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What Is Non-Hodgkin's Lymphoma?
Non-Hodgkin's lymphoma is a type of cancer. Lymphoma is a general
term for cancers that develop in the lymphatic
system. Hodgkin's disease is one type of lymphoma. (Hodgkin's
disease is the subject of another NCI booklet, What
You Need To Know About™ Hodgkin's Disease.) All other
lymphomas are grouped together and are called non-Hodgkin's lymphoma.
Lymphomas account for about 5 percent of all cases of cancer in this
country.
![[Diagram of lymphatic system]](../images/lymph.gif)
The lymphatic system is part of the body's immune
system. It helps the body fight disease and infection. The
lymphatic system includes a network of thin tubes that branch, like
blood vessels, into tissues throughout the body. Lymphatic vessels carry
lymph, a colorless, watery fluid that
contains infection-fighting cells called lymphocytes.
Along this network of vessels are small organs called lymph
nodes. Clusters of lymph nodes are found in the underarms, groin,
neck, chest, and abdomen. Other parts of
the lymphatic system are the spleen, thymus,
tonsils, and bone marrow. Lymphatic tissue is also found in other parts of the
body, including the stomach, intestines, and skin.
Cancer is a group of many related diseases that begin in cells, the
body’s basic unit of life. To understand non-Hodgkin's lymphoma, it is
helpful to know about normal cells and what happens when they become
cancerous. The body is made up of many types of cells. Normally, cells
grow and divide to produce more cells only when the body needs them.
This orderly process helps keep the body healthy. Sometimes cells keep
dividing when new cells are not needed, creating a mass of extra tissue.
This mass is called a growth or tumor.
Tumors can be either benign (not cancerous)
or malignant (cancerous).
In non-Hodgkin's lymphoma, cells in the lymphatic system become
abnormal. They divide and grow without any order or control, or old
cells do not die as cells normally do. Because lymphatic tissue is
present in many parts of the body, non-Hodgkin's lymphoma can start
almost anywhere in the body. Non-Hodgkin's lymphoma may occur in a
single lymph node, a group of lymph nodes, or in another organ. This
type of cancer can spread to almost any part of the body, including the
liver, bone marrow, and spleen.
Symptoms
The most common symptom of non-Hodgkin's lymphoma is a painless
swelling of the lymph nodes in the neck, underarm, or groin.
Other symptoms may include the following:
- Unexplained fever
- Night sweats
- Constant fatigue
- Unexplained weight loss
- Itchy skin
- Reddened patches on the skin
When symptoms like these occur, they are not sure signs of
non-Hodgkin's lymphoma. They may also be caused by other, less serious
conditions, such as the flu or other infections. Only a doctor can make
a diagnosis. When symptoms are present, it is important to see a doctor
so that any illness can be diagnosed and treated as early as possible. Do
not wait to feel pain; early non-Hodgkin's lymphoma may not cause
pain.
Diagnosis
If non-Hodgkin's lymphoma is suspected, the doctor asks about the
person's medical history and performs a physical exam. The exam includes
feeling to see if the lymph nodes in the neck, underarm, or groin are
enlarged. In addition to checking general signs of health, the doctor
may perform blood tests.
The doctor may also order tests that produce pictures of the inside
of the body. These may include:
- X-rays: Pictures of areas inside the
body created by high-energy radiation.
- CT (or CAT) scan: A
series of detailed pictures of areas inside the body. The pictures
are created by a computer linked to an x-ray machine.
- MRI (magnetic resonance imaging):
Detailed pictures of areas inside the body produced with a powerful
magnet linked to a computer.
- Lymphangiogram: Pictures of
the lymphatic system taken with x-rays after a special dye is
injected to outline the lymph nodes and vessels.
A biopsy is needed to make a diagnosis.
A surgeon removes a sample of tissue so that a pathologist
can examine it under a microscope to check for cancer cells. A biopsy
for non-Hodgkin's lymphoma is usually taken from a lymph node, but other
tissues may be sampled as well. Sometimes, an operation called a laparotomy
may be performed. During this operation, a surgeon cuts into the abdomen
and removes samples of tissue to be checked under a microscope.
