Noam Z. Drazin (Hematologist & Oncologist, Cedars-Sinai Medical Group) gives expert video advice on: What is the course of treatment for lymphoma?; How is "low-grade" lymphoma treated?; Is there any way to prevent lymphoma? and more...
Why would my doctor take a "watch and wait" approach with lymphoma?
The reason for waiting and watching is that low-grade haematological malignancies such as low-grade lymphomas and low-grade leukaemias are not able to be cured with standard therapy at all. We are basically achieving a palliation of treatment, a palliation of symptoms. Patients present with pain, we give them some sort of treatment to reduce that pain. Patients present or show to their doctor with large lymph nodes or large glands in their neck which are representative of a particular disease like lymphoma then we sometimes give therapy to reduce the size of these lymph nodes. The important thing in "waiting and watching" is that we wait until symptoms are severe enough or symptoms are present to require or necessitate treatment. That is where "waiting and watching" comes from.
What is the course of treatment for lymphoma?
The treatment course for patients with lymphomas and curable lymphomas (meaning the high grade or the aggressive lymphomas) involves a pretty protracted course of therapy, usually with chemotherapy, plus or minus radiation therapy afterwards. The standard course of therapy lasts anywhere between four and six months, and requires doctor appointments weekly to every three weeks, infusional visits, and nursing visits as needed to maintain your health and control of your symptoms. After their course of treatment most patients are verified to be in remission or cured using different screening modalities and imaging such as CT scans, PET scans, or MRIs. If it has been determined that patients don't need additional radiation therapy then they see me in follow-up, or see physicians in follow-up, every three months for the first two years, every six months for the subsequent three years, and then yearly after that.
What is "immunotherapy"?
Immunotherapy is a class of cancer therapeutics that utilizes antibodies to fight cancer, and I think the earliest and most classic example of immunotherapy utilized was in lymphomas and was a drug called Rituxan, which is a targeted monoclonal antibody or antibody against the B cells. The B cells are a particular type of lymphocyte that can become cancerous in lymphomas and we know that B cells (B lymphocytes) can cause non-Hodgkin's or Hodgkin's lymphoma. If we can block or stop B cells from growing or proliferating using a blocking agent or antibody like Rituxan we can stop the growth of certain lymphomas.
How is "low-grade" lymphoma treated?
We sometimes as physicians utilize a watch-and-wait or an observe type of therapy, which is basically doing nothing and watching until symptoms occur, because most patients with low-grade lymphomas don't have symptoms; they just have a very slow-growing tumour that may or may not present difficulties. The most common presentation of a patient with a low-grade lymphoma are lymph nodes. If they are small, they don't bother people. If they are larger, they do. The most common presentation of a low-grade lymphoma that needs treatment is a patient who is having difficulty shaving because their lymph nodes in their neck are interfering with their ability to shave. That would be your most common presentation of someone who may necessitate treatment for low-grade lymphomas. The goal of treatment with a low-grade lymphoma is not a cure in low-grade lymphoma, and that's important. The goal of treatment is to relieve or palliate symptoms, that is, to relieve or palliate lymph node enlargement by making them shrink, relieve or palliate pain that a lymph node is pressing upon, and relieve or palliate many other different types of symptoms. The ability to cure a patient with low-grade lymphoma doesn't really exist.
How is "high-grade" lymphoma treated?
As opposed to lower grade lymphomas where you wait for offending symptoms to get worse, high-grade lymphomas have the real potential of causing severe damage and mortality if not treated. The most wonderful thing about higher grade lymphomas and aggressive lymphomas are the ability to cure them even in advanced stages, and that can be utilised with significant advances in chemotherapy, bone marrow transplantation, as well as the combination of chemotherapy and radiation therapy. So, for the most part, with any diagnosis of a high-grade lymphoma whether it be by a lymph node biopsy, by a bone marrow biopsy, or by finding it circulating in the blood, we initiate treatment almost immediately. This is usually done with a combination of chemotherapy, immunotherapy, utilizing antibody based therapy, radiation therapy if necessary, and in the cases of advanced relapse lymphoma then bone marrow transplantation is utilised as well.
How is lymphoma "staged"?
In terms of staging and grading of lymphomas, I think the most important thing in terms of identifying, prognosis, and response to treatment of lymphoma, and duration of treatment is the stage of a lymphoma. Stage one lymphomas, whether it be non-Hodgkin's' lymphoma or Hodgkin's' lymphoma, involves only one lymph node group, whether it be the neck or the groin, one group only. Stage two lymphoma involves two non-contiguous (not connected) lymph node groups. So one lymphoma on the neck and another lymphoma in an armpit, or one side of the neck and one armpit, or one side of the neck and another side of the neck, or two non-contiguous lymph node groups. Stage three is when you have lymphomas on lymph nodes on both sides of the diaphragm, so crossing the mid-line. So, a lymphoma on a lymph node group on the neck and a lymphoma on a lymph node group in the groin constitutes stage three. And then stage four is any time you have bone marrow involvement in the lymphoma, or involvement of non-lymph node groups in the lymphoma. And the stagings get even more complicated if there's involvement of the spleen in the lymphoma or involvement of the small intestine or large intestine in the lymphoma, but for all intents and purposes of defining stage, one through four is the easiest way to identify lymphoma.
Will my lymphoma treatment plan differ if I am elderly?
I try not to pigeonhole my patients into particular age groups and look more at a functional status of a patient, which I describe as a physiologic age rather than a chronological age. I try to offer the most aggressive therapy to any patient I have based on their functional status. So I will not differ my chemotherapy or treatment based on their age unless they have specific co-morbid conditions or other medical problems that may impact their treatment.
How often will I be tested after I am in remission from lymphoma?
Once a patient achieves a remission from lymphoma, the patient is followed on a routine basis, usually every three months for the first two years, then every six months for the susbequent three years, and then yearly after the five-year point. It depends on the particular guidelines that physicians are following but the guidelines that I usually utilize are the National Comprehensive Cancer Network Guidelines which physicians can access, and that patients can also access on the Internet that utilize a screening tool of CT Scans or CAT scans along with a Pet scan or a Positron Emission Tomography scan or PET scan, every three to six months for the first two to three years.
Is there any way to prevent lymphoma?
I am not aware of any particular chemo prevention and/or dietary or lifestyle modification that exist, that will prevent the diagnosis of lymphoma. As of personally in my family, we've switched to only eating organic foods and limiting our exposure to toxins and pesticides in effort not just to prevent lymphomas, but to prevent other cancers, because I do believe in my hearts of hearts that I believe that there is an evironmental aspect of cancer that needs to be dealt with on a day to day basis.