Dr. John Hainsworth of the Sarah Cannon Research Institute explains the different types of non-Hodgkin’s lymphoma.
Q: Welcome to Understanding Cancer. Today we are speaking with Dr. John Hainsworth, director of the Sarah Cannon Cancer Research Institute in Nashville, Tennessee, with a focus on Non-Hodgkin’s lymphomas. Welcome, John.
A: Thank you.
Q: I’d like to start with maybe you giving an overall description of what Non-Hodgkin’s lymphoma really means.
A: Well, Non-Hodgkin’s lymphomas are always sort of difficult for patients because it’s a whole group of diseases rather than one. These are diseases that are derived from lymphocytes that populate lymph nodes or bone marrow. And since there are different populations of lymphocytes, the lymphomas that are derived from those can act very differently. So it really has to go beyond that you have Non-Hodgkin’s lymphoma to which one do you have, and how is it going to act, and how is it treated.
Q: So Non-Hodgkin’s lymphomas really represent a range of cancer types under this general umbrella, as you described. Do people break them down further into broader categories for thinking about them clinically and the way we treat them?
A: So I think that’s a very useful thing to do, and they’re separated into the indolent ones, or slow growing ones, and then the aggressive ones, or fast growing ones. Each of those groups have several, but the most common indolent lymphoma is called follicular lymphoma and the most common aggressive lymphoma is called diffuse large B cell lymphoma, or diffuse large cell lymphoma. Those are treated very differently and have very different prognoses, and hardly anything about them is the same, other than they’re called lymphoma.
Q: Do they tend to affect different types of patients, or different types of individuals?
A: In general, both of them are diseases that are more common in elderly patients. There are some young patients, however, that do get lymphoma, and when young patients get lymphoma – and here when I’m talking about young, I’d be talking about less than 50 years old – usually when young patients get lymphoma, they get the aggressive type, the diffuse large B cell type.
Q: So when a patient is referred to you with an initial diagnosis of a Non-Hodgkin’s lymphoma, what sort of evaluation do you do?
A: So the first thing you want to make very certain of is that you have the right diagnosis. These are somewhat difficult for pathologists to make the diagnosis, and as I’ve already said, it’s very important that you have – that you know which type of lymphoma, so often it requires some extra pathologic study, often some consultation with other pathologists to get the right diagnosis.
Once you know you have the right diagnosis, I think then the next thing to do is what’s called staging, where we find out how extensive the lymphoma is. These often start in lymph nodes, but it’s relatively uncommon to find them in just one spot, so they tend to involve lymph nodes in various areas of the body, sometimes other organs as well. So the first groups of tests are to do scans of various body areas to look at the bone marrow to see where the lymphoma has spread to.
Q: So the staging evaluation, in essence, breaks patients into categories of sort of early stage or more advanced stage disease?
Q: And does that have any treatment implications?
A: It does have treatment implications, actually, for both types – for both the indolent and the aggressive lymphoma. In general, the patients with lower stage may have similar treatment, but they have a different outcome expected, at least in diffuse large B cell lymphomas. In low-grade lymphomas, they often have an entirely different treatment, being early stage versus more advanced stage.
Q: And in addition to the bone marrow biopsy, what are the standard tests that would be part of the staging workup?
A: So the standard imaging tests would be CT scans, and those would be done of the chest and the abdomen and the pelvis to look at various lymph node areas. This is in addition to the usual physical exam. One test that’s a more recent test that’s been very valuable is called a PET scan, which is now considered a standard part of evaluation, particularly in the more aggressive lymphomas, where it actually is very accurate in assessing patients upfront and then after treatment.
Q: And in addition to these standard staging tests, are there any specific tests that are done on the tissue itself that can help with treatment planning?
A: There are a lot of things that are being evaluated clinically. At this point I would say that beyond the routine pathologic examination, there are multiple other tests, but none of them yet, in my opinion, have been established as being able to direct treatment. Some of them are important to be able to predict prognosis, but as far as to determine treatment and change treatment, no, not right now.
Q: And what type of physician should a patient be seeing if they’ve been diagnosed with a lymphoma?
A: Most patients are referred to medical oncologists, so either a medical oncologist or a hematologist, or very frequently now people have training in both of those. This isn’t as common as other diseases, particularly when you break down the lymphomas to all the different subtypes, and there certainly is a difference, I think, between experience of doctors, you know, just oncologists across the board. Some have a lot of experience and an interest in treating lymphomas and others don’t.
I guess one other thing I’d say right now is that there are many new treatments being evaluated, interesting new treatments for lymphomas, and in my opinion, it would do the patient well, in general, to be involved with someone who was involved in those clinical trials, or at least had access to clinical trials and new drugs and new treatments.
Q: Yeah, it seems to me there’s perhaps more novel treatment strategies being developed for this disease than a lot of the other more common cancers.
A: Yeah, I think that’s right. And to do what I just said used to mean perhaps driving hundreds of miles to academic centers where they had units in lymphomas, and I don’t think it means quite that anymore. I think for most patients in medium to large size cities, or with one of those close by, there are oncologists either in an academic center or not in an academic center that are involved in clinical research now.
Q: John, I want to thank you for your time today. I know our viewers will find this session most informative.
A: Good. Thank you very much.
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