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What Is Hodgkins?
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What Is Cancer?
Cancer is not just one disease but rather a group of diseases. All forms of
cancer cause cells in the body to change and grow out of control. Most types
of cancer cells form a lump or mass called a tumor. Cells from the tumor can
break away and travel to other parts of the body. There they can continue to
grow. This spreading process is called metastasis. When cancer spreads, it is
still named after the part of the body where it started. For example, if breast
cancer spreads to the lungs, it is still breast cancer, not lung cancer.
Another word for cancerous is malignant. So a cancerous tumor is called malignant.
But not all tumors are cancer. A tumor that is not cancer is called benign.
Benign tumors do not grow and spread the way cancer does. They are usually not
a threat to life. A few cancers, such as blood cancers (leukemia), do not form
a tumor.
What Is Hodgkin's Disease?
Hodgkin's disease (also called Hodgkin's lymphoma) is a type of cancer that
starts in lymphatic tissue. Lymphatic tissue includes the lymph nodes and other
organs that are part of the body's system that forms blood and protects against
germs. Lymph nodes (sometimes called lymph glands) are small, bean-shaped organs
found in many places throughout the body. The lymph nodes make and store white
blood cells that fight infection. Lymph vessels, narrow tubes something like
blood vessels, connect the lymph nodes. These lymph vessels carry a clear fluid
that contains the white blood cells. Other parts of the lymphatic system include
the spleen, the bone marrow, and the thymus. Because lymphatic tissue is found
in many parts of the body, Hodgkin's disease can start almost anywhere. This
disease causes the lymphatic tissue to become enlarged press on nearby structures.
The cancer can spread through the lymphatic vessels. If it gets into the blood
vessels it can then spread to almost any other place in the body. Hodgkin's
disease is named after Dr. Thomas Hodgkin who first recognized it in 1832. There
is another cancer called non-Hodgkin's lymphoma. The cancer cells of this disease
look different under a microscope from the cells of Hodgkin's disease.
How Many People Get Hodgkin's Disease?
The American Cancer Society predicts that in the year 2000 there will be about
7,400 new cases of Hodgkin's disease in this country. About 1,400 people will
die of the disease. Because of better treatment, death rates have fallen by
more than half since the early 1970's.
Both children and adults can get Hodgkin's disease but it is most common in
two age groups: early adulthood (ages 15-40), and late adulthood
(after age 55).
Treatment for most cases of Hodgkin's disease is very effective. The 1-year
relative survival rate after treatment is 93%; the 5-year and 10-year rates
are 82% and 72% respectively. At 15 years, the overall survival rate is 63%.
The survival rate refers to the percent of people with Hodgkin's disease who
live at least that many years after the cancer is diagnosed.
What Causes Hodgkin's Disease? Can It Be Prevented?
A risk factor is anything that increases a person's chance of getting disease
such as cancer. Different cancers have different risk factors. Scientists have
found a few risk factors that may make a person more likely to get Hodgkin's
disease. There seems to be a slightly higher risk of Hodgkin's disease among
people who have had "mono" (infectious mononucleosis). Some people
who have reduced immune systems, for example, those with AIDS, and organ transplant
patients, are also at a higher risk of Hodgkin's disease. Unlike many other
types of cancer, Hodgkin's disease does not seem to be caused by something wrong
with a person's genes or their diet or even something in the environment. Even
if someone does have one or more risk factors for Hodgkin's disease, it's impossible
to know for sure how much that risk factor contributed to causing the cancer.
For the most part, we can say that no major risk factors for Hodgkin's disease
have yet been found. Since we do not know what causes Hodgkin's disease is not
possible to prevent the disease. A great deal of research is under way to try
to find the cause of this cancer.
How Is Hodgkin's Disease Found?
