NON-HODGKIN’S LYMPHOMA FACTSHEET

[Pages:7]NON-HODGKIN'S LYMPHOMA FACTSHEET

What is Non-Hodgkin's Lymphoma?

Non-Hodgkin's lymphoma is a cancer which affects cells in the lymphatic system called lymphocytes. The various types of non-Hodgkin's lymphoma are divided into 'high grade' (fast growing) and 'low grade' (slow growing). Without treatment, the high grade types would be more rapidly fatal. However, high grade types tend to respond the best to treatment. Chemotherapy is the usual treatment, sometimes used with other treatments. With treatment, many people with non-Hodgkin's lymphoma are cured. What is lymphoma? A lymphoma is a cancer of cells in the lymphatic system. Lymphomas are divided into two types - Hodgkin's lymphoma and non-Hodgkin's lymphomas (which include various types of lymphoma). It is important to know exactly what type of lymphoma you have. This is because the treatments and outlook (prognosis) can vary greatly for different types of lymphoma. What is the lymphatic system? The lymphatic system consists of lymph nodes (often called lymph glands), a network of thin lymphatic channels (similar to thin blood vessels), and organs such as the spleen and thymus.

Small lymph nodes occur throughout the body. Lymph nodes that are near each other often form into groups or chains. For example, in the sides of the neck (cervical lymph nodes), the armpits (axillary lymph nodes), and in the groins (inguinal lymph nodes). The diagrams above show the main groups of lymph nodes (lymph glands), but lymph nodes occur in many places in the body. Lymph nodes are joined together by a network of lymphatic channels. Lymph mainly consists of a fluid that forms between the cells of the body. This contains nutrients and waste products which go into and out of cells. The watery lymph fluid travels in the lymph channels, through various lymph nodes, and eventually drains into the bloodstream. The lymphatic system is also a major part of the immune system. Lymph and lymph nodes contain white blood cells called lymphocytes and antibodies which defend the body against infection. The lymphocytes are made in the bone marrow. When they are mature they are released into the bloodstream and migrate into the lymphatic system. There are three types of mature lymphocytes:

? B-lymphocytes which make antibodies that attack infecting bacteria, viruses, etc. ? T-lymphocytes (which finish off their maturing in the thymus gland) have various functions including helping the Blymphocytes to make antibodies. ? Natural killer lymphocytes also help to protect against infection.

Source: patient.co.uk People with concerns about their own health should contact their GP or cancer team

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NON-HODGKIN'S LYMPHOMA FACTSHEET

Types of Non-Hodgkin lymphoma

There are over 20 different types of non-Hodgkin lymphoma. Each type has:

? a particular appearance when looked at under the microscope ? specific types of proteins in the cells ? a particular rate of growth ? its own specific treatments

Different types of NHL affect the body in different ways. The main types are listed below:

B-cell lymphomas ? Diffuse large B-cell ? Follicular ? Mantle cell ? Lymphoplasmacytic ? Burkitt lymphoma ? Primary mediastinal large B-cell ? Extranodal marginal zone B-cell ? MALT ? Nodal marginal zone B-cell ? Small Lymphocytic Lymphoma

T-cell lymphomas ? Peripheral T-cell ? Angioimmunoblastic T-cell ? Anaplastic large cell ? Hepatosplenic T-cell ? Subcutaneous panniculitis-like T-cell ? Enteropathy type T-cell ? Extranodal Natural Killer/T-cell, nasal type ? Skin (cutaneous) lymphomas ? including Mycosis fungoides/S?zary syndrome

Others ? Aids-related lymphoma ? Central nervous system lymphoma

The type of lymphoma can be diagnosed by removing a lymph node, or a tiny part of an affected organ, and examining it in the laboratory. This is called a biopsy.

B-cell lymphomas are more common than T-cell lymphomas, although teenagers and young adults are more likely to be diagnosed with a T-cell

lymphoma.

Source:

What causes a non-Hodgkin's lymphoma and how does it develop?

The cause is not known. If you have a poorly functioning immune system (for example, if you have AIDS) your risk of developing a non-Hodgkin's lymphoma is increased. However, this only accounts for a small number of cases and the cause of most cases is unknown.

What seems to happen is that a cancer (such as a lymphoma) starts from one abnormal cell. In the case of non-Hodgkin's lymphoma, the cancer develops from a lymphocyte cell which becomes abnormal. The exact reason why the cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal. If the abnormal cell survives it may multiply and produce many abnormal cells.

