Understanding Lymphoma

Understanding Lymphoma with Sandra J. Horning, MD, Chat Transcript
Monday, September 12, 2005, 2:00 – 3:00 PM ET
Moderator: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net Ask the ASCO Expert chat on Understanding Lymphoma, a live question-and-answer session hosted by Sandra J. Horning, MD.

During this hour, Dr. Horning will answer as many questions as possible. Due to an increasing number of chat participants and number of questions submitted for each chat event, time simply does not allow us to address all of your questions, and we encourage you to consult your doctor and cancer care team.

Some questions may be adapted so that Dr. Horning's answers can help as many people as possible.

Dr. Horning will take questions from 2:00 – 3:00 PM ET. As you prepare your questions, please keep in mind that Dr. Horning is unable to give individual medical advice in this setting, nor is she able to address questions that include information specific to one person's medical profile.

The information presented here is for informational and educational purposes only and is not intended to substitute the professional medical advice or treatment recommendations provided by your doctor.

This forum is neither intended nor appropriate to serve as a means of obtaining a second opinion on cancer diagnosis or treatment. In response to questions about specific drugs, Dr. Horning's comments will focus only on the state of current research and clinical trials.

Good afternoon and welcome. Thank you for joining us. Dr. Horning will now begin taking questions.

Sandra J. Horning, MD, is currently President of ASCO for 2005 – 2006.

In addition, Dr. Horning is a Professor of Medicine in the Divisions of Medical Oncology and Blood and Bone Marrow Transplantation at Stanford University.

Dr. Horning's research interests include the biology and management of lymphoproliferative disorders, and she is an advocate for new drug development. Currently, she is a project leader of two program project (P01) grants from the National Cancer Institute (NCI) for research in non-Hodgkin lymphoma research, and she also leads Hodgkin lymphoma research that is funded by an NCI research project (R01) grant.

Dr. Horning, thank you for taking the time to join us today.

Kemper: My father was just diagnosed with follicular lymphoma after a follow-up from a routine blood test. His doctor told him that he or she is not going to treat this right away, just monitor. Does this make sense? How is this monitored? Should he get a second opinion?

Dr. Horning: In the majority of cases, follicular lymphoma presents as an asymptomatic enlargement of one or more lymph nodes. The disease often progresses very slowly, and to date no therapy has been defined that is curative for patients with advanced stage follicular lymphoma. Therefore, because the disease grows slowly and immediate treatment is associated with toxicity, in many cases (about 40 % of all presentations) a management of close observation is practiced and is reasonable.

This observation is done both by the patient in reporting how he or she is feeling, whether lymph nodes or enlargement of existing lymph nodes have taken place; as well as physical examinations by the oncologist, periodic radiologic examinations, and blood testing.

The initial management of follicular lymphoma may vary from one oncologist to another, and it is always appropriate to consider a second opinion.

Neil: Recently, I was diagnosed with lymphoma. How should I go about finding the best doctor (or cancer center)? How do I know whether the doctor and/or center is up-to-date on the latest treatments?

Dr. Horning: The most important aspect of a new diagnosis of lymphoma is the correct diagnosis of the histologic subtype of the lymphoma, such that the doctor you don't see, the pathologist, becomes very important in the management of lymphoma. I recommend that each case of lymphoma be reviewed by a pathologist with expertise in the field of hematopathology.

With regard to selecting an appropriate center and physician, we are fortunate that there are so many in variable geographic locations across the country.

I believe that it is appropriate to ask the oncologist to whom you have been referred how many lymphoma patients he or she manages per year. In many practices, there are individuals who specialize in the management of malignant hematology, such that it is appropriate to ask in a practice where there are many oncologists, if the one to whom you were referred specializes in this area of lymphoma treatment.

It is probably a good investment if you find yourself in an area with little lymphoma expertise to utilize other resources, such as getting a second opinion or seeking assistance from societies, such as The Leukemia & Lymphoma Society and The Lymphoma Research Foundation.

irene: Multiple pathologists have said that my NHL is "difficult to diagnose." Some say that it is follicular NHL, while others say that it is lymphoplasmacytic lymphoma. How important is it to know which is the correct diagnosis? If it is important, what steps should I take to confirm the diagnosis?

Dr. Horning: Sometimes there are very real difficulties in distinguishing among the subtypes of NHL. Under these circumstances, it may be advantageous to submit the diagnostic material for an expert opinion at a major center that sees a large number of lymphoma cases regularly.

In other cases, it may be necessary to obtain a second diagnostic specimen; however, there are some circumstances where it is extremely difficult to make a precise diagnosis between two histologic subtypes. If the management of these would not differ greatly, for instance the distinction between follicular lymphoma and lymphoplasmacytic lymphoma, the management should go forward as both of these are considered to be indolent, or low-grade, lymphomas.

Guest107: I have been in remission for six years. Is this enough time to say I am "cured?" Are there follow-up checkups you would recommend?

