Hodgkin's disease is one of a group of cancers called lymphomas. Lymphoma is a general term for cancers that develop in the lymphatic system. Hodgkin's disease, an uncommon lymphoma, accounts for less than 1 percent of all cases of cancer in this country. Other cancers of the lymphatic system are called non-Hodgkin's lymphomas.
To understand Hodgkin's disease, it's helpful to know about normal cells and what happens when they become cancerous. The body is made up of many types of cells. Normally, cells grow and divide to produce more cells when the body needs them. This process helps keep the body healthy. When cells keep dividing into new cells not needed, a mass of extra tissue is formed. This mass is called a growth or tumor. Tumors can be either benign (not cancerous) or malignant (cancerous).
In Hodgkin's disease, cells in the lymphatic system become abnormal and divide too rapidly and grow without any order or control. Because lymphatic tissue is present in many parts of the body, Hodgkin's disease can start almost anywhere. Hodgkin's disease may occur in a single lymph node, a group of lymph nodes, or, sometimes, in other parts of the lymphatic system such as the bone marrow or spleen. This type of cancer tends to spread in a fairly orderly way from one group of lymph nodes to the next group. For example, Hodgkin's disease that arises in the lymph nodes in the neck spreads first to the nodes above the collarbones, and then to the lymph nodes under the arms and within the chest. Eventually, it can spread to almost any other part of the body.
At this time, the cause or causes of Hodgkin's disease are not known. By studying patterns of cancer in the population, researchers have found certain risk factors that are more common in people who get Hodgkin's disease than in those who do not. However, most people with these risk factors do not get Hodgkin's disease, and many who do get this disease have none of the known risk factors.
The following are some of the risk factors associated with this disease:
Age/Sex -- Hodgkin's disease occurs most often in people between 15 and 34 and in people over the age of 55. It is more common in men than in women.
Family History -- Brothers and sisters of those with Hodgkin's disease have a higher-than-average chance of developing this disease.
Viruses -- Epstein-Barr virus is an infectious agent that may be associated with an increased chance of getting Hodgkin's disease.
People who are concerned about the chance of developing Hodgkin's disease should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor's advice will be based on the person's age, medical history, and other factors.
Symptoms of Hodgkin's disease may include the following:
- A painless swelling in the lymph nodes in the neck, underarm, or groin
- Unexplained recurrent fevers
- Night sweats
- Unexplained weight loss
- Itchy skin
When symptoms like these occur, they are not sure signs of Hodgkin's disease. In most cases, they are actually caused by other, less serious conditions, such as the flu. When symptoms like these persist, however, it is important to see a doctor so that any illness can be diagnosed and treated. Only a doctor can make a diagnosis of Hodgkin's disease. Do not wait to feel pain; early Hodgkin's disease may not cause pain.
If Hodgkin's disease is suspected, the doctor asks about the person's medical history and performs a physical exam to check general signs of health. The exam includes feeling to see if the lymph nodes in the neck, underarm, or groin are enlarged. The doctor may order blood tests.
The doctor may also order tests that produce pictures of the inside of the body. These may include:
- X-rays: High-energy radiation used to take pictures of areas inside the body, such as the chest, bones, liver, and spleen.
- CT (or CAT) scan: A series of detailed pictures of areas inside the body, created by a computer linked to an x-ray machine.
- MRI (magnetic resonance imaging): Detailed pictures of areas inside the body produced with a powerful magnet linked to a computer.
- The diagnosis depends on a biopsy. A surgeon removes a sample of lymphatic tissue (part or all of a lymph node) so that a pathologist can examine it under a microscope to check for cancer cells. Other tissues may be sampled as well. The pathologist studies the tissue and checks for Reed-Sternberg cells, large abnormal cells that are usually found with Hodgkin's disease.
A patient who needs a biopsy may want to ask the doctor some of the following questions:
- Why do I need to have a biopsy?
- How long will the biopsy take? Will it hurt?
- How soon will I know the results?
- If I do have cancer, who will talk with me about treatment? When?
