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Cancer Medicine :: Lymphoma - Hodgkin Treatment

Lymphoma - Hodgkin

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. 

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. 

The original treatments for Hodgkin lymphoma, developed in the 1960s and 1970s, were very effective. However, long-term follow-up care of people who received these treatments has shown that they are at risk for side effects later in life, including infertility (the inability to have children), heart problems (such as heart failure, leaky heart valves, and heart attacks) and secondary cancers, such as lung cancer and breast cancer in women. These long-term problems were partly caused by the types of chemotherapy used at that time and partly caused by the use of high doses of radiation therapy. 

To avoid or reduce the risk of these problems, today’s treatments for Hodgkin lymphoma involve newer types and doses of chemotherapy and the use of radiation therapy directed at smaller areas of the body. Most patients with classical Hodgkin lymphoma, even stage I or stage II, often receive some chemotherapy, followed by radiation therapy to the affected lymph node areas. For some patients with early stage-disease, it may be possible to have treatment with only a relatively short course of chemotherapy, with or without the need for radiation therapy. This applies to only a few patients and should be discussed with their doctor. For stage III or stage IV disease, chemotherapy is still the primary treatment, although additional radiation therapy may be recommended, especially to areas of large lymph nodes.

Descriptions of the most common treatment options for Hodgkin lymphoma are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. 

Radiation therapy

Radiation therapy is the use of high energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Radiation therapy for Hodgkin lymphoma is always external-beam radiation therapy, which is radiation given from a machine outside the body. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. Whenever possible, radiation therapy is now directed to the affected lymph node areas to reduce the risk of side effects. Some newer techniques of radiation therapy that may be used for some patients include involved-node radiotherapy (focuses the radiation on the lymph nodes that contain cancer), intensity modulated radiotherapy (IMRT; varies the strength of the radiation beams so less healthy tissue is affected), and proton therapy (uses protons rather than x-rays to treat the cancer).

Immediate side effects from radiation therapy depend on the area of the body that is being treated. These may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Patients who receive radiation to the neck may have a sore mouth and/or throat. Most side effects go away soon after treatment is finished. 

Although the risk for long-term side effects reduces as treatments improve, radiation therapy may still sometimes cause long-term side effects, also called late effects. To lessen the risk of long-term side effects, clinical trials are being done to determine the best doses and smallest possible area to direct the radiation therapy. 

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication, or a hematologist, a doctor who specializes in treating blood disorders. A chemotherapy regimen usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

Many different types of chemotherapy may be used for Hodgkin lymphoma. The most commonly used combination of drugs in the United States is called ABVD. Another combination of drugs known as BEACOPP is now widely used in Europe and is being used more often in the United States. The drugs that make up these combinations of chemotherapy are listed below:

ABVD: Doxorubicin (Adriamycin), bleomycin (Blenoxane), vinblastine (Velban, Velsar), and dacarbazine (DTIC-Dome). ABVD chemotherapy is usually given every two weeks for two to eight months.

BEACOPP: Bleomycin, etoposide (Toposar, VePesid), doxorubicin, cyclophosphamide (Cytoxan, Neosar), vincristine, procarbazine (Matulane), and prednisone (multiple brand names). There are several different treatment schedules, but different drugs are usually given every two weeks.

ICE: Ifosfamide (Ifex), carboplatin (Paraplatin), etoposide. ICE is usually given every three to four weeks for two to three months. This chemotherapy is most commonly used for patients when the Hodgkin lymphoma has come back after treatment with ABVD or BEACOPP.

It is unclear which of these chemotherapy treatments is best for patients with Hodgkin lymphoma, and the best treatment may differ depending on the type and stage of the lymphoma. For this reason, many clinical trials are underway comparing these different chemotherapy treatments. These clinical trials are designed to find out which combination works best with the fewest short-term and long-term side effects.

During chemotherapy, your doctors will usually repeat some of the original tests, especially CT scans and PET scans. These tests are used to monitor the lymphoma and see how well treatment is working.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Although the risk of long-term side effects has decreased as treatments have improved, chemotherapy still can cause long-term side effects. 

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Stem cell transplantation/bone marrow transplantation

A stem cell transplant is a medical procedure in which bone marrow is replaced by highly specialized cells, called hematopoietic stem cells. Hematopoietic stem cells are found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is stem cells in the blood that are typically being transplanted, not the actual bone marrow tissue.

Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the results of any previous treatment and the patient’s age and general health. It is very important to talk with a doctor at an experienced transplant center about the risks and benefits of stem cell transplantation. Stem cell transplantation is not used as a first treatment for Hodgkin lymphoma, but it may be recommended for patients who have lymphoma remaining in the bone marrow after treatment or who have a recurrence.

There are two types of stem cell transplantation depending on the source of the replacement blood stem cells: autologous (AUTO) and allogeneic (ALLO).

In both types, the goal of transplantation is to destroy cancer cells in the marrow, blood, and other parts of the body and allow replacement blood stem cells to create healthy bone marrow. In most stem cell transplants, the patient is treated with high doses of chemotherapy and/or radiation therapy to destroy as many cancer cells as possible. 

Palliative/supportive care 

Lymphoma and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the disease, an important part of care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the lymphoma and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment. 

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible. 

Recurrent Hodgkin lymphoma

A remission is when lymphoma cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.  

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the disease will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the disease returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the lymphoma does return. 

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Recurrent cancer is uncommon for people with Hodgkin lymphoma.

If it does recur, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Most often, the first step is to give a ‘second-line’ chemotherapy treatment, such as ICE (see Chemotherapy, above). The purpose of this chemotherapy is to reduce the amount of Hodgkin lymphoma as much as possible before a stem cell transplant so that the transplant has the best possible chance of curing the disease. The new drug brentuximab vedotin (Adcetris) has been recently approved by the FDA for patients with recurrent Hodgkin lymphoma, and it may also be a treatment option. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. 

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Progressive Hodgkin lymphoma

Progressive disease is when the cancer becomes larger or spreads while the patient is being treated for the original lymphoma. However, progressive disease is uncommon for people with Hodgkin lymphoma.

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.

Most patients will be advised to receive a stem cell transplantation (see above), which appears to be more effective in treating progressive Hodgkin lymphoma than standard chemotherapy. Supportive care will also be important to help relieve symptoms and side effects.

For many patients, a diagnosis of progressive lymphoma can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from lymphoma is not always possible. If treatment is not successful, the disease may be called advanced or terminal disease.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important. 

Palliative care given toward the end of a person’s life is called hospice care. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.

Side Effects

Fear of treatment side effects is common after a diagnosis of lymphoma, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for Hodgkin lymphoma are described in detail within the Treatment section. Side effects depend on a variety of factors, including the stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with Hodgkin lymphoma. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care.

Late Effects of Treatment

People who received treatment for Hodgkin lymphoma have an increased risk of developing other diseases or conditions later in life because both chemotherapy and radiation therapy can cause permanent damage. Treatments have improved in the last 30 years, and now patients are less likely to experience late effects; however, there is still some risk. Therefore, it is important that patients see their doctors for their follow-up care regularly to watch for any new side effects.

Some survivors of Hodgkin lymphoma have a higher risk of developing a secondary cancer, especially acute myeloid leukemia (following certain types of chemotherapy), non-Hodgkin lymphoma, lung cancer, or breast cancer. The risk of a secondary cancer is likely to be lower in the future because the treatments used now have fewer risks. Patients can lower their risk of secondary cancers by limiting other risk factors, such as smoking.

Radiation therapy to the chest area can cause lung damage, increase the risk of heart disease, and increase the risk of lung cancer and breast cancer. It is important that men and women who received radiation to the chest limit other risk factors that may lead to heart damage, such as smoking, obesity, and high cholesterol. It is important that women who received radiation therapy to the chest begin regular breast cancer screening at an early age.

Patients who received anthracyclines (doxorubicin) or bleomycin during chemotherapy have a higher risk of heart damage and lung damage, respectively.

Radiation therapy to the neck area (specifically, or as part of total body irradiation [TBI] during a stem cell transplantation) can cause thyroid problems, most commonly hypothyroidism. Hypothyroidism is when the body produces too little thyroid hormone, which regulates metabolism. This problem can be managed by taking a thyroid hormone supplement pill.

