidepressants may also be needed, as advised by your doctor. Whatever path you choose, it's important to seek out the help that works best for you.

It's common to feel stressed and overwhelmed after being diagnosed with lymphoma. Try to identify aspects you can manage such as deciding what personal information to share. When you’re ready, seek out the information you need and take your time to learn about lymphoma at your own pace. 

Complementary therapies

In addition to spending time with family and friends, you can also use complementary therapies like mindfulness, meditation, visualization, exercise, engaging in your favourite activities, and including relaxation in your daily routine. These can aid in alleviating stress and enhancing overall well-being. It is crucial to explore different methods to find what works best for you.

Lifestyle modifications

Exercise and physical activity

Engaging in physical activity is essential for maintaining mental and physical health prior to, during, and following cancer therapy. It lessens the negative effects of treatment and prevents infections, improves muscle strength, and enhances overall QoL. Moderate activities like walking and strength exercises are also beneficial.

It is important to see your doctor to ensure safety, especially if you have any medical issues like anaemia, neutropenia, or thrombocytopenia. 

Diet and nutrition

If you have FL, following a healthy diet is essential for maintaining your physical and mental health. It is also important to prepare to tolerate and recover from your treatment. Including fruits, vegetables, carbs, protein, fibre, fats, and fluids in your diet can support immune system health, energy, and overall wellness. Specific dietary modifications can help control symptoms that may occur due to treatment (eg appetite loss, nausea, taste changes, or digestive difficulties). However, it is better to seek tailored guidance from a medical team or nutritionist to guarantee sufficient nutrition and manage any potential side effects or nutritional challenges.

Summary

Follicular lymphoma is a chronic blood cancer affecting B lymphocytes and is often diagnosed in older adults. The symptoms of follicular lymphoma and the side effects of its treatments can greatly affect a person's quality of life. To improve your quality of life, it is important to manage symptoms effectively and address the side effects of treatments. Supportive strategies such as psychological support, and maintaining a healthy lifestyle, including a balanced diet and regular exercise, are also essential in improving your quality of life.