If a biopsy reveals Hodgkin's disease, the doctor needs to learn the stage, or extent, of the disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Treatment decisions depend on these findings.
The doctor considers the following to determine the stage of Hodgkin's disease:
- The number and location of affected lymph nodes;
- Whether the affected lymph nodes are on one or both sides of the diaphragm (the thin muscle under the lungs and heart that separates the chest from the abdomen); and
- Whether the disease has spread to the bone marrow, spleen, or places outside the lymphatic system, such as the liver.
In staging, the doctor may use some of the same tests used for the diagnosis of Hodgkin's disease. Other staging procedures may include additional biopsies of lymph nodes, the liver, bone marrow, or other tissue. A bone marrow biopsy involves removing a sample of bone marrow through a needle inserted into the hip or another large bone. Rarely, an operation called a laparotomy may be performed. During this operation, a surgeon makes an incision through the wall of the abdomen and removes samples of tissue. A pathologist examines tissue samples under a microscope to check for cancer cells.
Radiation therapy and chemotherapy are the most common treatments for Hodgkin's disease, although bone marrow transplantation, peripheral stem cell transplantation, and biological therapies are being studied in clinical trials.
These are some questions a patient may want to ask the doctor before having radiation therapy:
- What is the goal of this treatment?
- What are its risks and possible side effects?
- What side effects should I report to you?
- How will the radiation be given?
- When will the treatments begin? When will they end?
- How will I feel during therapy?
- What can I do to take care of myself during therapy?
- How will we know if the radiation therapy is working?
- How will treatment affect my normal activities?
Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for Hodgkin's disease usually consists of a combination of several drugs. It may be given alone or followed by radiation therapy.
These are some questions patients may want to ask the doctor before starting chemotherapy:
- What is the goal of this treatment?
- What drugs will I be taking?
- Will the drugs cause side effects? What can I do about them?
- What side effects should I report to you?
- How long will I need to take this treatment?
- What can I do to take care of myself during treatment?
- How will we know if the drugs are working?
Clinical trials are the exploration of new ways of giving radiation therapy and chemotherapy, new drugs and new drug combinations, and biological therapies. Doctors conduct these to learn about the effectiveness and side effects of new treatments. In some trials, all patients receive the new treatment. In others, doctors compare different therapies by giving the new treatment to one group of patients and the standard treatment to another group; or they may compare one standard treatment with another. Research like this has led to significant advances in the treatment of Hodgkin's disease. Each achievement brings researchers closer to the eventual control of cancer.
People who take part in clinical trials have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science.
Patients who are interested in entering a clinical trial should talk with their doctor. They may also want to read the National Cancer Institute booklet Taking Part in Clinical Trials: What Cancer Patients Need To Know, which describes how studies are carried out and explains their possible benefits and risks. The NCI Web site at cancer.gov provides detailed information about ongoing studies for Hodgkin's disease. Another way to learn about clinical trials is through the Cancer Information Service.
Treatments for Hodgkin's disease are very powerful. It is hard to limit the effects of therapy so that only cancer cells are destroyed. Because treatment also damages healthy cells and tissues, it often causes side effects.
The side effects of cancer treatment depend mainly on the type and extent of the therapy. Side effects may not be the same for everyone, and they may even change from one treatment to the next. Doctors and nurses can explain the possible side effects of treatment. They can also lessen or control many of the side effects that may occur during and after treatment.
The side effects of radiation depend on the treatment dose and the part of the body that is treated. During radiation therapy, people are likely to become extremely tired, especially in the later weeks of treatment. Rest is important, but doctors usually advise patients to try to stay as active as they can. It is common to lose hair in the treated area and for the skin to become red, dry, tender, and itchy. There may also be permanent darkening or "bronzing" of the skin in the treated area.
When the chest and neck are treated, patients may have a dry, sore throat and some trouble swallowing. Sometimes, they have shortness of breath or a dry cough. Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. Often, changes in diet or medicine can ease these problems.
Radiation therapy also may cause a decrease in the number of white blood cells, which help protect the body against infection, or platelets, the cells that help the blood clot. The doctor monitors a patient's blood count very carefully during radiation treatment. If necessary, treatment may have to be postponed to let the blood counts return to normal.
