Skip to Navigation Skip to Search Skip to Content
Search All Centers

Hodgkin Lymphoma: Your Questions Answered

Read Transcript Download/Print Transcript

Published on August 19, 2019

What’s new in Hodgkin lymphoma care? Renowned expert Dr. Sweetenham discusses the role of chemo and radiation therapy with emerging research on novel immunotherapies, and how doctors are working to minimize toxicities. Dr. Sweetenham also gives insight on side effect management strategies and reproductive health for patients undergoing treatment for Hodgkin lymphoma. Watch now to learn Hodgkin lymphoma expert advice.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Featuring

You might also like

Transcript |

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you’ll get care that's most appropriate for you.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:

Hello and welcome to Patient Power.  I'm Andrew Schorr.  We're talking about Hodgkin lymphoma, and we have with us a noted, world‑famous expert, and that's Dr. John Sweetenham, who's at UT Southwestern in Dallas. Welcome to Patient Power. 

Dr. Sweetenham:

Thanks. It's great to be here. 

Andrew Schorr:

Dr. Sweetenham, so first of all people always want to know is the landscape of treatment changing for Hodgkin, and are there some improvements either in trials that are promising or in new, approved treatments that might be better than what's been available before?   

Dr. Sweetenham:

Yeah. There certainly is a changing landscape in the treatment of Hodgkin lymphoma.  I think that chemotherapy as being the kind of mainstay of treatment for a long time, now supplemented in some people by radiation therapy, I think as the years go by the role of radiation therapy is gradually diminishing, which isn't to say it isn't a very important component of treatment for some people, but because we know that radiation, particularly in certain parts of the body, carries some potential late side effects, we're now trying to minimized amount of radiation that we use, and there are various ways in which that can be done. 

For the majority of patients that chemotherapy still is at the moment widely regarded at the standard of care, but there are some new drugs being introduced into the treatment of Hodgkin lymphoma now which are not chemotherapy and which act in very distinct ways.  Probably the one or two which are making the most buzz at the moment are a group of drugs which affect immunity and affect the body's immune response to the presence of Hodgkin lymphoma. 

These are drugs which go under the name checkpoint inhibitors, and there are two of them in particular, a drug called nivolumab (Opdivo) and another one called pembrolizumab (Keytruda), which are proving to be very effective in Hodgkin lymphoma.  Initially, they've been used for patients who have already had substantial treatments, but increasingly now we're seeing studies and new trials where these drugs are being brought up into the frontline, so that in one particularly large study that's been progress at the moment patients receive the drug nivolumab by itself initially and then the standard chemotherapy is added. 

The other big change has been the advent of a drug called brentuximab vedotin (Adcetris). This is now been around for several years, but again this is a drug which is now used more frequently in the first‑line treatment of Hodgkin lymphoma than it was previously.  And there are a bunch of newer drugs coming along as well, so things are definitely moving along. 

And I think now people are beginning to talk about the prospect at some future point, probably a few years out, but yet when the treatment of Hodgkin lymphoma may not be include chemotherapy at all.  It may be a completely chemotherapy‑free treatment. 

Andrew Schorr:

But as you mentioned, chemo remains a mainstay for many people.  And so as we've been looking over what Hodgkin patients are talking about, so many are saying, well, how do I deal with this side effect, whether it's fatigue or nausea or itching or hair loss?  And people are saying what can I do?  Can acupuncture help, medical marijuana, CBD oil?  Maybe you could talk a little bit about helping people through the treatments that you have. 

Dr. Sweetenham:

Yeah, absolutely. So broadly I think you can kind of break out the side effects of the chemotherapy treatments into the short‑term ones, which are those which you get during the treatments, and then the long‑term ones that come afterwards.  Many people, of course, are very‑‑you know, are struggling through their chemotherapy, and it does bring with it sometimes a lot of the side effects that you've mentioned. 

I think the key thing is, first of all, to talk to your oncologist about those side effects and which ones are bothering you most, and then he or she can direct you to the best place for help with those.  An increasing number of cancer centers now have supportive care, supportive oncology programs, and those programs consist typically of specialists who are trained in the management of side effects of chemotherapy, be they a neuropathy where patients get numbness and tingling in the finger tips and toe tips. That's a side effects which can frequently be managed sometimes with medications, sometimes with acupuncture, as you suggested. 

And I think it's a very individual thing.  I don't think there's a one‑size‑fits‑all route for patients to have management of their side effects, but I would say talk to your oncologist.  Ask your oncologist whether there is a supportive oncology team at the place where you're getting your care that can help you, and those would be the first two things that I would do. 

There are many interventions that can be used for many different side effects from antinausea medications through cold caps for hair loss, through, as I mentioned, acupuncture , other strategies good for nausea, often good for neuropathy.   