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A patient who needs a biopsy may want to ask the doctor some
of the following questions:
- Why do I need to have a biopsy?
- How long will the biopsy take? Will it hurt?
- How soon will I know the results?
- If I do have cancer, who will talk with me about
treatment? When?
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Types of Non-Hodgkin's Lymphoma
Over the years, doctors have used a variety of terms to classify the
many different types of non-Hodgkin's lymphoma. Most often, they are
grouped by how the cancer cells look under a microscope and how quickly
they are likely to grow and spread. Aggressive
lymphomas, also known as intermediate and high-grade lymphomas, tend to
grow and spread quickly and cause severe symptoms. Indolent
lymphomas, also referred to as low-grade lymphomas, tend to grow
quite slowly and cause fewer symptoms.
Staging
If non-Hodgkin's lymphoma is diagnosed, the doctor needs to learn the
stage, or extent, of the disease. Staging is
a careful attempt to find out whether the cancer has spread and, if so,
what parts of the body are affected. Treatment decisions depend on these
findings.
The doctor considers the following to determine the stage of
non-Hodgkin's lymphoma:
- The number and location of affected lymph nodes;
- Whether the affected lymph nodes are above, below, or on both
sides of the diaphragm (the thin
muscle under the lungs and heart that separates the chest from the
abdomen); and
- Whether the disease has spread to the bone marrow, spleen, or to
organs outside the lymphatic system, such as the liver.
In staging, the doctor may use some of the same tests used for the
diagnosis of non-Hodgkin's lymphoma. Other staging procedures may
include additional biopsies of lymph nodes, the liver, bone marrow, or
other tissue. A bone marrow biopsy
involves removing a sample of bone marrow through a needle inserted into
the hip or another large bone. A pathologist examines the sample under a
microscope to check for cancer cells.
Treatment
The doctor develops a treatment plan to fit each patient's needs.
Treatment for non-Hodgkin's lymphoma depends on the stage of the
disease, the type of cells involved, whether they are indolent or
aggressive, and the age and general health of the patient.
Non-Hodgkin's lymphoma is often treated by a team of specialists that
may include a hematologist, medical
oncologist, and/or radiation
oncologist. Non-Hodgkin's lymphoma is usually treated with chemotherapy,
radiation therapy, or a
combination of these treatments. In some cases, bone
marrow transplantation, biological
therapies, or surgery may be
options. For indolent lymphomas, the doctor may decide to wait until the
disease causes symptoms before starting treatment. Often, this approach
is called "watchful waiting."
Taking part in a clinical trial
(research study) to evaluate promising new ways to treat non-Hodgkin's
lymphoma is an important option for many people with this disease. For
more information, see the "Clinical Trials"
section.
Getting a Second Opinion
Before starting treatment, patients may want a second opinion to
confirm their diagnosis and treatment plan. Some insurance companies
require a second opinion; others may cover a second opinion if the
patient or doctor requests it.
There are a number of ways to find a doctor who can give a second
opinion:
- The patient's doctor may be able to suggest specialists to
consult.
- The Cancer Information Service, at 1-800-4-CANCER, can tell
callers about cancer treatment facilities, including cancer centers
and other programs supported by the National Cancer Institute.
- Patients can get the names of doctors from their local medical
society, a nearby hospital, or a medical school.
- The Official ABMS Directory of Board Certified Medical
Specialists lists doctors' names along with their specialty and
medical background. This resource, produced by the American Board of
Medical Specialties, is available in most public libraries and on
the Internet.
Preparing for Treatment
Many people with cancer want to learn all they can about their
disease and their treatment choices so they can take an active part in
decisions about their medical care. When a person is diagnosed with
cancer, shock and stress are natural reactions. These feelings may make
it difficult for people to think of everything they want to ask the
doctor. Often, it helps to make a list of questions. To help remember
what the doctor says, patients may take notes or ask whether they may
use a tape recorder. Some people also want to have a family member or
friend with them when they talk to the doctor--to take part in the
discussion, to take notes, or just to listen.
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These are some questions a patient may want to ask the doctor
before treatment begins:
- What kind of non-Hodgkin's lymphoma do I have?
