Hodgkin's and Non Hodgkin's Lymphoma Treatment

Hodgkin and non-Hodgkin lymphoma are two types of cancers originating in the lymphatic system, a vital part of the body’s immune system. Lymphomas are characterised by the abnormal growth of lymphocytes, a type of white blood cell.

Hodgkin’s Lymphoma (HL)

1. Hodgkin lymphoma, also known as Hodgkin’s disease, is a relatively rare form of lymphoma. 
2. It is distinguished by the presence of Reed-Sternberg cells, large abnormal cells. 
3. These are found in the lymph nodes and other lymphatic tissues. 
4. Hodgkin lymphoma typically spreads from one group of lymph nodes to another and may involve other organs.

Non-Hodgkin’s Lymphoma (NHL)

1. Non-Hodgkin lymphoma is a broader category that includes various types of lymphomas without Reed-Sternberg cells. 
2. There are multiple subtypes of non-Hodgkin lymphoma, each with its distinct characteristics, prognosis, and treatment options. 
3. Non-Hodgkin lymphoma can originate from different types of lymphocytes and affect various lymphatic tissues, including lymph nodes, bone marrow, and other organs.

When you are diagnosed with Hodgkin’s or non-Hodgkin’s lymphoma, the next step is to find the cancer stage. The cancer stage helps determine the amount, location, and spread of cancer in your body. Based on this information, the doctor decides the best treatment plan for the disease. 

Hodgkin and Non-Hodgkin Lymphoma Stages

The staging system used to classify Hodgkin and non-Hodgkin lymphoma is the Lugano classification, based on the old Ann Arbor system. The classification has four stages: I, II, III, and IV. 

1. Stage I: Lymphoma is in stage I in either of the following situations:
   1. Cancer is present in only one lymph node area or lymphoid organ, like the thymus or tonsils (I). 
   2. Cancer develops in only one part of one organ outside the lymph system (IE). 
2. Stage II: Lymphoma is in stage II in either of the following situations:
   1. Cancer is present in two or greater lymph node regions on the same side (above or below) of the diaphragm (II). 
   2. Cancer extends locally from the lymph nodes to a nearby organ (IIE). 
3. Stage III: Lymphoma is in stage III in either of the following situations:
   1. Cancer is found in the lymph node areas on both sides of the diaphragm (III). 
   2. Cancer is present in the lymph nodes above the diaphragm and the spleen.
4. Stage IV: Cancer has spread into at least one organ outside the lymph system, including the liver, bone marrow, or lungs.

Several Hodgkin’s lymphoma treatment options are available, such as chemotherapy, radiation therapy, immunotherapy, targeted therapy, and stem cell transplant. However, the treatment choice varies depending on multiple factors, such as:

1. The type of Hodgkin’s lymphoma (nodular lymphocyte-predominant and classical Hodgkin lymphoma treatment)
2. The stage of Hodgkin’s lymphoma 
3. Your age
4. Your overall health
5. Personal preferences

Stages IA and IIA, Favourable

This stage of Hodgkin’s lymphoma includes cancer in only one side of the diaphragm (either above or below) and does not constitute any unfavourable factors. The following factors characterise the stage:

1. It is not bulky (large). 
2. Cancer is in less than three lymph node areas.
3. It does not cause B symptoms (fever, night sweats, and weight loss). 
4. The Erythrocyte Sedimentation Rate or ESR (a blood test that shows inflammation in the body) is not elevated. 

The treatment modalities for Stages IA and IIA are as follows:  

1. Chemotherapy: Usually, treatment in this early stage of the disease is chemotherapy which includes two to four cycles of an ABVD regimen (doxorubicin, bleomycin, vinblastine, dacarbazine), followed by radiation to the initial site of cancer. Selected patients may receive chemotherapy alone in three to six cycles. 
2. Radiation Therapy: If you cannot have chemotherapy alone because of health issues, you may receive radiation therapy alone. The treatment uses high-energy beams to kill cancer cells.   
3. Stem Cell Transplant: If you do not respond to chemotherapy and radiation, the treatment may be followed by a stem cell transplant. In this procedure, you receive healthy stem cells to replace destroyed ones. 
4. Immunotherapy: Another option for stage 1 Hodgkin’s lymphoma treatment is immunotherapy drugs like nivolumab, brentuximab vedotin, and pembrolizumab. Immunotherapy helps boosts the immune system to fight the cancer. 