The cancerous lymphocytes tend to collect in lymph nodes. The lymph nodes then get bigger and form cancerous tumours. Some abnormal cells may travel to other parts of the lymphatic system. You may therefore develop lots of large cancerous lymph nodes, and an enlarged spleen.

Cancerous lymphocytes can also form lymphoma tumours in places in the body outside of the lymphatic system. This is because lymphocytes can come in and out of the lymphatic system and travel in the bloodstream. For example, in one type of non-Hodgkin's lymphoma a tumour develops in the lining of the stomach, and a non-Hodgkin's lymphoma is a rare cause of a brain tumour.

Source: patient.co.uk

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NON-HODGKIN'S LYMPHOMA FACTSHEET

What are the symptoms of Non-Hodgkin's lymphoma?

Swollen lymph nodes

The most common early symptom is to develop one or more swollen lymph nodes in one area of the body - most commonly the side of the neck, an armpit or the groin. The swollen lymph nodes tend to be painless and gradually get bigger. If the affected lymph nodes are in the chest or abdomen, you will not be aware of them swelling in the early stages of the disease.

(Note: the most common cause of swollen lymph nodes is infection. For example, it is very common to develop swollen nodes in the neck during a bout of tonsillitis. Lymphoma is an uncommon cause of swollen lymph nodes. However, a lymphoma may be suspected if lymph nodes remain swollen for more than a couple of weeks or so, or if there is no infection to account for the swelling.)

Other symptoms

Various other general symptoms may develop. For example: sweats (especially at night), fevers, weight loss, tiredness, being off food, anaemia, itch all over the body.

Various other symptoms may develop if the lymphoma occurs outside the lymphatic system. For example, stomach pain if the lymphoma develops in the stomach.

As a non-Hodgkin's lymphoma develops you may feel generally unwell. If the lymphoma tumours become large and press on nearby parts of the

body, various other symptoms can develop. For example, you may develop cough or breathing problems if the tumour enlarges in the lymph nodes

inside the chest.

Source: patient.co.uk

How is non-Hodgkin's lymphoma diagnosed and assessed?

To confirm the diagnosis (biopsy)

If your doctor suspects that you may have a lymphoma you will be referred to a specialist. A specialist will normally arrange a biopsy of one of the swollen nodes. A biopsy is when a small sample of tissue is removed from a part of the body. The sample is then looked at under the microscope to look for abnormal cells and is tested in other ways. (Sometimes an entire lymph node is removed to look at under the microscope.)

Grade of the lymphoma

The biopsy samples are looked at under the microscope to asses the cancer cells. By looking at certain features of the cells, and by doing various other tests on the cells, the exact type of the lymphoma can be diagnosed. Examples of types of non-Hodgkin's lymphomas include: diffuse large Bcell lymphoma, lymphoblastic lymphoma, follicular lymphoma, anaplastic large-cell lymphoma, lymphoplasmacytic lymphoma - but there are various other types.

Although there are many types of non-Hodgkin's lymphoma, they are generally divided (graded) into two categories - high and low grade.

? High grade (fast growing). The cancerous cells tend to grow and multiply quite quickly and are more 'aggressive'. ? Low grade (slow growing). The cancerous cells tend to grow and multiply quite slowly and are not so 'aggressive'.

Assessing the extent and spread (staging)

If the biopsy confirms that you have a non-Hodgkin's lymphoma, then further tests are usually advised. For example, you may have a CT scan, an MRI scan, blood tests, a bone marrow biopsy, or other tests. This assessment is called 'staging'. The aim of staging is to find out how much the lymphoma has grown locally, and whether it has spread to other lymph nodes or to other parts of the body. The staging system that is commonly used for non-Hodgkin's lymphomas is:

? Stage 1 - The lymphoma is confined to one group of lymph nodes only.

? Stage 2 - The lymphoma affects two or more groups of lymph nodes. However, they are all on the same side of the diaphragm. (The diaphragm is the large muscle that separates the chest from the abdomen and helps us to breathe. So, for stage 2, all the affected nodes will either be above or below the diaphragm.)

? Stage 3 - The lymphoma affects nodes on both sides of the diaphragm.

? Stage 4 - The lymphoma affects parts of the body outside of the lymphatic system.