- What is the stage of the disease?
- What are my treatment choices? Which do you recommend for
me? Why?
- What are the risks and possible side
effects of each treatment?
- What side effects should I report to you?
- How long will treatment last?
- What are the chances that the treatment will be
successful?
- Will treatment affect my normal activities? If so, for how
long?
- Are new treatments under study? Would a clinical trial be
appropriate for me?
- What is the treatment likely to cost?
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Patients do not need to ask all their questions or remember all the
answers at one time. They will have other chances to ask the doctor to
explain things and to get more information.
Methods of Treatment
Chemotherapy and radiation therapy are the most common treatments for
non-Hodgkin's lymphoma, although bone marrow transplantation, biological
therapies, or surgery are sometimes used.
Chemotherapy is the use of drugs to kill cancer cells.
Chemotherapy for non-Hodgkin's lymphoma usually consists of a
combination of several drugs. Patients may receive chemotherapy alone or
in combination with radiation therapy.
Chemotherapy is usually given in cycles: a treatment period followed
by a recovery period, then another treatment period, and so on. Most
anticancer drugs are given by injection into a blood vessel (IV);
some are given by mouth. Chemotherapy is a systemic
treatment because the drugs enter the bloodstream and travel
throughout the body.
Usually a patient has chemotherapy as an outpatient (at the hospital,
at the doctor's office, or at home). However, depending on which drugs
are given and the patient's general health, a short hospital stay may be
needed.
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These are some questions patients may want to ask the doctor
before starting chemotherapy:
- What is the goal of this treatment?
- What drugs will I be taking?
- Will the drugs cause side effects? What can I do about
them?
- What side effects should I report to you?
- How long will I need to take this treatment?
- What can I do to take care of myself during treatment?
- How will we know if the drugs are working?
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Radiation therapy (also called radiotherapy) is the use of
high-energy rays to kill cancer cells. Treatment with radiation may be
given alone or with chemotherapy. Radiation therapy is local
treatment; it affects cancer cells only in the treated area.
Radiation therapy for non-Hodgkin's lymphoma comes from a machine that
aims the high-energy rays at a specific area of the body. There is no
radioactivity in the body when the treatment is over.
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These are some questions a patient may want to ask the doctor
before having radiation therapy:
- What is the goal of this treatment?
- What are its risks and possible side effects?
- What side effects should I report to you?
- How will radiation be given?
- When will the treatments begin? When will they end?
- What can I do to take care of myself during therapy?
- How will we know if the radiation therapy is working?
- How will treatment affect my normal activities?
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Sometimes patients are given chemotherapy and/or radiation therapy to
kill undetected cancer cells that may be present in the central
nervous system (CNS). In this treatment, called central nervous
system prophylaxis, the doctor injects
anticancer drugs directly into the cerebrospinal
fluid.
Bone marrow transplantation (BMT) may also be a treatment
option, especially for patients whose non-Hodgkin's lymphoma has recurred
(come back). BMT provides the patient with healthy stem
cells (very immature cells that produce blood cells) to replace
cells damaged or destroyed by treatment with very high doses of
chemotherapy and/or radiation therapy. The healthy bone marrow may come
from a donor, or it may be marrow that was removed from the patient,
treated to destroy cancer cells, stored, and then given back to the
person following the high-dose treatment. Until the transplanted bone
marrow begins to produce enough white blood cells, patients have to be
carefully protected from infection. They usually stay in the hospital
for several weeks.
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These are some questions patients may want to ask the doctor
before having a BMT:
- What are the benefits of this treatment?
- What are the risks and possible side effects? What can be
done about them?
- What side effects should I report to you?
- How long will I be in the hospital? What care will I need
after I leave the hospital?
- How will the treatment affect my normal activities?
- How will I know if the treatment is working?
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Biological therapy (also called immunotherapy) is a form of
treatment that uses the body’s immune system, either directly or
indirectly, to fight cancer or to lessen the side effects that can be
caused by some cancer treatments. It uses materials made by the body or
made in a laboratory to boost, direct, or restore the body’s natural
defenses against disease. Biological therapy is sometimes also called
biological response modifier therapy.