Dr. Horning: It's wonderful to hear that you have been in remission for six years, and the risk of further activity of an underlying lymphoma varies considerably according to the diagnosis. What we consider to be the diffuse-aggressive lymphomas, such as diffuse large B-cell or Burkitt's lymphoma, are very unlikely to recur after six years, whereas the indolent lymphomas, such as follicular lymphoma, may demonstrate activity after many years in remission.

The frequency of follow-up visits to the oncologists and diagnostic tests should reflect these differences according to different histologic subtype.

Whatever the diagnosis, a remission of six years is definitely very favorable.

Guest165: Is lymphoma transmittable?

Dr. Horning: Lymphoma is not a contagious disorder, nor is lymphoma considered to be an inherited or genetic disorder.

We don't understand the etiology of lymphoma, but the major areas that have been implicated include a relationship to underlying infection, immune deficiency, or environmental exposure.

There is much work to be done to understand why people get lymphoma.

Guest140: I am being treated with chemotherapy and have several side effects (some mild, some severe). At what point should I call my doctor? I don't want to bother her with every discomfort.

Dr. Horning: During the course of chemotherapy management for lymphoma, it is important to have a regular and open dialogue with your oncology professionals.

Side effects should be reported whether mild or severe, as it is possible that something that seems mild could evolve into something more serious.

It is good to think of the oncology providers as a team that includes nurses, physicians, and others in the office or hospital that are there to best meet your needs.

HSM: Could you talk about how a person gets into a clinical trial? I attend a local lymphoma support group, and many of us would like to know more about clinical trials.

Dr. Horning: Clinical trials are very important in the ongoing effort to make progress in lymphoma and in other cancers as well. The best initial resource for discussing clinical trials is your oncologist, and it is important to have this discussion early before a treatment decision and plan is made.

It is always appropriate to ask if there are any clinical trials that you would qualify for and that may offer a benefit to you.

Getting information about clinical trials may require some investigation on your part as well by accessing Internet resources, such as those available from the National Cancer Institute (NCI), and from foundations, such as The Leukemia & Lymphoma Society and The Lymphoma Research Foundation. In addition, most major medical centers maintain a roster of their clinical trials and resource numbers on their websites.

HG: I am concerned with the possible side effects of the CHOP chemotherapy, particularly to the heart. What pretest should be considered to minimize potential risks?

Dr. Horning: CHOP-chemotherapy (cyclophosphamide [Cytoxan, Neosar], doxorubicin [Adriamycin], vincristine [Oncovin], and prednisone [a type of corticosteroid]) is frequently prescribed for lymphoma. One of the main ingredients, doxorubicin, can result in toxicity to the heart when given in large, cumulative doses.

Fortunately, the usual treatment for lymphoma results in a lesser dose and less potential risk.

However, patients with any pre-existing history of heart disease or are age 50 or older, should have a baseline study that indicates the health of the heart.

This type of test assesses how well the heart pumps and its muscular function. If this test indicates severe problems with the heart, a substitution for doxorubicin can be made.

If the test results show a borderline function, the test can be repeated during the course of treatment to make sure that a full course of CHOP-chemotherapy can be completed safely.

Moderator: Transcripts of today's chat will be available September 13, 2005, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

guest11: I am a 48-year-old female, and I would like to know what the most promising treatment is for mantle cell lymphoma, stage IVB. My bone marrow is at 70% involvement.

Dr. Horning: The best treatment for mantle cell lymphoma, which typically presents as advanced stage disease, consists of multi-agent chemotherapy. Although a survival advantage for an individual treatment for mantle cell lymphoma has not been described, the results from several studies indicate that a more intensive treatment, especially for patients under the age of 60, results in more durable remissions.

This intensive treatment may consist of a regimen, such as hyperCVAD (fractionated cyclophosphamide, doxorubicin, vincristine, and dexamethasone [Dexasone]) or CHOP, followed by transplantation.

Rituximab (Rituxan) increases response rates in mantle cell lymphoma. Because there is no single preferred treatment, clinical trials are plentiful in mantle cell lymphoma and should be considered as a therapeutic option.

These treatments include the investigation of new agents, such as bortezomib (Velcade) and allogeneic transplantation.

Guest181: Are there any known, long-term side effects from the treatment of lymphoma? My son, who is now 17, was diagnosed at age 10 and aggressively (and successfully) treated.

Dr. Horning: The long-term side effects of lymphoma treatment depend on the specifics of that treatment, including the individual agents used, the cumulative doses of those agents, whether radiation was used, where it was applied, and the dose given.

The age of the patient at the time of treatment is also an important consideration for some side effects, such as heart or lung toxicity and fertility.

Based on the type of treatment, fertility in boys and men may be compromised. In addition, the use of chemotherapy, again depending upon the drugs and doses used, may cause problems with the blood-forming cells in the bone marrow. This can result in a lower-than-normal reading of the individual blood counts and, in some cases, again depending upon the particular details of the treatment, increase the risk of a secondary leukemia.