Symptoms of Hodgkin's Disease There are no screening tests to find Hodgkin's
disease early, and some people with the disease have no symptoms at all. When
theydo occur, symptoms can include enlarged, painless lymph nodes. But in most
people, especially children, enlarged lymph nodes are caused by an infection
or other illness and not cancer. If you (or your child) have lymph nodes over
an inch in size and no recent infection, it is best to have them checked by
the doctor. Other symptoms of Hodgkin's disease can be caused by the swelling
of lymph nodes inside the chest, creating pressure on the windpipe. These symptoms
can include coughing or shortness of breath. Some people have fever, drenching
night sweats, or weight loss. The fever can come and go over periods of several
days or weeks. Itching, tiredness, and decreased appetite are other symptoms
that can occur. If you or you child have these symptoms, talk to your doctor
right away. And remember, there are often reasons for these symptoms other than
cancer.
Tests to Diagnose Hodgkin's Disease
If there is any reason to think that a person has Hodgkin's disease, the doctor
will want to conduct certain tests. The first step would be a complete medical
history and thorough physical exam to see whether there is an infection. During
the exam, the doctor will pay special attention to the lymph nodes. Since it
is so common for people, especially children, to have swollen lymph nodes the
doctor will probably prescribe antibiotics first to see if the lymph nodes shrink.
If they do not, then more testing will be done. The only way to know for sure
whether a person has Hodgkin's disease is to do a biopsy, that is, an examination
of a tissue sample under the microscope. There are several different kinds of
biopsies, and the doctor will choose the one best suited for the patient. The
goal is to obtain enough tissue to make a diagnosis as quickly as possible with
the fewest side effects. Some biopsies involve cutting through the skin to remove
an entire node or a small part of a large tumor. In another type of biopsy,
the doctor uses a thin needle to remove a small amount of fluid and tiny bits
of tissue from the tumor. A doctor with special training in blood and lymphoid
tissue disease examines all biopsy samples under a microscope. Sometimes the
first biopsy does not provide a definite answer and more biopsies are needed.
How Is Hodgkin's Disease Staged?
Staging is the process of finding out how far the cancer has spread. This is
very important because the treatment and the outlook for recovery depend on
the stage of the cancer. The staging system for Hodgkin's disease is called
the Ann Arbor Staging Classification. This system has four stages, labeled stage
I through stage IV (1-4). In general, the lower the number, the less the cancer
has spread. A higher number, such as Stage IV, means a more serious cancer.
After a biopsy has confirmed that Hodgkin's disease is present, the next step
is clinical staging. This consists of taking the patient's medical history,
doing a physical exam, and then doing several kinds of imaging studies. Imaging
studies such as CT (computed tomography) and MRI (magnetic resonance imaging)
are used to create pictures of the inside of the body. They can help show the
size and shape of lumps or tumors that might be cancerous. For many people,
the results of the clinical staging are all that are needed to plan their treatment.
Others, however, require another step called pathological staging. In this process,
the doctor performs an operation called a laparotomy, checking inside the abdomen
to see if any of the organs contain cancer. Small pieces of tissue are removed
and looked at under a microscope to see if Hodgkin's disease is present. The
spleen is also usually removed at this time.
Survival Rates by Stage of Hodgkin's Disease
The 5-year survival rate refers to the percent of patients who live at least
5 years after their cancer is treated. Many of these patients live longer than
5 years. Five-year relative survival rates are seen as more accurate because
they do not include statistics for people who die of causes other than their
cancer. Since these figures go back 5 years, results for people diagnosed recently
can be even better since treatments are always improving.
Stage 5-year relative survival rate
I 90% to 95%
II 90% to 95%
III 85% to 90%
IV about 80%
How Is Hodgkin's DiseaseTreated?
In recent years, much progress has been made in treating Hodgkin's disease.
For nearly all patients, complete cure is the goal of treatment, and about 90%
of patients are cured with chemotherapy or radiation therapy. After Hodgkin's
disease is staged, the doctor will discuss treatment choices with you. It is
important to take time and think about all the choices. Some factors to consider
include you (or your child's) overall health and the type and stage of the disease.
Be sure that you understand all the risks and side effects before making a decision.