Each stage is also divided into A or B. A means that you do not have symptoms of night sweats, fevers or weight loss. B means that you do have one or more of these symptoms. So, for example, if you have Stage 2B, it means that you have two or more groups of lymph nodes affected, but both are either above or below the diaphragm, and you also have one or more of night sweats, fevers or weight loss.

By finding out the type, grade and stage of the lymphoma it helps doctors to advise on the best treatment options. It also gives a reasonable

indication of outlook (prognosis).

Source: patient.co.uk

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT wcisu.wales.nhs.uk

NON-HODGKIN'S LYMPHOMA FACTSHEET

What are the treatments for Non-Hodgkin's lymphoma?

The treatment advised for each case depends on various factors such as: the exact type and stage of the lymphoma and in particular whether it is high or low grade, your age, your general health, the size of the affected nodes, and which parts of the body are affected. Treatments which may be considered include the following.

Chemotherapy Chemotherapy is a treatment which uses anti-cancer drugs to kill cancer (lymphoma) cells, or to stop them from multiplying. High grade nonHodgkin's lymphomas are usually treated with chemotherapy drugs given straight into the vein (intravenous chemotherapy). A combination of drugs is usually used. The most common combination used is of the drugs: cyclophosphamide, doxorubicin, vincristine and prednisolone. (This combination is often referred to as CHOP.) For low grade non-Hodgkin's lymphomas, when active treatment is advised then intravenous chemotherapy or chemotherapy tablets are the most commonly used treatments.

Monoclonal antibodies This treatment is sometimes used in addition to chemotherapy. (For example, a product called rituximab is the commonly used monoclonal antibody.) Monoclonal antibodies are small proteins and are different to normal chemotherapy. They work by attaching to the abnormal lymphocytes which helps to destroy them without harming other cells.

Radiotherapy Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. It tends to be mainly used if you just have one or two affected lymph nodes.

Stem cell transplant A stem cell transplant (sometimes called a bone marrow transplant) is sometimes done. Stem cells are the immature cells that develop into mature blood cells in the bone marrow. Lymphocytes are derived from blood stem cells. Briefly, it involves high dose chemotherapy (and sometimes radiotherapy) to kill all the abnormal lymphocytes. However, this also kills the stem cells that make normal blood cells. So, after the chemotherapy you are given a transplant of stem cells which then make normal blood cells.

Surgery Surgery is not a usual treatment. Occasionally, an operation may be done to remove an organ (such as the spleen) or part of an organ that is badly damaged by a lymphoma. Sometimes a large mass of tumour may be removed to 'de-bulk' the tumour prior to chemotherapy.

Watch and wait No treatment may be advised at first for low grade non-Hodgkin's lymphomas. This approach is called 'watch and wait'. This approach is mainly used if you feel generally well and have no symptoms from the lymphoma (apart from painless swollen nodes). Low grade non-Hodgkin's lymphomas can grow very slowly and may not need any treatment for quite some time - over a year or so. Chemotherapy or other treatments may be delayed until the disease causes symptoms. Your specialist will want to review you every so often to check on the size of the lymph nodes, how fast they are growing, and to check you over. They will advise on when treatment should be started. You should have a full discussion with a specialist who knows your case. They will be able to give the pros and cons, likely success rate, possible side-effects, and other details about the various possible treatment options for your type and stage of lymphoma. You should also discuss with your specialist the aims of treatment. For example:

? Treatment may aim to cure the lymphoma. Some non-Hodgkin's lymphomas can be cured. In particular, most high-grade nonHodgkin's lymphomas can be cured with treatment. (Doctors tend to use the word 'remission' rather than the word 'cured'. Remission means there is no evidence of cancer (lymphoma) following treatment. If you are 'in remission', you may be cured. However, in some cases a lymphoma returns months or years later. This is why doctors are sometimes reluctant to use the word cured.) ? Treatment may aim to control the lymphoma. If a cure is not realistic, with treatment it is often possible limit the growth or spread of the lymphoma so that it progresses less rapidly. This may keep you free of symptoms for some time. In particular, many low-grade non-Hodgkin's lymphomas cannot be cured but can be 'controlled', often for quite some time. ? Treatment may aim to ease symptoms. If a cure is not possible, treatments may be used to reduce the size of lymphoma tumours which may ease symptoms such as pain. If a non-Hodgkin's lymphoma is advanced then you may require treatments such as painkillers or other treatments to help keep you free of pain or other symptoms.