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These are some questions patients may want to ask the doctor
before starting biological therapy:
- What is the goal of this treatment?
- What drugs will I be taking?
- Will the treatment cause side effects? If so, what can I
do about them?
- What side effects should I report to you?
- Will I have to be in the hospital to receive treatment?
- How long will I need to take this treatment?
- When will I be able to resume my normal activities?
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Surgery may be performed to remove a tumor. Tissue around the
tumor and nearby lymph nodes may also be removed during the operation.
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These are some questions a patient may want to ask the doctor
before surgery:
- What kind of operation will it be?
- How will I feel after the operation?
- If I have pain, how will you help?
- Will I need more treatment after surgery?
- How long will I be in the hospital?
- When will I be able to resume my normal activities?
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Clinical Trials
Many people with non-Hodgkin's lymphoma take part in clinical
trials (research studies). Doctors conduct clinical trials to learn
about the effectiveness and side effects of new treatments. In some
trials, all patients receive the new treatment. In others, doctors
compare different therapies by giving the new treatment to one group of
patients and the standard therapy to another group; or they may compare
one standard treatment with another. Research like this has led to
significant advances in the treatment of cancer. Each achievement brings
researchers closer to the eventual control of cancer.
Doctors are studying radiation therapy, new ways of giving
chemotherapy, new anticancer drugs and drug combinations, biological
therapies, bone marrow transplantation, peripheral
blood stem cell transplantation, and new ways of combining
various types of treatment. Some studies are designed to find ways to
reduce the side effects of treatment and to improve the patient's
quality of life.
People who take part in these studies have the first chance to
benefit from treatments that have shown promise in earlier research.
They also make an important contribution to medical science.
Patients who are interested in taking part in a clinical trial should
talk with their doctor. They may also want to read the National Cancer
Institute booklet Taking
Part in Clinical Trials: What Cancer Patients Need To Know,
which describes how studies are carried out and explains their possible
benefits and risks. The NCI cancerTrials™ Web site at http://cancertrials.nci.nih.gov
provides detailed information about ongoing studies for non-Hodgkin's
lymphoma. Another way to learn about clinical trials is through the Cancer
Information Service.
Side Effects of Treatment
Treatments for non-Hodgkin's lymphoma are very powerful. It is hard
to limit the effects of therapy so that only cancer cells are removed or
destroyed. Because treatment also damages healthy cells and tissues, it
often causes side effects.
The side effects of cancer treatment depend mainly on the type and
extent of the therapy. Side effects may not be the same for everyone,
and they may even change from one treatment to the next. Doctors and
nurses can explain the possible side effects of treatment. They can also
lessen or control many of the side effects that may occur during and
after treatment.
Chemotherapy
The side effects of chemotherapy depend mainly on the drugs and the
doses the patient receives. As with other types of treatment, side
effects may vary from person to person.
Anticancer drugs generally affect cells that divide rapidly. In
addition to cancer cells, these include blood cells, which fight
infection, help the blood to clot, or carry oxygen to all parts of the
body. When blood cells are affected, the patient is more likely to get
infections, may bruise or bleed easily, and may feel unusually weak and
tired. The patient's blood count is monitored during chemotherapy and,
if necessary, the doctor may decide to postpone treatment to allow blood
counts to recover.
Cells in hair roots also divide rapidly; therefore, chemotherapy may
lead to hair loss. Patients may have other side effects such as poor
appetite, nausea and vomiting, or mouth and lip sores. They may also
experience dizziness and darkening of skin and fingernails.
Most side effects go away gradually during the recovery periods
between treatments or after treatment is over. However, certain
anticancer drugs can increase the risk of developing a second cancer
later in life.
In some men and women, chemotherapy causes a loss of fertility
(the ability to produce children). Loss of fertility may be temporary or
permanent, depending on the drugs used and the patient's age. For men, sperm
banking before treatment may be an option. Women's menstrual
periods may stop, and they may have hot flashes and vaginal dryness.
Menstrual periods are more likely to return in young women. The National
Cancer Institute booklet Chemotherapy
and You has helpful information about chemotherapy and coping
with side effects.
