Non-Hodgkin's Lymphoma; a Bipartisan Affliction

We have all heard the word lymphoma, a cancer of the lymph system. In this time of national political debate, it is worth noting that this serious cancer has taken national leaders' lives on both sides of the aisle, both Democrats and Republicans. This should be a reason for bipartisan support of increased funding of the budget of the National Cancer Institute.

Two of our national leaders have succumbed to non-Hodgkin's lymphoma (NHL). On the Democratic side, Senator Arlen Specter died of progressive NHL after 7 years battling the illness (and brain tumor and Hodgkin's disease) and serving in the Senate after his chemotherapy twice.

On the Republican side, Senator Fred Thompson developed NHL in 2004. Treatment produced a complete remission, during which time he was a candidate for the presidency in 2008. He succumbed to recurrent NHL on November 1, 2015 after his long control of the disease.

Also, Republican Governor Larry Hogan of Maryland has recently received chemotherapy and immunotherapy of widespread NHL, while still serving in his position. After his therapy, tests have shown that he is in a complete remission.

NHL is a cancer of the lymph nodes, spleen or lymphatic cells in the blood and bone marrow. In 2015, 71,000 people will have developed lymphoma, accounting for 4% of all cancers. 1 in 50 people will develop lymphoma, and in 2012, 549,000 people were living with lymphoma or were cured. Risk factors for developing NHL are having HIV infection, having an organ transplant in the past or being on immunosuppressive drugs, having H. pylori infection in the stomach, being older, or having been exposed to insecticides.

Due to funding through our National Cancer Institute, there has been remarkable progress in the battle against NHL. There is now a 70% survival 5 years after the diagnosis. Genomic advances have helped to distinguish lymphomas from other cancers and also indicated which patients have less or more aggressive types of NHL.

For the milder forms of the disease (follicular lymphoma, nodular lymphoma, MALT lymphoma, and marginal zone lymphoma are several low grade NHL variants), watchful waiting without treatment has been discovered to be appropriate for some patients, while others with this slowly progressing form of the disease have achieved long remissions with mild oral drugs such as ibrutinib or bendamustine, low toxicity antibody treatments with rituximab, or possible cures with more intensive therapies with stem cell transplants. Radio-immunotherapy has been effective with either tositumumab or ibritumomab tiuxetan. Newer active treatments also include idealisib. But for most patients, the disease ultimately relapses after months to many years of remission and can lead a more aggressive course with patients dying of infections or reduced organ function due to lymphoma involvement.

For the more aggressive forms of NHL (diffuse lymphomas, lymphoblastic lymphomas, Burkitt's lymphoma and T-cell lymphomas are some of the intermediate and high grade lymphomas), the combination of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) with rituximab antibody therapy has been curative in many patients, and now the additional use of etoposide, bendamustine or bortezomib may have increased the cure rates. Chemoimmunotherapy has been effective in some NHL patients with brentuximab vedotin. Patients with higher risk can receive stem cell transplants to raise their chances of cure, and older patients can have reduced intensity transplants and achieve excellent results.

Once in remission from any of the above excellent treatments, a patient's quality of life is very good. Senator Specter was a leader in the Senate, Senator Thompson was able to run a presidential campaign, and Gov. Hogan is now able to lead Maryland.

Dr. Cary's take home tips for lymphomas are:

• If you have a lymph node or gland that is swollen and does not decrease in size in 1-2 weeks, consult your physician to determine if a biopsy is needed to see if it is a lymphoma (either Hodgkin's disease or NHL). Since NHL can progress rapidly, earlier diagnosis can allow earlier treatment with less side effects and fewer metastases.
• If your doctor does not recommend a biopsy and treatment does not reduce the size of the lymph node, get a second opinion.
• If you have any of the systemic symptoms of lymphoma, fever or night sweats or weight loss, that persist for 2 weeks, ask your doctor is these symptoms could be due to lymphoma and if tests should be done for that disease (tests include CAT scans or MRIs).
• If you are found to have a lymphoma, get information about the illness from trusted websites (including National Cancer Institute and others I recommend in my book Surviving American Medicine). This will help you to work with your oncologist to choose the best treatment for you, and to understand the risks of any treatment.
• New research is improving the outlook for lymphomas. If you have NHL consider enrolling in a clinical trial.
• Everyone should consider supporting the efforts to increase funding for the National Cancer Institute so that cure rates can be improved, and clinical trials can be more available.