Stages I and II, Unfavourable

While the cancer is limited to only one side of the diaphragm, this stage is characterised by one or more of the following mentioned risk factors:

1. It is bulky (the tumour is large). 
2. Cancer is in three or more different areas of the lymph nodes. 
3. Cancer is present outside the lymph nodes (extranodal involvement).
4. It is causing B symptoms.
5. The ESR is high. 

The treatment modalities for Stages I and II are as follows:

1. Chemotherapy and Radiation: Hodgkin lymphoma treatment in this stage starts with chemotherapy drugs (the ABVD regimen for 4-6 cycles or Stanford V for 3 cycles). Chemotherapy may be followed by radiation therapy at the sites of the tumour. 
2. Stem Cell Transplant: If you do not respond to chemotherapy and radiation, the doctor may recommend a stem cell transplant to replace the destroyed stem cells with healthy ones. 
3. Immunotherapy: Like the favourable stage I and II of Hodgkin lymphoma, immunotherapy with drugs like nivolumab or brentuximab vedotin may be an option.

Stages III and IV

In this stage of Hodgkin lymphoma, doctors generally recommend the following treatments:

1. Chemotherapy: While chemotherapy is also used for earlier stages, this stage includes more intense chemo regimes than earlier stages. 
   1. The ABVD regimen is used for at least six cycles. 
   2. Usually, doctors prefer more intense treatments like the Stanford V regimen for three cycles or the BEACOPP (bleomycin sulfate, etoposide phosphate, doxorubicin hydrochloride, cyclophosphamide, vincristine sulfate, procarbazine hydrochloride, and prednisone) regimen. 
   3. Sometimes, the doctor may recommend the drug brentuximab vedotin with chemotherapy. 
2. Radiation Therapy: You may receive radiation therapy after chemotherapy, especially when there are large tumour areas. 
3. Stem Cell Transplant: If you do not respond to other treatments, a stem cell transplant may need to be performed.
4. Immunotherapy: Like other stages, immunotherapy with drugs like nivolumab, brentuximab vedotin, and pembrolizumab may be another option. 

A relatively newer treatment for all stages and types of Hodgkin’s lymphoma includes targeted therapy. This classic Hodgkin lymphoma treatment option uses medications to attack cancer cells. It delivers a drug to the inside of the Reed-Sternberg cells (large, atypical white blood cells found in people with Hodgkin’s lymphoma) to destroy these cells.

Several treatment options for non-Hodgkin’s lymphoma are available, including chemotherapy, radiation therapy, stem cell transplant, targeted therapy, and immunotherapy. The best treatment for NHL depends on factors such as:

1. The stage of the disease
2. The type of NHL
3. Specific proteins in the cancer cells
4. Gene changes in the cancer cells
5. Symptoms you experience
6. Overall health
7. Treatment preferences

Stage I and Stage II

For early-stage Non-Hodgkin lymphoma, treatment options may include chemotherapy, radiation therapy, immunotherapy, targeted therapy, or a combination. Treatment choice depends on the subtype and characteristics of the lymphoma and individual patient factors.

You may not need treatment immediately if you have an indolent (slow-growing) subtype of non-Hodgkin lymphoma. The doctor may monitor the lymphoma for several months with regular checkups and tests. They may recommend treatment if the cancer starts to grow. 

Stage II (bulky disease), Stage III, and Stage IV 

Advanced-stage NHL typically involves chemotherapy combined with immunotherapy, targeted therapy, or radiation therapy. 