Radiation therapy can be difficult, but it can usually be treated or controlled. It may also help to know, in most cases, side effects are not permanent. Patients may want to discuss with their doctor the possible long-term effects of radiation treatment on fertility and the increased chance of second cancers after treatment. For men, sperm banking before treatment may be a choice. Women's menstrual periods may stop, and they may have hot flashes and vaginal dryness. Menstrual periods are more likely to return for younger women. The National Cancer Institute booklet Radiation Therapy and You has helpful information about radiation therapy and managing its side effects.
The side effects of chemotherapy depend mainly on the specific drugs and the doses the patient receives. As with other types of treatment, side effects may vary from person to person.
Anticancer drugs generally affect cells that divide rapidly. When blood cells are affected, the patient is more likely to get infections, may bruise or bleed easily, and may feel unusually weak and tired.
Chemotherapy may also lead to hair loss, which is a major concern for many patients. Some anticancer drugs only cause the hair to thin out, while others may result in the loss of all body hair. People may cope with hair loss better if they decide how to handle hair loss before starting treatment.
Cells that line the digestive tract also divide rapidly, and are often damaged by chemotherapy. As a result, side effects may include poor appetite, nausea and vomiting, and/or mouth and lip sores.
Most side effects go away gradually during the recovery periods between treatments or after treatment is over. Sometimes, however, chemotherapy results in a permanent loss of fertility. The National Cancer Institute booklet Chemotherapy and You has helpful information about chemotherapy and coping with side effects.
People who have had Hodgkin's disease should have regular follow-up examinations after their treatment is over and for the rest of their lives. Follow-up care is an important part of the overall treatment process, and people who have had cancer should not hesitate to discuss it with their health care provider. Patients treated for Hodgkin's disease have an increased chance of developing leukemia; non-Hodgkin's lymphoma; and cancers of the colon, lung, bone, thyroid, and breast. Regular follow-up care ensures that patients are carefully monitored, any changes in health are discussed, and new or recurrent cancer can be detected and treated as soon as possible. Between follow-up appointments, people who have had Hodgkin's disease should report any health problems as soon as they appear.
People often talk about Hodgkin's disease as the "good cancer" or the "curable cancer." While cure rates for patients diagnosed in early stages remains relatively high, far too high of a percentage diagnosed experience recurrence. Patients diagnosed in the later stages experience a much poorer prognosis.
About 30% - 40% of those diagnosed in later stages will have either refractory disease that does not respond to treatment or recurrent disease that reappears after a period of remission.
Hodgkin's Lymphoma affects all age levels, from children as young as two or three years of age, to older adults beyond the age of 55. The biggest incidence occurs in those from 15 to 35 years, those in the prime of their lives: high school and college students, young married people, mothers and fathers with young children of their own.
For people with refractory or recurrent disease, the only real hope of a cure comes from a stem cell transplant. Transplants carry enormous risks and are very difficult to endure, requiring lengthy hospital stays. 1-2% percent of people will die within the first 100 days of their transplant. Eventually, 30 to 50% will relapse again and for them, there is no cure available today.
3-4 people in the United States die each day of Hodgkin's Lymphoma.
Recent research has primarily been focused on lowering the toxicity of treatment. Chemotherapy and radiation protocols, while producing high cure rates, have left many patients with severe and sometimes fatal long-term effects such as secondary cancers, mostly lung, breast, and thyroid cancer, cardiomyopathy and congestive heart failure, sterility, thyroid failure, radiation fibrosis, and many more effects.
While long-term effects are expected to be less for people diagnosed today, cure rates have not improved in more than 20 years.
Because Hodgkin's is considered curable by many and affects a relatively small number of people, about 8,400 each year in the United States, researchers and drug companies have no incentive to study this disease in search of a cure.
Initially research will be conducted at the Alese Coco Hodgkin's Research Laboratory at Columbia University. Research funds and grants will also be awarded to other research facilities throughout the United States.