An estimated 8,500 people in the United States will likely be diagnosed with Hodgkin lymphoma in 2018, according to the National Cancer Institute. In 2015, some 209,000 people in the United States were living with Hodgkin lymphoma. (1) With modern therapy, 85 percent of all patients area curable.
Hodgkin Lymphoma: Two Main Types of Disease
Lymphoma is a cancer that originates in the lymph node system, a network of vessels that is part of the immune system. The vessels carry lymph, a watery fluid that transports white blood cells called lymphocytes throughout the system. Hodgkin lymphoma comes in two main types: classical, and nodular lymphocyte-predominant. Most Hodgkin lymphomas are the classical type. There are a variety of treatments for lymphoma, each tailored to a particular form of lymphoma. Correct diagnosis is essential if patients are to be given the optimal treatment. Treatment of Hodgkin lymphoma depends on various factors, including not only the particular form of Hodgkin disease but also the patient’s age and general health, along with the stage of the cancer. (2) Treatment of Hodgkin lymphoma can include most of the customary cancer treatments — chemotherapy, radiation, immunotherapy (including monoclonal antibodies), and stem-cell transplant. The main treatments for Hodgkin lymphoma are chemotherapy and radiation. One or both might be used. Hodgkin disease can be treated by a hematologist, who treats blood disorders; a medical oncologist, who uses chemotherapy; or a radiation oncologist, who uses radiation therapy. You might also encounter nutritionists, social workers, and others. Experts say it’s wise to carefully consider all treatment options. Each has its own benefits and its own set of side effects. You might also want to seek a second opinion — especially if, given the high cure rate for this cancer, your doctor is pessimistic about your prognosis. If you’re not sure about the options, be sure to ask your doctor to explain. For help, take a look at the American Cancer Society publication What Should You Ask Your Doctor about Hodgkin Lymphoma? (3)
Chemotherapy Is First-Line Treatment for Hodgkin Lymphoma
Chemotherapy is the main treatment for Hodgkin lymphoma. The regimen usually consists of several drugs, each of which attacks cancer in a different way. The most common regimen in the United States is a four-drug treatment called ABVD, consisting of the following drugs:
Adriamycin (doxorubicin)Blenoxane (bleomycin)Velban (vinblastine)Dacarbazine (DTIC)
A new version of ABVD was published in January 2018 in The New England Journal of Medicine. In the new regimen, the drug Adcetris (brentuximab vedotin) is substituted for Blenoxane. Many experts feel that this version should replace ABVD as the primary chemotherapy because research indicates that the survival rate is better with this combination. Another regimen used for patients more resistant to chemotherapy is BEACOPP, a combination of seven drugs. Radiation is sometimes given along with or after chemotherapy. Side effects, which vary depending on which drugs are used and how long treatment lasts, can include hair loss, nausea and vomiting, bruising, bleeding, infection and others. Tell your doctor if you experience any of these, because sometimes they can be controlled. Drugs are often given to prevent nausea and vomiting. Long-term side effects can include heart and lung damage and an increased risk of getting other cancers, especially following radiation. (4)
Radiation Is a Treatment Add-On for Some Patients
Some people with Hodgkin lymphoma get radiation therapy, often after chemotherapy and especially when there is a bulky tumor mass (usually in the chest). The radiation is delivered as an external beam after doctors have taken careful measurements to determine where to guide the beam. Treatments are usually given five days a week for several weeks. A newer approach called involved site radiation therapy (ISRT), preferred by many doctors, aims the beam only at the lymph nodes that originally contained lymphoma and nearby areas. This reduces the exposure of normal tissue to radiation. Another form of radiation that limits radiation exposure is called proton beam radiation. It’s value has not been proven yet, and it’s only available at a limited number of facilities. The side effects of radiation include skin redness or blistering, fatigue, dry mouth, nausea, and diarrhea. Radiation can also lower blood counts, increasing the risk of infection. Long-lasting side effects include increased risk of another cancer in the part of the body exposed to radiation, damage to the thyroid gland, and an increased risk of heart attack and stroke. (5)
Immunotherapy Is Increasingly an Option for People With Hodgkin
Some patients with Hodgkin lymphoma are candidates for immunotherapy, (6) an umbrella term referring to efforts to boost the immune system to find and destroy cancer cells more effectively. One way to do this is with the creation of what are called monoclonal antibodies, which are genetically engineered in the laboratory to attack a specific target on a cancer cell. In this case, a monoclonal antibody could be made to recognize, say, a specific protein on the surface of a lymphocyte, which is the cell in which Hodgkin lymphoma begins. One such monoclonal antibody is Rituxan (rituximab), which attaches to a substance called CD20 on some lymphoma cells. It can be used with nodular lymphocyte predominant Hodgkin disease, often in combination with chemotherapy or radiation. It’s usually given intravenously (through an IV) in a doctor’s office, generally once a week for four weeks. Side effects include chills, fever, nausea, rashes, fatigue, and headaches. More serious side effects include trouble breathing and low blood pressure. Another such monoclonal antibody is Adcetris, which attacks a molecule called CD30. The drug is made by attaching an antibody to a chemotherapy drug. The antibody locates the cancer cell, and delivers the chemotherapy drug to that cell only and kills it when it tries to divide. It has helped many patients whose Hodgkin disease has come back after other treatments. In March 2018, the Food and Drug Administration (FDA) approved Adcetris for the treatment of adult patients with previously untreated stage 3 or 4 classical Hodgkin lymphoma in combination with chemotherapy. That is, it is now considered first-line treatment for those patients. It had been approved earlier for use in some other circumstances. (6) The immunotherapy drug Opdivo (nivolumab), which binds to “checkpoints” on lymphocytes to activate them and prompt them to attack Hodgkin lymphoma, has also received FDA approval for use in Hodgkin disease patients who have not been helped by other treatments.
High Dose Chemotherapy and Stem-Cell Transplants
Stem cell transplants are sometimes given to patients for hard-to-treat cases, in which the disease doesn’t disappear after chemotherapy or radiation, or it if comes back after treatment. High-dose chemotherapy can damage bone marrow, where blood is made. Removing some of the cells allows doctors to use high-dose chemotherapy and then replace the damaged marrow cells with the healthy marrow cells harvested earlier. There are two kinds of stem-call therapy. In autologous stem-cell transplant, a patient’s own blood cells are taken from bone marrow or blood in the weeks before treatment and stored while a patient gets high-dose chemotherapy or radiation. The cells are then given back to the patients after treatment. This is the type most commonly used with Hodgkin lymphoma. In the other kind, allogeneic stem-cell transplants, the blood cells come from someone else, usually a brother or sister. It’s a complex treatment that should be done only at a cancer center where doctors have experience with it. (7)