Radiation Therapy
The side effects of radiation depend on the treatment dose and the
part of the body that is treated. During radiation therapy, people are
likely to become extremely tired, especially in the later weeks of
treatment. Rest is important, but doctors usually advise patients to try
to stay as active as they can.
It is common to lose hair in the treated area and for the skin to
become red, dry, tender, or itchy. There may also be permanent darkening
or "bronzing" of the skin in the treated area.
When the chest and neck are treated, patients may have a dry, sore
throat and trouble swallowing. Some patients may have tingling or
numbness in their arms, legs, and lower back. Radiation therapy to the
abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort.
Often, changes in diet or medicine can ease these problems.
Radiation therapy also may cause a decrease in the number of white
blood cells, cells that help protect the body against infection. If that
happens, patients need to be careful to avoid possible sources of
infection. The doctor monitors a patient's blood count during radiation
therapy. In some cases, treatment may have to be postponed to allow
blood counts to recover.
Although the side effects of radiation therapy can be difficult, they
can usually be treated or controlled. It may also help to know that, in
most cases, side effects are not permanent. However, patients may want
to discuss with their doctor the possible long-term effects of radiation
treatment on fertility and the increased chance of second cancers after
treatment is over. The National Cancer Institute booklet Radiation
Therapy and You has helpful information about radiation therapy
and managing its side effects.
Bone Marrow Transplantation
Patients who have a bone marrow transplant face an increased risk of
infection, bleeding, and other side effects from the large doses of
chemotherapy and radiation they receive. In addition, graft-versus-host
disease (GVHD) may occur in patients who receive bone marrow
from a donor. In GVHD, the donated marrow attacks the patient's tissues
(most often the liver, the skin, and the digestive tract). GVHD can
range from mild to very severe. It can occur any time after the
transplant (even years later). Drugs may be given to reduce the risk of
GVHD and to treat the problem if it occurs.
Biological Therapy
The side effects caused by biological therapy vary with the specific
type of treatment. These treatments may cause flu-like symptoms such as
chills, fever, muscle aches, weakness, loss of appetite, nausea,
vomiting, and diarrhea. Patients also may bleed or bruise easily, get a
skin rash, or retain fluid. These problems can be severe, but they
usually go away after treatment stops.
Surgery
The side effects of surgery depend on the location of the tumor, the
type of operation, the patient's general health, and other factors.
Although patients are often uncomfortable during the first few days
after surgery, the pain can usually be controlled with medicine. People
can talk with their doctor or nurse about pain relief. It is also common
for patients to feel tired or weak for a while. The length of time it
takes to recover from an operation varies for each patient.
Nutrition During Cancer Treatment
Eating well during cancer treatment means getting enough calories and
protein to help prevent weight loss and regain strength. Good nutrition
often helps people feel better and have more energy.
Some people with cancer find it hard to eat a balanced diet because
they may lose their appetite. In addition, common side effects of
treatment, such as nausea, vomiting, or mouth sores, can make eating
difficult. Often, foods taste different. Also, people being treated for
cancer may not feel like eating when they are uncomfortable or tired.
Doctors, nurses, and dietitians can offer advice on how to get enough
calories and protein during cancer treatment. Patients and their
families also may want to read the National Cancer Institute booklet Eating
Hints for Cancer Patients, which contains many useful
suggestions.
Recovery and Outlook
It is natural for anyone facing cancer to be concerned about what the
future holds. Understanding the nature of cancer and what to expect can
help patients and their loved ones plan treatment, anticipate lifestyle
changes, and make quality of life and financial decisions.
Cancer patients frequently ask their doctors or search on their own
for an answer to the question, "What is my prognosis?"
Prognosis is a prediction of the future course and outcome of a disease
and an indication of the likelihood of recovery. However, it is only an
estimate. When doctors discuss a patient's prognosis, they are
attempting to project what is likely to occur for that individual
patient.
Sometimes patients use statistics to try to figure out their chances
of being cured. However, statistics reflect the experience of a large
group of patients and cannot be used to predict what will happen to a
particular patient because no two patients are alike. The prognosis for
a person with non-Hodgkin's lymphoma can be affected by many factors,
particularly the type and stage of the cancer and the patient's age,
general health, and response to treatment. The doctor who is most
familiar with a patient's situation is in the best position to help
interpret statistics and discuss that person's prognosis.