1. Intrathecal Chemotherapy: If there is a risk of lymphoma spreading to the fluid around your brain and spinal cord, you may need intrathecal chemotherapy. During this treatment, the healthcare team inserts a thin needle between the bones of the lower back to inject chemotherapy drugs directly into the spinal fluid. 
2. Stem Cell Transplant: The procedure may be considered for certain cases of aggressive NHL or where cancer recurs after treatment. 

There are several treatments for non-Hodgkin’s lymphoma, and scientists are conducting clinical studies to test more treatment approaches. Participation in clinical trials may be recommended for NHL with high-risk features. You can seek the advice of your healthcare provider to find the right one. Some new treatments for non-Hodgkin’s lymphoma include:

1. Chemotherapy: Recently, several new chemotherapy drugs, like bendamustine and pralatrexate, have been approved for use against certain types of non-Hodgkin’s lymphoma.  
2. Targeted Therapies: Unlike standard chemotherapy drugs, researchers have developed newer drugs targeting rapidly growing cells. Newer targeted drugs that have shown positive results in early studies include venetoclax, ruxolitinib, crizotinib, duvelisib, etc.
3. Immunotherapy: While immunotherapies like monoclonal antibodies and immune checkpoint inhibitors are already being used for non-Hodgkin’s lymphoma treatment, new therapies like CAR T-cell therapy have also shown positive results. 
   1. In this treatment, T-cells (a type of immune system cell) are removed from your blood and changed in the laboratory to add specific receptors on their surface. 
   2. The T-cells are multiplied in the lab and injected into the blood to help them attack the lymphoma cells. 
4. Lymphoma Vaccines: Unlike vaccines for infections, lymphoma vaccines are used to cure rather than prevent the disease. 
   1. These vaccines are immunotherapy designed to stimulate the body’s immune system to recognise and attack lymphoma cells. 
   2. Lymphoma vaccines are still under development and investigation in clinical trials. While they hold promise as a potential treatment approach, they are not yet widely available as standard therapies.

A relative survival rate compares patients with the same type and stage of disease with the overall population. It identifies the percentage of people with cancer likely to live for a certain time (usually five years) after their diagnosis. However, survival rates are estimates and cannot predict an individual case. They are useful in providing a better understanding of the likelihood of successful treatment. 

Hodgkin’s Lymphoma

The overall five-year survival rate of Hodgkin’s lymphoma is 89%. Survival rates as per different stages are as follows: 

The prognosis for Hodgkin’s lymphoma is generally poorer when the patient:

1. Has bulky disease or B symptoms
2. Is male
3. Is older than 45
4. Has a high white blood cell count (above 15,000)
5. Has a low red blood cell count (haemoglobin below 10.5)
6. Has a low albumin level, a protein made by the liver (below 4)
7. Has a low lymphocyte count, a type of white blood cell in the immune system (below 600)
8. Has a high ESR rate (over 30 with B symptoms and over 50 without B symptoms)

Non-Hodgkin’s Lymphoma 

The overall five-year survival rate for individuals with NHL is 74%. However, the survival rates can vary depending on the stages and different types of lymphoma. Patients with non-Hodgkin’s lymphoma usually have a good prognosis when they:

1. Are 60 or below
2. In Stage I or Stage II of cancer
3. Have no lymphoma outside of lymph nodes, or it has spread only to one area outside the lymph nodes
4. Can function normally and complete daily activities
5. Have normal serum LDH (elevated LDH levels in the blood indicate tissue damage)

After lymphoma treatment, lifestyle changes can contribute to overall well-being and aid in recovery. The following are the lifestyle changes that can make you feel better and improve your long-term health:

1. Seek Emotional Support: Prioritise your emotional well-being by seeking support from loved ones, joining support groups, or seeking professional counselling or therapy. Caring for your mental health is crucial.
2. Manage Stress: Practice stress management techniques like guided imagery, mindfulness, meditation, yoga, or deep breathing exercises. Reserve 20 minutes or more for these exercises every day to gain benefits.
3. Get a Good Night’s Sleep: Aim for 7-8 hours every night. Getting enough sleep helps improve your health, mood, attention, memory, coping ability, etc. Moreover, avoid screen time and stimulants before bed. It would help to keep your room as dark as possible. 
4. Regular Exercise: Engage in regular physical activity, as your healthcare team recommends. Exercise can help improve energy levels, increase strength, and manage weight. Avoid sitting or lying down for prolonged periods.
5. Eat a Nutritious Diet: Focus on a balanced diet rich in fruits, vegetables, and fibre, like whole grains and beans. Stay hydrated and limit processed meats, red meat, high-calorie, low-nutrient food, and excessive alcohol consumption.
6. Avoid Environmental Toxins: Environmental toxins, like tobacco smoke, can increase your cancer risk. So if you smoke, quit smoking.

Treatment for Hodgkin’s and non-Hodgkin’s lymphoma helps destroy lymphoma cells. However, it can also damage several healthy cells, leading to side effects. Side effects may differ from one individual to another and vary depending on the type and duration of treatment. Some common side effects of lymphoma treatment that can affect your day-to-day life include:

1. Hair loss
2. Dry, sore, and itchy skin
3. Fatigue
4. Bowel problems
5. Nausea and vomiting
6. Neuropathy (nerve damage)
7. Sore mouth
8. Sleep problems

Other serious side effects of the treatment may include:

1. Infection
2. Anaemia (low red blood cells)
3. Neutropenia (low white blood cells)
4. Thrombocytopenia (low platelets)
5. Reduced fertility 
6. Secondary cancers
7. Cardiovascular problems
8. Lung problems

Can Lymphoma Recur?

Yes, lymphoma can recur, meaning it can come back after a period of remission or successful treatment. The risk of recurrence can vary depending on several factors, including the specific type and stage of lymphoma, the initial treatment received, and individual characteristics. 

1. When lymphoma returns after at least six months of successful treatments, it is said to be relapsed. 
2. When it returns within six months of treatments, the lymphoma is refractory. 

Classical Hodgkin lymphoma treatment is generally more successful and less likely to relapse. Types of lymphomas more likely to relapse include low-grade non-Hodgkin lymphoma and some high-grade non-Hodgkin lymphomas. 

If lymphoma does recur, further treatment options will be explored based on various factors, like the type and location of the recurrence, the individual’s overall health, and previous treatments. In some cases, additional chemotherapy, radiation therapy, targeted therapy, immunotherapy, or stem cell transplantation may be considered.

If you are undergoing treatment for lymphoma, you should call your doctor when you notice changes in your body that indicate a worsening condition despite the ongoing treatment. If your treatment is complete, you will have regular follow-up appointments so the doctor can monitor your health and look for recurrence signs. 

Call a doctor immediately if you experience persistent side effects that do not subside with prescribed medications or when you experience signs of recurrence, including:

1. Swollen lymph nodes for more than a few weeks
2. Night sweats for more than a few weeks 
3. Unexplained weight loss
4. Fatigue
5. Itching
6. Persistent pain
7. Changes in bowel movement

The non-Hodgkin and Hodgkin lymphoma treatment has significantly advanced, offering improved patient outcomes and increased hope. Classic Hodgkin lymphoma treatment often combines chemotherapy, radiation therapy, and stem cell transplant. Non-Hodgkin lymphoma treatment approaches vary based on the subtype and stage, including chemotherapy, immunotherapy, radiation therapy, targeted therapy, and stem cell transplantation.

HexaHealth, a leading healthcare provider, can play a vital role in supporting patients with Hodgkin’s and non-Hodgkin’s lymphoma. Our comprehensive and patient-centred approach offers expert medical guidance and healthcare services to help you throughout your treatment journey. Our team of specialists collaborates to create personalised treatment plans, provide emotional support, and ensure the best possible care and outcomes for lymphoma patients. So what are you waiting for? Get in touch with us TODAY!

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