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Initial Lymphoma Treatment Decisions

Posted Aug 24 2008 1:49pm
ANNOUNCER: Non-Hodgkin's lymphoma is a cancer of the immune system.

ALEXANDRA LEVINE, MD: Lymphoma is a tumor of lymphocytes; that's a type of white blood cell that's normally responsible for your immune system, your defense against germs and other foreign invaders. Normally, the lymphocytes will start dividing if there is something to react against. In lymphoma, those cells start to divide for no reason at all and they don't know how to stop.

ANNOUNCER: Eighty-five percent of non-Hodgkin's lymphoma develops from malignant b-lymphocytes or b-cells.

ALEXANDRA LEVINE, MD: It's interesting because most people believe that lymphoma is one disease, but in fact, there are at least 30 different types of lymphoma. The diagnosis of lymphoma must be under the microscope, so we will do this by a biopsy, usually going to a big lymph node. Once a lymphoma has been diagnosed, the next step is to figure out what is the extent of disease? Where is it? And the purpose of that staging is to figure out exactly where the disease is so that we know how to treat.

ANNOUNCER: Staging includes a review of patient medical history, a physical examination and diagnostic procedures.

MORTON COLEMAN, MD: The three most commonly used tests are the bone marrow, the PET scan and the CAT scan.

ANNOUNCER: Treatment is also based on whether or not the lymphoma is indolent or aggressive.

MORTON COLEMAN, MD: Indolent referring to lazy or not very aggressive, and the aggressive lymphoma being a more virulent type of the disease.

ANNOUNCER: There are many treatment options available for lymphoma.

ALEXANDRA LEVINE, MD: Often we will use radiation. Sometimes we use multi-agent chemotherapy. We also can use monoclonal antibodies. We can use monoclonal antibodies with a little bit of radiation on them, something called radionuclides, we can even use stem cell transplant.

ANNOUNCER: Patients with indolent lymphomas often do not need treatment for years.

DAVID FISHER, MD: So if someone doesn't have any symptoms at first, we actually won't even treat them. We'll keep a close eye on them and treat them if they start to develop symptoms such as fatigue, loss of appetite, weight loss, or if we see the lymph nodes are growing at a rate where we think that they're going to start to develop symptoms.

ALEXANDRA LEVINE, MD: Our usual chemotherapy works by killing cells that divide fast, and in these lymphomas that are indolent and slow-growing, they simply don't divide fast enough to be curable by chemotherapy alone. In those patients, we may very often use monoclonal antibodies.

ANNOUNCER: Patients with b-cell indolent lymphoma may be treated with a monoclonal antibody called Rituxan.

DAVID FISHER, MD: It's a manmade antibody that binds to a protein on the lymphocytes called CD20 and attacks them directly.

MORTON COLEMAN, MD: It can perhaps signal the cell to die, to undergo what we call programmed cell death or apoptosis, but can also set off various other events in the surrounding environment of the cell, such that various killer cells can be induced to come in and kill the tumor cell. Or you can set off a system called a complement system which can punch holes in the tumor cell.

ALEXANDRA LEVINE, MD: If regular antibody therapy does not work, or if the amount of tumor is quite large, we may use chemotherapy plus rituximab in addition. And the data in those patients has been very exciting; clear changes in survival time, a true benefit to the patient.

MORTON COLEMAN, MD: Virtually every regimen for b-cell lymphomas now incorporates monoclonal antibody therapy. It has clearly enhanced our ability to cure the aggressive lymphomas, which we now cure with great regularity and it's probably enhanced our ability to cure the aggressive lymphomas by anywhere from 20 to 30 percent of patients.

ANNOUNCER: There are some side effects from rituximab that patients may experience.

ALEXANDRA LEVINE, MD: The most important side effect is something we sometimes call the first dose phenomenon.

MORTON COLEMAN, MD: A number of patients will develop chills and fever and they'll find it quite uncomfortable. However, we are able to manage these side effects quite easily.

There are an enormous number of new agents that are being tested. One of the nice things about the current era of treatment is that we have a better understanding of the inherent biology of these diseases, and that allows us to develop a whole panoply of new drugs.

ALEXANDRA LEVINE, MD: I think it's important for the patients with lymphoma to understand what a very important and exciting time it is for lymphoma research now in the United States and elsewhere. Diseases that were not treatable or curable in the past are clearly treatable and potentially curable now.

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