Hodgkin’s lymphoma is a cancer of the lymph system. It is diagnosed by identifying a characteristic cell under the microscope (the Reed-Sternberg cell). Hodgkin’s lymphoma typically begins in the lymph nodes in one region of the body and then spreads through the lymph system in a predictable manner. It may spread outside the lymph system to other organs such as the lungs, liver, bone, and bone marrow. Hodgkin's lymphoma is one of the more curable cancers but long term survivors may experience a myriad of complications from their curative therapy.
According to an article published in the Annals of Oncology, survivors of Hodgkin’s lymphoma have a significantly increased rate of cardiac and thyroid complications. In addition, survivors tend to have more fatigue; however, this may in part be associated with cardiac issues.
Researchers from the Brigham and Women’s Hospital and the Dana-Farber Cancer Institute recently conducted a study to further evaluate late effects that survivors of Hodgkin’s lymphoma may experience. This study included 511 survivors, who were compared with siblings who had not been diagnosed with Hodgkin’s. The average age of both survivors and siblings was 44 years.
- Survivors had a 26% rate of cardiac complications, compared with 16% of siblings.
- Hypothyroidism (low levels of thyroid hormones) occurred in 65% of survivors, compared with 3% of siblings
- Survivors reported more fatigue than siblings, as ascertained through a questionnaire.
- Researchers state that variables associated with fatigue among survivors included cardiac disease, psychiatric condition, tobacco use, and low levels of exercise; among siblings, the only variable associated with fatigue was low levels of exercise.
Risk of Heart Attack
Patients treated for Hodgkin’s lymphoma are at an increased risk of death from a heart attack for 25 years following therapy. In order to reduce the risk of death from cardiac complications, individuals diagnosed with Hodgkin’s lymphoma may wish to discuss monitoring procedures for the early detection and treatment of heart conditions.
Patients with Hodgkin’s lymphoma whose cancer is found in the lymph nodes in the chest may receive radiation to the chest. In addition, patients with Hodgkin’s lymphoma often receive treatment with chemotherapy. Some chemotherapy combinations may include agents referred to as anthracyclines.
Researchers from England conducted a clinical study to further evaluate the potential risk of heart attacks in patients with Hodgkin’s lymphoma. This study included 7,033 patients who were treated for Hodgkin’s lymphoma between 1967 and 2000. Their risk of heart attack was compared to that of the general public.
- Patients with Hodgkin’s lymphoma had a significantly higher rate of deaths caused by heart attacks than the general population. This risk persisted for up to 25 years following initial therapy.
- Risk of death from heart attack was significantly increased among patients who were diagnosed and treated before age 65.
- The risk of death from heart attack was significantly increased for patients treated with radiation to the chest and who received treatment with anthracyclines, the chemotherapy agent vincristine, or the chemotherapy regimen consisting of doxorubicin, bleomycin, vinblastine, and dacarbazine.
The researchers concluded that patients with Hodgkin’s lymphoma are at an increased risk of death from heart attack for 25 years following initial therapy, particularly among patients treated before the age of 65. Because early detection and intervention for cardiac complications can improve outcomes, patients diagnosed with Hodgkin’s lymphoma—particularly those at a higher risk of developing heart complications—may wish to speak with their physician regarding their individual risk of heart attack and possible monitoring for cardiac conditions.4
Risk of Stroke
A stroke happens when blood flow to part of the brain is interrupted. The most common type of stroke is an ischemic stroke, in which a blood clot blocks a vessel in the brain. The other type of stroke is a hemorrhagic stroke, in which a blood vessel breaks and bleeds into the brain.
A transient ischemic attack (TIA), sometimes called a “mini-stroke”, happens when the blood supply to the brain is only briefly interrupted.
To explore the risk of stroke and TIA among survivors of Hodgkin’s lymphoma, researchers in the Netherlands collected information about 2,201 patients. The patients had been diagnosed between 1965 and 1995, were under the age of 51 at the time of diagnosis, and had survived for at least five years after diagnosis. The risk of stroke and TIA in these patients was compared to the risk in the general Dutch population.
- The risk of stroke was roughly twice as high in the Hodgkin’s survivors as in the general population. The risk of TIA was three times as high in the Hodgkin’s survivors.
- An estimated 7% of Hodgkin’s survivors experienced a stroke or TIA during the 30 years following treatment.
- Radiation to the neck and mediastinum (the central part of the chest) increased the risk of stroke and TIA, but chemotherapy did not.
- High blood pressure also increased the risk of stroke.
Patients who have been treated with radiation therapy for Hodgkin’s lymphoma may wish to talk with their doctor about how to reduce their risk of stroke.5
Risk of Second Cancers
Compared to treatment with conventional therapy alone, treatment of Hodgkin’s lymphoma with conventional therapy followed by high-dose therapy and autologous stem-cell transplantation does not further increase the risk of second cancers, according to a study published in the Journal of Clinical Oncology .
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For patients with relapsed or refractory Hodgkin’s lymphoma (lymphoma that has returned after conventional treatment or that is resistant to conventional treatment), treatment with high-dose therapy and autologous stem cell transplantation may be a potential cure.