Source: patient.co.uk

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT wcisu.wales.nhs.uk

NON-HODGKIN'S LYMPHOMA FACTSHEET

Benefits and disadvantages of treatment

Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur. Although many of the treatments can cause side effects, these can usually be controlled with medicines. Some people ask what would happen if they did not have any treatment.

Treatment can be given for different reasons, and the potential benefits will vary for each person. Low-grade NHL is usually very sensitive to chemotherapy and radiotherapy, and treatment can reduce the amount of lymphoma (partial remission) or get rid of it for a time (complete remission). Many people with low-grade NHL can have the illness controlled for many years and can live an almost normal life for a lot of that time. Treatment can improve symptoms and increase life expectancy for most people.

Without treatment, high-grade NHL would usually get bigger and spread quite quickly, and most people would not live for much longer. Most of the side effects of treatment can be well controlled and the treatment is usually effective. A complete cure is possible for many people with high-grade NHL. Some people will find that their initial treatment does not work, and then another type of treatment will be used.

Sometimes, if the lymphoma has come back after initial treatment, the treatment may only be able to control

it, leading to an improvement in symptoms and a better quality of life. However, for some people in this

situation the treatment will have no effect upon the cancer and they will get the side effects without any of the

benefits.

Source: .uk

What is the prognosis (outlook)?

The prognosis depends on various factors. For example, the exact type, grade, and stage of the lymphoma. Very generally:

Many people with a high grade non-Hodgkin's lymphoma will be cured. Therefore, the usual aim of treatment for high grade non-Hodgkin's lymphoma is to cure it. A cure is most likely in cases which are at an early stage, but there is still a good chance of a cure even with those in more advanced stages. Although a high grade non-Hodgkin's is fast growing and 'aggressive', the cells tend to be more easily killed with chemotherapy than low grade non-Hodgkin's lymphomas. (Without treatment, high grade non-Hodgkin's grow fairly quickly and would lead to death, often within a few months after diagnosis.)

With low grade non-Hodgkin's lymphomas, because they are slow growing, chemotherapy is less likely to be curative than with high-grade non-Hodgkin's lymphomas. However, treatment may control the disease and keep you free of symptoms for months or years. Also, because they are slow growing, often low grade nonHodgkin's lymphomas appear to be 'indolent' and not really progress very much for quite some time.

The treatment of cancers such as non-Hodgkin's lymphoma is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your type and stage of non-Hodgkin's lymphoma is likely to respond to treatment.

Source: patient.co.uk

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT wcisu.wales.nhs.uk

NON-HODGKIN'S LYMPHOMA FACTSHEET

* Please note the following information is for Wales only *

Summary

Non-Hodgkin's lymphoma represents roughly 3% of all registrations for both male and female cancers and is ranked 9th for both sexes too. The mean age at diagnosis for males is 63.5 years and 66.9 years for females.

Average registrations per annum (1992-2006) Relative Frequency Rank Mean age at diagnosis (years) Cumulative Rate (0-64 years) Cumulative Rate (0-74 years) Percentage Annual Change in EASR (incidence) Percentage Annual Change in EASR (mortality) Percentage Death Certificate Only Average deaths per annum (1992-2006) Mortality:Incidence Ratio (1992-2006)