There are now excellent guidelines and resources for evaluating late effects and monitoring children treated for lymphoma and other cancers from the Children's Oncology Group (COG). These guidelines were published in the Journal of Clinical Oncology (JCO) in January, and there is an extensive website resource that may be accessed by your oncologist.

Guest47: I have been having memory problems after chemotherapy—ABVD (doxorubicin, bleomycin [Blenoxane], vinblastine [Velban], and dacarbazine [DTIC])—if that matters. Is this common? Is there anything that can be done to help?

Dr. Horning: The effects of chemotherapy on memory are an area that has received attention and is also an area of ongoing investigation.

Individual patients have described difficulties with memory and other mental activities that some have described as "chemobrain." For individuals who are having difficulty in this area, I would advise discussing these further with your oncologist.

It may be that formal testing would be in order to define the extent of the problem and to provide a baseline for future measurement.

There are a number of activities and recommendations that can be used to enhance memory, improve recall, and increase the level of satisfaction with mental performance.

Therefore, I recommend that these be further discussed, whether a relationship to prior to chemotherapy can be established.

Guest29: I am writing because I have a 28-year-old friend with immunoblastic lymphoma, stage III or stage IV, and we would like to find out a bit more about treatment options. Thank you.

Dr. Horning: Immunoblastic lymphoma falls within the category of the most common subtype of lymphoma, called diffuse large B-cell lymphoma.

This type of lymphoma is curable and the treatment should be approached as such. A standard for this B-cell disorder would include combination chemotherapy with a regimen, such as CHOP and the anti-CD20 antibody rituximab.

The prognosis for this type of lymphoma depends on several clinical factors, and, based on the areas involved at presentation, may require modifications of treatment. These should be discussed with your oncologist.

Clinical trials with alternate chemotherapy regimens and new agents are in progress, and it would be appropriate to inquire about these with your physician.

Moderator: Transcripts of today's chat will be available September 13, 2005, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

Guest197: Could you tell me more about "targeted radiation therapy," such as tositumomab (Bexxar) and ibritumomab tiuxetan (Zevalin) to treat NHL, and how they work? Can a person access these drugs outside of a clinical trial?

Dr. Horning: Both tositumomab and ibritumomab tiuxetan are types of treatment called radio-immunotherapy. They link radiation in the form of a radioactive isotope with an anti-CD20 monoclonal antibody that directs the radiation to the B-cell lymphoma.

Both of these are approved for use outside of a clinical trial for patients with recurrent or refractory follicular and transformed lymphoma.

Other uses of tositumomab and ibritumomab tiuxetan are limited to clinical trials.

It is important to know that tositumomab and ibritumomab tiuxetan are contraindicated if the bone marrow is heavily involved with lymphoma or the platelet count is low.

Fordstrom: Are there any updates on the development of a lymphoma vaccine?

Dr. Horning: The concept of a vaccine for lymphoma is a very attractive one for both patients and physicians. On that basis, accrual to clinical trials that will define the effectiveness of this approach has been brisk.

We are now awaiting the results of a definitive phase 3 trial that was completed last year. Vaccines work best when there is minimal lymphoma, so they have been used after chemotherapy, rituximab, or both.

There are some differences in the preparation of lymphoma vaccines that distinguish one from another, and also whether they are paired with cell-based therapy, such as dendritic cells.

In some, this is an area of active investigation, but we still don't know if these vaccines will meet their promise. The results of the phase 3 trials will provide an answer to this.

Trish: I am finishing chemotherapy next week for Hodgkin lymphoma, and I have a post-treatment appointment after that. I've been so focused on treatment that I don't know what comes next. What should I be discussing with my oncologist at this appointment?

Dr. Horning: This is a very good question. At the completion of treatment, it is appropriate to inquire how one should proceed with living.

A discussion with your doctor about how you will be monitored for a possible recurrence of your disease, including the details of how often you will be seen and will have tests, should be discussed.

In addition, a discussion should take place about the treatment you have received and any risks that treatment poses for your health. A prescription for wellness should be given about lifestyle issues and ways that you can help to reduce the risks of future problems that can range from a recurrence of your disease to a reduction in risk or prevention of toxicities, including second cancers. These are general principles for patients completing a course of treatment, not just for Hodgkin disease or lymphoma.

Moderator: The chat is now ending. Thank you for your thoughtful questions.

We hope this discussion has been valuable, and we regret not being able to answer every question. We want to thank Dr. Horning for lending us her time and expertise.

TRANSCRIPTS: The full text of today's chat will be available on Cancer.Net (www.cancer.net) September 13, 2005, by 12:00 PM ET. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

SAVE THE DATE: Please join Cancer.Net for a live chat about Understanding Leukemia on Monday, September 19, 2005, from 2:00 – 3:00 PM ET.

The featured expert is Charles Schiffer, MD, of Wayne State University School of Medicine and the Karmanos Cancer Institute.

The chat room is now closed. Thanks again for joining us.

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Last Updated: September 13, 2005