The objective of high-dose therapy is to kill the maximum number of cancer cells. However, high-dose therapy also produces more side effects, particularly to the blood-producing hematopoietic stem cells. Hematopoietic stem cells are immature blood cells produced in the bone marrow that mature into red blood cells (which carry oxygen to tissues), white blood cells (which fight infection), and platelets (which aid in blood clotting).
Procedures such as bone marrow transplantation or peripheral blood stem cell transplantation are used to restore stem cells that were destroyed by high-dose therapy. In an autologous hematopoietic stem cell transplantation (AHSCT), the patient’s own stem cells are collected before therapy and then re-infused afterwards.
Patients with Hodgkin’s lymphoma are known to have an increased risk of second cancers after conventional therapy, but it is uncertain whether patients who received both conventional therapy and high-dose therapy coupled with AHSCT have an even greater risk.
In order to compare risk of second cancers by type of treatment for Hodgkin’s lymphoma, researchers in British Columbia evaluated 1732 patients with Hodgkin’s lymphoma who were treated between 1976 and 2002. Of these 1732, 1530 were treated with conventional therapy alone and 202 were treated with conventional therapy followed by high-dose therapy and autologous stem-cell transplantation. The 202 patients treated with AHSCT all had evidence of relapsed or refractory Hodgkin’s lymphoma. Identification of second cancers occurred during a median of 10 years of follow-up:
- Overall, 9% of patients developed a second cancer during follow-up.
- The most common second cancers were lung (31 cases), breast (18 cases), gastrointestinal (16 cases), and treatment-related acute myeloid leukemia or myelodysplastic syndrome (18 cases).
- Patients who were treated with conventional therapy followed by high-dose therapy and AHSCT had a risk of second cancers (8%) that was similar to the risk among patients treated with conventional therapy alone (10%).
The researchers conclude that although patients with Hodgkin’s lymphoma have an increased risk of developing a second cancer, this risk is not increased further by treatment with high-dose therapy and autologous stem cell transplantation.
Breast Cancer and Mammography
According to the results of a study published in the Annals of Oncology, annual screening mammography may miss some cases of early invasive breast cancer among young Hodgkin’s lymphoma survivors who were treated with supra-diaphragmatic (above the diaphragm) radiation therapy.
Survivors of Hodgkin’s lymphoma have an increased risk of later developing a second cancer. Breast cancer is a common second cancer in female Hodgkin’s survivors, particularly among those who received supra-diaphragmatic radiation therapy at a young age.
In an attempt to improve early breast cancer detection among young Hodgkin’s survivors, researchers in Canada established a high-risk screening clinic. The clinic was open to female Hodgkin’s survivors who had received supra-diaphragmatic radiation therapy before the age of 30. Screening consisted of annual mammography and clinical breast exam starting eight years after Hodgkin’s treatment.
A total of 115 women agreed to participate in the breast cancer screening program, and 100 of these women had annual screening. The women had been diagnosed with Hodgkin’s lymphoma at a median age of 22 years, and had a median age of 35 years when they entered the screening program.
Of the 100 women who participated in annual screening, 12 were diagnosed with breast cancer. Seven of the breast cancers presented as palpable masses (masses that were felt by hand), and five were identified by mammography. Of the seven cancers that were palpable, six were invasive and four occurred in women who had had a negative screening mammogram within the previous 6-12 months. Of the five cancers identified by mammography, four were ductal carcinoma in situ (DCIS).
The researchers note: “Our results indicate that annual mammography can detect DCIS in this population, but may miss early invasive [breast cancer]. This underscores recent American Cancer Society guidelines recommending use of screening MRI as an adjunct to mammography in these women.”
To improve the early detection of breast cancer, the American Cancer Society currently recommends annual breast magnetic resonance imaging (MRI) in addition to mammography for women at high risk of breast cancer. This includes women who received radiation therapy to the chest between the ages of 10 and 30 years.
- High-Dose Therapy and Autologous Hematopoietic Stem-Cell Transplantation Does Not Increase the Risk of Second Neoplasms for Patients with Hodgkin’s Lymphoma: A Comparison of Conventional Therapy Alone Versus Conventional Therapy Followed by Autologous Hematopoietic Stem-Cell Transplantation. Journal of Clinical Oncology. 2005;23:7994-8002.
- Ng A, Li S, Recklitis C, et al. A comparison between long-term survivors of Hodgkin’s disease and their siblings on fatigue level and factors predicting for increased fatigue. Annals of Oncology. 2005; 16: 1949-1955.
- Lee L, Pintilie M, Hodgson DC, Goss PE, Crump M. Screening mammography for young women treated with supradiaphragmatic radiation for Hodgkin’s lymphoma. Annals of Oncology. 2008;19:62-67.
- Swerdlow A, Higgins C, Smith P, et al. Myocardial infarction mortality risk after treatment for Hodgkin disease: a collaborative British cohort study. Journal of the National Cancer Institute. 2007; 99:206-214.
- De Bruin ML, Dorresteijn LDA, van’t Veer MB et al. Increased risk of stroke and transient ischemic attack in 5-year survivors of Hodgkin Lymphoma. Journal of the National Cancer Institute. 2009;101:928-937.