Males Females

248

220

3.2%

2.9%

9th

9th

63.5

66.9

0.6%

0.5%

1.2%

0.9%

*

1.4%* 2.7%**

**

-1.6%* -0.7%

3.1%

3.2%

114

104

45.8% 47.6%

Significant at 5% level Significant at 1% level

Number of Cases Age Specific Rates per 100,000 population

Number of incident cases and age-specific rates, 1992-2006

600

90

80 500

70

400

60

50 300

40

200

30

20 100

10

0

0

Under 5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Age Group

Males Cases

Females Cases

Males ASR

Females ASR

Prevalence Statistics (at 31st December 2006) in Wales

Males

Up to 1 year >1 to 5 years >5 to 10 years >10 to 20 years Total up to 20 years

Number 274 764 552 633 2223

Rate per 100,000 18.96 52.88 38.21 43.81 153.86

% prev in pop 0.02 0.05 0.04 0.04 0.15

% in each time interval 12.33 34.37 24.83 28.48 100.00

Females

Up to 1 year >1 to 5 years >5 to 10 years >10 to 20 years Total up to 20 years

Number 248 672 532 546 1998

Rate per 100,000 16.30 44.18 34.97 35.89 131.35

% prev in pop 0.02 0.04 0.03 0.04 0.13

% in each time interval 12.41 33.63 26.63 27.33 100.00

WELSH CANCER INTELLIGENCE AND SURVEILLANCE UNIT wcisu.wales.nhs.uk

NON-HODGKIN'S LYMPHOMA FACTSHEET

Trends in Incidence 1992-2006

Males

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Total Crude Rate EASR WASR

1992 0 2 0 2 3 8 3 7 7 22 11 29 28 43 29 24 12 10

240 17.24 15.73 11.65

1993 1 1 0 0 2 2 4 8 5 14 18 11 22 28 28 24 18 4

190 13.61 12.03 8.71

1994 1 1 0 0 2 3 3 5 7 10 16 16 28 24 44 21 7 9

197 14.09 12.54 9.07

1995 0 3 1 1 2 4 5 3 2 15 15 28 23 30 49 29 20 12

242 17.28 14.97 10.65

1996 2 2 1 1 3 1 6 7 5 17 25 17 27 38 38 33 20 15 258

18.42 16.12 11.65

1997 0 0 1 4 0 2 4 8 6 13 17 23 19 30 37 31 16 11

222 15.81 13.66 9.74

1998 1 3 2 1 2 3 1 9 6 13 23 20 32 43 27 42 24 7

259 18.41 15.68 11.43

1999 2 3 1 1 1 6 4 3 7 11 13 22 17 17 34 37 16 9

204 14.49 12.25 8.98

2000 1 4 1 4 1 2 7 6 9 11 23 27 15 24 29 29 11 7

211 14.98 13.00 9.74

2001 2 2 1 1 0 4 4 4 6 13 18 26 26 43 37 31 17 16

251 17.82 15.04 10.93

2002 2 2 2 4 0 4 1 3 9 14 17 22 35 31 42 41 25 16 270

19.10 15.68 11.45

2003 0 2 2 2 1 4 4 7 15 13 20 30 30 38 40 47 23 9

287 20.13 16.52 11.98

2004 0 1 0 3 3 4 6 7 10 14 16 28 43 35 44 33 22 14

283 19.73 16.27 11.89

2005 2 1 0 0 3 2 0 6 10 10 18 31 29 47 50 28 23 21

281 19.54 15.70 11.23

2006 0 1 0 1 3 4 2 6 4 19 21 40 42 46 43 45 36 16

329 22.77 17.98 12.74

Females

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Total Crude Rate EASR WASR

1992 0 1 0 0 1 2 1 3 4 6 13 13 16 21 33 25 17 16

172 11.58 8.49 6.01

1993 0 0 1 2 1 2 4 7 3 6 12 15 15 21 19 16 17 15

156 10.49 8.17 6.01

1994 0 2 1 2 2 3 3 5 7 6 14 12 17 14 22 23 20 10

163 10.95 8.51 6.40

1995 0 1 0 0 0 3 6 5 1 8 17 14 19 26 31 23 22 21

197 13.24 9.71 6.94

1996 0 0 0 2 2 5 1 4 9 15 17 16 24 18 27 26 21 15 202

13.55 10.57 7.85

1997 0 0 0 0 1 2 3 5 7 10 8 14 12 26 28 33 22 21

192 12.88 9.02 6.36

1998 1 0 1 0 2 1 1 3 6 12 13 20 19 34 40 36 18 28

235 15.75 11.31 8.08

1999 0 1 0 1 1 3 3 5 10 14 17 15 27 24 31 36 19 12

219 14.67 11.20 8.25

2000 1 0 1 1 1 1 3 3 6 12 14 18 28 21 25 33 25 28

221 14.75 10.59 7.65

2001 1 0 0 0 0 1 4 2 7 5 11 19 23 33 36 39 36 24

241 16.05 10.87 7.57

2002 1 0 0 0 4 3 5 6 4 18 17 22 21 24 33 34 32 26 250

16.56 11.99 8.75

2003 0 1 1 1 1 0 2 2 5 12 19 24 21 35 28 34 35 24

245 16.20 11.35 8.04

2004 0 1 0 1 3 0 2 1 6 14 15 23 13 24 36 42 38 21

240 15.81 10.68 7.46

2005 0 0 0 2 3 1 6 6 12 14 16 14 25 25 41 38 36 27

266 17.49 12.22 8.80

2006 0 0 0 0 1 3 2 4 7 7 14 27 36 35 50 45 29 34

294 19.33 13.20 9.21

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