When doctors talk about surviving cancer, they may use the term remission
rather than cure. Although many people with non-Hodgkin's lymphoma are
successfully treated, doctors use the term remission because cancer can
return. It is important to discuss the possibility of recurrence with
the doctor.
Follow up Care
People who have had non-Hodgkin's lymphoma should have regular follow
up examinations after their treatment is over. Follow up care is an
important part of the overall treatment plan, and people should not
hesitate to discuss it with their health care provider. Regular follow
up
care ensures that patients are carefully monitored, any changes in
health are discussed, and new or recurrent cancer can be detected and
treated as soon as possible. Between follow up appointments, people who
have had non-Hodgkin's lymphoma should report any health problems as
soon as they appear.
Support for People with Cancer
Living with a serious disease is not easy. People with cancer and
those who care about them face many problems and challenges. Coping with
these problems is often easier when people have helpful information and
support services. Several useful booklets, including Taking
Time, are available from the Cancer Information Service and
through other sources listed in the "National Cancer
Institute Information Resources" section.
Friends and relatives can be very supportive. Also, it helps many
patients to discuss their concerns with others who have cancer. Cancer
patients often get together in support groups, where they can share what
they have learned about coping with cancer and the effects of treatment.
It is important to keep in mind, however, that each person is different.
Treatments and ways of dealing with cancer that work for one person may
not be right for another--even if they both have the same kind of
cancer. It is always a good idea to discuss the advice of friends and
family members with the health care provider.
People living with cancer may worry about what the future holds. They
may worry about holding their jobs, caring for their families, keeping
up with daily activities, or personal relationships. Concerns about
tests, treatments, hospital stays, and medical bills are also common.
Doctors, nurses, and other members of the health care team can answer
questions about treatment, working, or other activities. Meeting with a
social worker, counselor, psychologist, or member of the clergy can be
helpful to people who want to talk about their feelings or discuss their
concerns. Often, a social worker can suggest groups that can help with
rehabilitation, emotional support, financial aid, transportation, or
home care.
Additional information about locating support services for people
with cancer and their families is available through the Cancer
Information Service and other sources described in the "National
Cancer Institute Information Resources" section.
Risk Factors Associated with Non-Hodgkin's Lymphoma
The incidence of non-Hodgkin's lymphoma has increased dramatically
over the last couple of decades. This disease has gone from being
relatively rare to being the fifth most common cancer in the United
States. At this time, little is known about the reasons for this
increase or about exactly what causes non-Hodgkin's lymphoma.
Doctors can seldom explain why one person gets non-Hodgkin's lymphoma
and another does not. It is clear, however, that cancer is not caused by
an injury, and is not contagious; no one can "catch"
non-Hodgkin's lymphoma from another person.
By studying patterns of cancer in the population, researchers have
found certain risk factors that are
more common in people who get non-Hodgkin's lymphoma than in those who
do not. However, most people with these risk factors do not get
non-Hodgkin's lymphoma, and many who do get this disease have none of
the known risk factors.
The following are some of the risk factors associated with this
disease:
- Age/Sex--The likelihood of getting non-Hodgkin's lymphoma
increases with age and is more common in men than in women.
- Weakened Immune System--Non-Hodgkin's lymphoma is more
common among people with inherited immune deficiencies, autoimmune
diseases, or HIV/AIDS, and among people taking immunosuppressant
drugs following organ transplants.
- Viruses--Human T-lymphotropic virus type I (HTLV-1) and
Epstein-Barr virus are two infectious agents that increase the
chance of developing non-Hodgkin's lymphoma.
- Environment--People who work extensively with or are
otherwise exposed to certain chemicals, such as pesticides,
solvents, or fertilizers, have a greater chance of developing
non-Hodgkin's lymphoma.
People who are concerned about non-Hodgkin's lymphoma should talk
with their doctor about the disease, the symptoms to watch for, and an
appropriate schedule for checkups. The doctor's advice will be based on
the person's age, medical history, and other factors.
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