Andrew Schorr:

Dr. Sweetenham, the other thing people are asking about is also monitoring, whether it's PET scans or x‑rays to see how they've done, and people obviously have some concern about radiation over time.  So is there a standard now as far as monitoring if somebody is in remission?   

Dr. Sweetenham:

There is a pretty widely accepted standard now, and for most patients that would include PET scanning.  The way that we use PET scans has changed quite a lot over the last probably five years. And now they're used at three points. They're used initially at diagnosis. They're typically used after a couple of cycles of chemotherapy, something that is widely known as an interim PET scan, and that scan is done because we can use that PET scan to modify treatment, perhaps reduce the intensity the treatment or maybe increase the intensity of treatment depending upon the result of that scan.  And then at the end of treatment there's typically an exit CT to make sure that there's no evidence of disease. 

The current thinking and the current standard of care is that if at the end of first‑line treatment you have a negative PET scan, so the PET scan has gone back to normal, there's really no benefit from continuing to have ongoing scans.  And there are a couple of reasons for that. One of them, as you mentioned, is that scans bring a significant risk of radiation exposure, not an individual scan, but if you had a CT or PET scan every year for the next 50 years you're stacking up a lot of radiation exposure over that time. 

But secondly, and more importantly, there are several very large studies that show that a visit to the physician, a physical exam and some lab work are probably all—not probably, but really all that most people need and that scans are simply not a very accurate or reliable way of detecting a relapse of the disease. 

So the bottom line now, and I think the way that many of us practice now, myself included, is that if the CT scan or PET scan at the end of treatment is negative we won't routinely do further what are called surveillance scans.  If a patient gets a new symptom or has a new concern, then of course we're going to investigate that with scans.  But if a patient is feeling well, they're doing well, the physical exam is normal, the lab work is normal, there's no benefit from routine scans in those patients.   

Andrew Schorr:

The last area I wanted to ask you about is I guess what we'd call oncofertility.  We mentioned chemo, so people may have very strong drugs to fight their Hodgkin, and yet they maybe in their 20s or 30s, child‑bearing age.  So where are we with that, where people still have the chance to have the child they'd hoped for? 

Dr. Sweetenham:

Yeah, this is a subject where there's been a great deal of activity over the last several years in terms of improving fertility services for folks with conditions such as Hodgkin lymphoma. 

First of all, the good news.  And the good news is that for most young patients who have chemotherapy for Hodgkin lymphoma and who only ever need first‑line therapy—so in other words, if you have a course of chemotherapy for Hodgkin lymphoma and the disease is cured, the likelihood of low fertility is actually quite low.  In other words, most of those people are going to retain their fertility. The men may drop their sperm count in the short term.  Most women will probably have some time when their periods stop, but then they'll resume, but for the most part, they can anticipate regaining normal or close to normal fertility. 

Having said that, every patient who is going to undergo chemotherapy for Hodgkin lymphoma should discuss this issue with their oncologist.  For men, even though the risk of infertility is very low we always recommend freezing their own sperm before the treatment starts if that's possible, even though it's highly unlikely that they will ever need to use them. 

In women, we know the number of strategies for preserving fertility is increasing very dramatically, everything from some drugs that can be taken to kind of suppress the ovaries during chemotherapy right through to some of the strategies including egg cryopreservation and so on that can be done now.  And we recommend that young women about to undergo therapy for Hodgkin lymphoma should be seen by a reproductive specialist, which would usually be a gynecologist, prior to starting the chemotherapy if that's possible. 

Andrew Schorr:

And then lastly, I always ask you this at the end because you're our window into the future. So for people with Hodgkin or should they need treatment again, the first treatment didn't work out so well for them, are you hopeful that people can lead a hopefully a long life? 

Dr. Sweetenham:

Absolutely. So now with our current standards of care the patients with Hodgkin lymphoma whose disease comes back and they require more therapy, about half those patients are going to be cured second time around by the second‑line treatment that they get.  But the challenge is that those treatments are tough, and they include stem cell transplantation. 

What we're starting to see now is that with some of the newer agents, including the checkpoint inhibitors that I mentioned earlier, there's a suggestion that some patients may with those treatments alone be able to survive for a very long time. And, in fact, I can see a future where transplant will be needed in far fewer patients with Hodgkin lymphoma, and some of the other drugs which are emerging at the moment may be adequate to control or even cure the disease in the longer term. 

 Andrew Schorr:

Well, I know people love that word cure.  Thank you for your devotion to patients around the world who have Hodgkin lymphoma. We wish you well there at UT Southwestern in Dallas, Dr. Sweetenham.  Thank you so much for being with us again on Patient Power. 

Dr. Sweetenham:

Thanks. Great to talk to you again. 

Andrew Schorr:

I'm Andrew Schorr.  Remember, knowledge can be the best medicine of all. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.