The two main methods of treating Hodgkin's disease are chemotherapy, the use
of cancer-killing drugs, and radiation therapy, the use of high-energy x-rays
to kill cancer cells and shrink tumors. Sometimes one treatment is used and
sometimes both. Bone marrow transplantation, discussed later, is used for certain
people. For the most part, surgery plays little role in the treatment of Hodgkin's
disease.
Chemotherapy
Chemotherapy for Hodgkin's disease can be given as a shot or a pill. Chemotherapy
refers to the use of drugs to kill cancer cells. Usually the drugs are given
into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout
the body to destroy the cancer cells. Several drugs are given at the same time.
Although the drugs kill cancer cells, they also damage normal cells, causing
side effects. The exact side effects depend on the type and dose of drugs used
and the length of time they are taken, but they can include hair loss, mouth
sores, greater chance of infection, easy bruising or bleeding, fatigue, loss
of appetite, nausea, and vomiting. These side effects are temporary and go away
after treatment is finished. If you have side effects, your cancer care team
can suggest steps to ease their impact. For example, other drugs can be given
along with the chemotherapy to prevent or reduce nausea and vomiting. In addition,
some of these drugs can have side effects that occur long after treatment is
finished. These can affect a person's heart, lungs, growth, and ability to have
children. There is also a risk of developing a second type of cancer. It's important
to discuss these possible side effects with the doctor before treatment begins.
Radiation Therapy
Radiation therapy is the use of high-energy x-rays to destroy cancer cells.
When radiation therapy is given for Hodgkin's disease, it usually involves a
focused beam of radiation, given from a machine outside the body. This is known
as external beam radiation. Radiation therapy is often given after 3 to 4 courses
of chemotherapy. Radiation therapy can produce some serious side effects including
damage to nearby healthy tissue. Other problems can include skin changes similar
to sunburn, tiredness, upset stomach, and loose bowels. There can be long-term
side effects as well. To reduce the risk of side effects, doctors are careful
to give the exact dose needed and to aim the beam so it hits only the cancer.
Bone Marrow Transplantation
Sometimes Hodgkin's disease stops responding to standard treatment. In those
cases, another type of treatment might be offered as part of a clinical trial
(see below) or outside of a clinical trial. In one approach, the patient's own
bone marrow is removed and stored. Then very high doses of chemotherapy (with
or without radiation therapy) are given to the patient to kill the cancer. These
high doses will destroy bone marrow, too. So, after the treatment, the stored
marrow is given back to the patient through a vein. The bone marrow cells enter
the bloodstream and return to the bone, replacing the marrow and making new
red and white blood cells. Another type of transplant is called peripheral blood
stem cell transplant (PBSCT). For this treatment, a machine removes the patient's
blood a little at a time. Only the stem cells--immature cells from which all
blood cells develop--are removed. The rest of the blood is returned to the body.
This process usually takes a few hours. The stem cells arethen frozen until
they are returned to the patient after treatment is finished. Doctors are finding
that it is better to do these procedures earlier rather than later in the course
of the disease. If the first set of treatments doesn't completely get rid of
the cancer, many doctors would recommend transplantation right away. On the
other hand, if a patient's disease comes back after it had gone away for a long
time, most doctors would favor a second course of standard treatment before
doing transplantation. What Happens After Treatment for Hodgkin's Disease
Each type of treatment for Hodgkin's disease can have side effects. Some, like
loss of fertility, may be permanent. You may be able to hasten your (or your
child's) recovery by being aware of the side effects before treatment starts.
You might also be able to take steps to reduce the side effects and shorten
the length of time that they last. Remember that every person's body is unique,
and so are his or her responses and emotional needs. In some ways, each patient's
cancer is like no one else's. No one can predict how each patient will respond
to cancer or its treatment. Statistics can paint an overall picture, but you
or your child may have special strengths such as a healthy immune system, a
history of good nutrition, a strong family support system, or a deep spiritual
faith. All of these have an impact on how you cope with cancer. Follow-up care
is important after treatment. The health care team will explain what tests are
needed and how often they should be done. Hodgkin's disease survivors will need
blood tests as well as x-rays, CT scans, and other imaging studies to look for
recurrent disease or long-term side effects. The good news about Hodgkin's disease
is that most people with this disease are cured. The bad news is that because
so many people are living for a long time, we are learning about serious side
effects that happen years after the treatment is over. One of the most serious
side effects of Hodgkin's disease treatment is the chance of the survivor developing
a second cancer. Some kinds of chemotherapy (or chemotherapy and radiation therapy)
can slightly increase the risk of the person treated developing acute leukemia
later in life. But radiation therapy alone does not increase the risk for leukemia.