Radiation therapy to the pelvic area can lead to infertility in women or men unless the ovaries or testicles are block from the radiation during treatment. Also, teenagers and adults who received chemotherapy may be at higher risk for low sperm counts (for men) or damage to the ovaries (for women). Men who received combination chemotherapy may be at risk for infertility after treatment. The risk appears to be associated with drugs known as alkylating agents, which are used much less often in current chemotherapy regimens for Hodgkin lymphoma. Although the risk of infertility for men is low after chemotherapy for Hodgkin lymphoma, it is still possible, and men who are considering having a family should consider sperm storage before starting chemotherapy. Men who have had a stem cell transplantation are almost always infertile after this treatment. Women who received chemotherapy for Hodgkin lymphoma have an increased risk of infertility or early menopause. Again, this is mostly related to alkylating drugs and is less common with modern chemotherapy treatments. It is unusual, but not impossible, for women to become pregnant after stem cell transplantation.

After Treatment

After treatment for Hodgkin lymphoma ends, talk with your doctor about developing a follow-up care plan. This plan may include doctor visits and medical tests to monitor your recovery for the coming months and years. Follow-up care after treatment for Hodgkin lymphoma is important to monitor for possible recurrence of the lymphoma and late effects of treatment. 

How often a person needs follow-up care and which tests are performed depends on several factors, including the original extent of the Hodgkin lymphoma and the type of treatment. Typically, all of the tests—including CT scans, PET scans, and bone marrow biopsies—are repeated after treatment ends to make sure that the lymphoma is gone. Then, the frequency of additional screening depends on the results of the tests done immediately after treatment.

In general, each follow-up visit includes a discussion with the doctor, a physical examination, and blood tests. During some visits, scans are done. At most cancer centers, follow-up visits are scheduled every two to three months during the time right after treatment when the risk of recurrence is highest, and the time between visits increases over time. Later visits may only be two to three times per year until five years has passed; then, annual visits should be continued with an oncologist. Special attention should be paid to cancer screening and detection, as well as heart risk factors, for the person’s lifetime. For patients who received radiation therapy to the neck or chest, monitoring thyroid function is important.

Follow-up care should also address the person’s quality of life, including emotional concerns. In particular, Hodgkin lymphoma survivors are encouraged to be aware of the symptoms of depression and talk with their doctor immediately if they have such symptoms.

Patients who had Hodgkin lymphoma should get an annual flu shot. It may be recommended that some patients get an immunization against pneumonia, which may be done every five to seven years. 

People recovering from Hodgkin lymphoma are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level.

Latest Research

Doctors are working to learn more about Hodgkin lymphoma, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Measuring treatment effectiveness. A main focus of research for Hodgkin lymphoma is monitoring how well treatment is working to help make decisions about when to change treatment. Some new clinical trials are looking at changing chemotherapy depending on the results of a PET scan early in the treatment.

New chemotherapy. New chemotherapy, combinations of chemotherapy, lower doses, and shorter schedules are being studied in clinical trials to reduce short-term side effects and long-term health risks to patients receiving chemotherapy. Other drugs are being tested for recurrent Hodgkin lymphoma and may be added to the current standard drugs used for progressive disease.

Immunotherapy. Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to bolster, target, or restore immune system function. Some treatments involve antibodies that attach to proteins on the surface of cancer cells. Some antibodies have radioactive substances attached that will direct radiation therapy to the lymphoma (called radioimmunotherapy), and other antibodies direct drugs to the cancer cells. Research on the recently approved drug brentuximab vedotin is ongoing to find out how best to use this drug.

Gene profiling. Some researchers are looking at the specific genes and proteins that are found in Hodgkin lymphoma. These genes and proteins provide more information about the behavior of Hodgkin lymphoma, which may help better target the lymphoma with chemotherapy or immunotherapy.

Other treatments. Vaccine therapy is being studied to see if it helps the body’s immune system kill cancer cells. Stem cell transplantation is being studied in combination with chemotherapy and immunotherapy regimens for new or recurrent Hodgkin lymphoma. Mini-allogeneic or allogeneic transplantation is being tested in combination with chemotherapy and immunotherapy for new or recurrent Hodgkin lymphoma. Several new types of drugs which work in a different way than chemotherapy, called targeted therapy, are also being studied. Many of these are given in tablet (pill) form.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current Hodgkin lymphoma treatments in order to improve patients’ comfort and quality of life.

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