Advances in Hematologic Malignancies Issue 1, Spring 2013
Improvements in the diagnosis of lymphoma and therapeutic strategies have led to important gains in survival over the past several decades. According to the most recently available estimates, the five-year survival rate for all types of lymphoma is 70.6 percent, and there are more than 660,000 people in the United States now living with, or in remission from, one of these diseases.1
Lymphoma survivors are followed long-term by both medical oncologists and primary care physicians. Classical Hodgkin lymphoma (HL) and diffuse large B-cell non-Hodgkin lymphoma (DLBCL NHL) are thought to have the greatest curability of the more than 70 subtypes of lymphoma, due to improvements in combination chemotherapy, radiation, and stem cell transplantation — all of which unfortunately also have the potential to compromise survivors' health and quality of life. 2,3,4,5,6,7
Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) has long been a leader in the treatment of hematologic malignancies, including lymphoproliferative disorders. Over the years, clinicians in the DF/BWCC Center for Hematologic Oncology have worked to modify therapies for lymphoma to diminish toxicity without compromising response. While we are hopeful that these changes will lead to a reduction in both short- and long-term toxicity, we recognize that many of the survivors still face an array of treatment-related health risks. Treatment-related toxicity can be prevented through changes in upfront therapy, improved understanding of factors contributing to complications of therapy, and ancillary treatments specifically designed to diminish the risk of complications.
One example of an approach combining these pathways involves the risk of premature coronary artery disease (CAD) in HL survivors treated with chest irradiation. These individuals have up to five times the risk of CAD compared with the general population.8,9 In addition to their efforts to reduce the total radiation dose administered and minimize exposure to healthy tissues, Peter Mauch, MD, and Andrea Ng, MD, MPH, of the DF/BWCC Department of Radiation Oncology, led a study of lipid screening in survivors of HL, and found that statin therapy for screen-positive patients both improves survival and is cost-effective.10 (Previous research had demonstrated that traditional cardiac risk factors — hypertension, hyperlipidemia, diabetes mellitus, and smoking — play a role in the development of premature CAD in lymphoma survivors, providing a rationale for this study.9,11)
Early detection of complications, including secondary malignancies, is another major focus of the Dana-Farber Cancer Institute Adult Survivorship Program. Clinical screening trials looking at secondary malignancies (especially breast, lung, and colorectal cancers) and cardiac dysfunction are ongoing within the program. The results of these studies will provide an essential evidence base to improve the long-term outcomes of our growing lymphoma survivor population.
The DF/BWCC Center for Hematologic Oncology, in collaboration with the Dana-Farber Adult Survivorship Program, is also developing comprehensive guidelines for the post-treatment care of lymphoma survivors, which we plan to make available to collaborating health care providers. These guidelines will focus on disease-specific follow-up, including visit frequency, imaging modality and imaging frequency, and laboratory test requirements. In addition, the guidelines will also include specific treatment-related toxicity prevention, screening, and monitoring recommendations.
Finally, we are also developing patient education materials focused on the "emotional toxicity" of cancer treatment, including coping with the fear of recurrence.
All of us here at DF/BWCC understand that many of our lymphoma survivors choose to be followed locally with other oncology providers or their primary care providers, rather than to return to Boston. As a nurse practitioner with a concentration on lymphoma-specific survivorship issues, I am working to translate our new guidelines into a survivorship care plan format. The ultimate aim is to better educate our lymphoma survivors and their primary care providers about post-treatment health care needs.
— Richard Boyajian, RN, NP, of the Dana-Farber Adult Survivorship Program, with Melissa A. Cochran, RN, NP, of the DF/BWCC Adult Bone Marrow/Stem Cell Transplantation Program
1Cancer Facts & Figures 2011. Atlanta, GA: American Cancer Society; 2011.
2 Cosset JM, Henry-Amar M, Meerwaldt JH. Long-term toxicity of early stages of Hodgkin's disease therapy: the EORTC experience. EORTC Lymphoma Cooperative Group. Ann Oncol. 1991;2 Suppl 2:77-82.
3 Hoppe RT. Hodgkin's disease: complications of therapy and excess mortality. Ann Oncol. 1997;8(Suppl 1):115-118.
4 Ng AK, Bernardo MV, Weller E, et al. Second malignancy after Hodgkin disease treated with radiation therapy with or without chemotherapy: long-term risks and risk factors. Blood. Sep 15 2002;100(6):1989-1996.
5 Harrington CB, Hansen JA, Moskowitz M,Todd BL, Feuerstein M. It’s not over when it’s over: long-term symptoms in cancer survivors-a systematic review. Int J Psychiatry Med. 2010;40:163-181.
6 Stein KD, Syrjala KL, Andrykowski MA. Physical and psychological long-term and late effects of cancer. Cancer. 2008;112 (suppl 11):2577-2592.
7 Stricker CT, Jacobs LA. Physical late effects in adult cancer survivors. Oncology (WillistonPark). 2008;22(suppl 8 Nurse Ed):33-41.
8 Aleman BM, van den Belt-Dusebout AW, De Bruin ML, et al: Late cardiotoxicity after treatment for Hodgkin lymphoma. Blood 109:1878-1886, 2007
9 Gaya AM, Ashford RF: Cardiac complications of radiation therapy. Clin Oncol (R Coll Radiol) 17: 153-159, 2005
10 Chen, A. B., Punglia, R. S., Kuntz, K. M., Mauch, P. M., & Ng, A. K. (2009). Cost effectiveness and screening interval of lipid screening in Hodgkin's lymphoma survivors. Journal of Clinical Oncology, 27(32), 5383-5389.
11 Hull MC, Morris CG, Pepine CJ, et al: Valvular dysfunction and carotid, subclavian, and coronary artery disease in survivors of Hodgkin lymphoma treated with radiation therapy. JAMA 290:28312003