Other types of cancer can also develop. These can occur because of radiation
treatment. Young women (under age 30) who are treated with radiation to the
chest have a much higher chance of developing breast cancer several years after
their treatment. These women should be especially careful about following American
Cancer Society guidelines for early detection of breast cancer. The guidelines
stress mammography, clinical breast examination, and breast self-examination.
Both men and women treated with radiation have a higher chance of developing
lung cancer and thyroid cancer. Although there is no accepted screening test
for lung cancer or thyroid cancer, frequent follow-up physical exams and chest
x-rays may be helpful. It should be no surprise that the chance of getting lung
cancer is very much higher in smokers, so not smoking is especially important
among survivors of Hodgkin's disease. A less serious, but still important long-term
effect of chemotherapy and radiation therapy is sterility. Men treated with
nitrogen mustard lose their ability to produce sperm. Spermproduction usually
returns-- but not always. Likewise, women may stop ovulating and menstruating
with chemotherapy. These functions may or may not return to normal after treatment.
Radiation treatment to the ovaries will permanently sterilize a woman unless
the ovaries are surgically placed outside the radiation field. For unknown reasons,
the immune system of people with Hodgkin's disease does not work properly. All
Hodgkin's survivors should keep up with their vaccinations, including flu shots,
and make sure that they get treatment for any infections. The thyroid and the
heart can also be affected by treatment. Many people who have had radiation
to their thyroid will develop a condition where the gland does not produce enough
thyroid hormone. They will need thyroid medication. Thyroid function should
be tested at least yearly. Radiation to the heart can injure the arteries that
supply oxygen and nourishment to the heart muscle. In the past, people who have
had radiation to the chest have had a higher rate of heart attacks. With more
modern radiation treatment, this has become less a problem, but it's still important
that survivors not smoke and that they follow the ACS diet guidelines to reduce
their chances of heart problems.
Survivors need follow-up care for many years or decades after treatment for
Hodgkin's disease. They should make a special effort to keep all appointments
with the cancer care team, to follow their instructions carefully, and to report
any new or recurring symptoms to the doctor right away.
Resistant and Recurrent Hodgkin's Disease
Treatment for Hodgkin's disease should get rid of all traces of the cancer.
If tests show that some disease remains, the doctor might suggest trying a different
kind of treatment, for example, a bone marrow transplant. If Hodgkin's disease
returns at a later time, then further treatment will depend upon what kind of
treatment was given initially. If chemotherapy had been used at first, different
drugs might be tried. But, once radiation is given to a part of the body, it
usually cannot be given again. For example, if someone had Hodgkin's disease
in their chest that had been treated with radiation, more radiation could not
be used if the disease came back. This holds true no matter how much time has
gone by.
How Can I Learn More?
The American Cancer Society has more information about Hodgkin's disease.
Call 1-800-ACS 2345 or visit our Internet site at www.cancer.org
National Cancer Institute
Cancer Information Service 1-800-4-CANCER
Internet address: www.nci.nih.gov
The Leukemia & Lymphoma Society
1-800-955-4572 or 1-914-949-5213
Internet Address: www.leukemia-lymphoma.org
Books
A Cancer Survivor's Almanac: Charting Your Journey. Edited by Barbara Hoffman,
JD. National Coalition for Cancer Survivorship. Chronimed Publishing, 1996.
Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery,
by Gerald P.
Murphy, MD, Lois B. Morris, and Dianne Lange. The American Cancer Society. Viking,
1996.
Sexuality and Fertility After Cancer by Leslie R. Schover, PhD. John Wiley &
Sons,
Inc., 1997.
